San Marcos Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at San Marcos Rehabilitation and Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, patternF684Aug 1, 2025

  Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of five residents reviewed for quality of care. The facility failed to: Manage Resident #1's diarrhea and urine when her MASD worsened causing her skin to be inflamed with erosions and severe excoriation (rubbing of the skin leading to abrasions or erosions) to her groin, buttocks, thighs, and axilla (arm pit) which consequently required treatment in the burn unit at the hospital from [DATE] - 07/17/25. […]

• Immediate jeopardy, patternF697Aug 1, 2025

  Based on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of five residents reviewed for quality of care. The facility failed to: Manage Resident #1's diarrhea and urine when her MASD worsened causing her skin to be inflamed with erosions and severe excoriation (rubbing of the skin leading to abrasions or erosions) to her groin, buttocks, thighs, and axilla (arm pit) which consequently required treatment in the burn unit at the hospital from [DATE] - 07/17/25. […]

• Actual harm, isolatedF689Apr 15, 2024

  Based on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as possible for one (Resident #1) of four residents reviewed for accidents hazards, in that: The facility failed to ensure all rough edges of Resident #1's bed frame were covered, resulting in a laceration to his left leg during a transfer. This failure could place residents at risk of pain, bruising, or skin tears. The findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including type II diabetes, acquired absence of unspecified leg below knee, bullous pemphigoid (a rare skin condition that causes large, fluid-filled… […]

• No harm, potential for more than minimal, widespreadF732Dec 30, 2025

  Based on observation, interview, and record review, the facility failed to post the following information on a daily basis: (i) Facility name. (ii) The current date. (iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: (A) Registered nurses. (B) Licensed practical nurses or licensed vocational nurses (C) Certified nurse aides. (iv) Resident census for 1 of 1 facility reviewed for posted nurse staffing. The facility failed to post nurse staffing as required from 12/19/2025 to 12/29/2025. […]

• No harm, potential for more than minimal, patternF755Nov 4, 2024

  Based on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of three residents reviewed for medications. The facility failed to administer three doses of insulin after Resident #1 was admitted on [DATE] due to pending delivery from the pharmacy. This failure could affect residents by putting them at risk of exacerbation of their health conditions and deterioration of their health. […]