Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at San Luis Care Center during CMS and state inspections, most recent first.
Food service sanitation and storage practices were not maintained as required. The facility’s only ice machine had a white substance inside the bin, a food cart was sanitized with a quaternary solution that tested below the facility’s stated ppm range, and the residents’ break room refrigerator contained expired and improperly stored items while the freezer had no thermometer. Staff and the DON/IP acknowledged inconsistent temperature monitoring and incomplete logs for the residents’ refrigerator.
Medication storage and labeling were not maintained correctly in the facility. An inhaler for a resident with COPD was found without an open date or BUD, an RN left a med cart unlocked and unattended while giving meds, and a second cart had incomplete CDR entries, an unlabeled insulin bottle, ear wax drops without resident labels or open dates, and open wound care supplies stored with meds. Staff and the DON stated the cart should be locked and medications should be labeled with open dates and stored appropriately.
Inadequate Dietary Staff Competency and Recipe Compliance: Two FSWs were found without documented competency checks and were not able to demonstrate key kitchen duties. One FSW did not follow facility recipes for sandwiches and enchiladas and was unsure of thawed supplement use-by dates, while another FSW did not know the required dish machine temperature. The DM and DSD reported limited in-service training and no competency records for kitchen staff.
Food Lacked Flavor and Was Improperly Prepared: A resident meal item, asparagus with red pepper, was served bland and lacking flavor during a lunch tray observation. The DM acknowledged the issue, and a FSW stated seasonings were not measured and the asparagus was cooked on the stove for about 30 minutes before being held on the steam table. The facility recipe called for specific ingredients and seasonings, but reviewed kitchen in-services did not address following recipes.
Puree asparagus served on a meal test tray contained multiple strings and thin pieces throughout the food mixture, and the DM acknowledged the strings should not have been present. An FSW said she cooked frozen asparagus, added broth to thin it, and often had trouble with strands when making the puree. Five residents on a level 4 puree diet received the asparagus, and facility guidance required pureed foods to be smooth, lump-free, and confirmed using IDDSI tests.
Infection control failures involved two residents’ HHN masks being left undated on bedside tables instead of being labeled and stored in bags, while staff confirmed the masks should be changed weekly and kept bagged. A third resident on EBP for a urinary catheter and nephrostomy tube was transferred by a PTA wearing gloves but no gown, despite EBP applying to transfers and mobility. Staff and the DON acknowledged the expected infection control practices, and the facility policy addressed labeling of resident-use respiratory equipment and use of EBP during close-contact care.
Kitchen Oven Not Maintained in Safe Operating Condition: The facility failed to keep one of two kitchen ovens operational. A FSW was observed preparing multiple pans of food in the remaining working oven, while the FSW stated the other oven had not worked for about five months and staff had to time food preparation around using only one oven. The MD stated the oven pilot had gone out recently, that he relied on kitchen staff to report problems, and a prior work order showed the right oven had been checked and documented as working.
Unrepaired blinds and damaged room walls affected four residents’ rooms, with missing slats, broken horizontal blinds, and scratches and missing paint noted during observation. One resident stated sunlight shining through the broken blinds caused headaches, and a family member said they would prefer complete blinds. The MD acknowledged the rooms were not home-like, and CNAs stated the damage would be upsetting to residents and families. Residents involved had significant medical conditions including hemiplegia, fractures, COPD, Alzheimer's disease, type 2 DM, HIV, and sepsis.
A resident with a Foley catheter and significant urinary diagnoses had the catheter drainage bag left uncovered and visible on the side of the bed. During observation, staff confirmed the bag was not in a dignity bag, and multiple staff members stated the bag should always be covered to protect privacy, dignity, and prevent embarrassment.
A resident with anxiety, dementia, and repeated falls was given lorazepam IM on two occasions without an informed consent in the record. Staff interviews confirmed the consent was missing, and the LVN, UM, DON, and ADM all stated the medication should not have been administered before the resident and family were informed of the risks and benefits and signed consent.
A resident was admitted with psychosis and depression, and later received psychotropic medications for crying, yelling out, and tearfulness. The facility did not complete a new PASARR Level I screening after the resident’s prior PASARR did not include these diagnoses or medication use, and the DON and UM stated they were unsure when a new PASARR was required.
A resident admitted with multiple fractures and an order to monitor right upper extremity sling placement did not have a care plan for the sling. The resident was observed in bed without the sling and stated she frequently removed it. Staff confirmed the EMR lacked a sling care plan, and the DON and UM stated the intervention should have been in the care plan to guide nursing care.
An LPN documented medications in the eMAR before actually giving them to two residents, including one resident whose meds were later found not to have been taken at the time of charting. In another event, an RN gave a resident an MDI for self-administration without shaking it first. Staff and the DON stated meds should be documented after administration and MDIs should be shaken well before use.
A resident with dementia, depression, and anxiety did not receive scheduled buspirone during a med pass because the medication was not available. The RN stated she would call the pharmacy after finishing meds for the wing, and the LVN, DON, and ADM confirmed that licensed nurses were responsible for ensuring routine meds were available and reordered before they ran out.
Lack of RD oversight and food service competency. The facility did not ensure the RD provided frequent consultation to the DM, and surveyors observed multiple food service errors, including an incorrect meal tray for a resident, puree asparagus with strings that did not meet IDDSI expectations, and chicken enchiladas prepared without following the recipe’s measured ingredients. Staff also lacked documented competency and in-service records, and the RD stated she had no formal documentation showing frequent consultation with the DM.
A resident on a renal, consistent carbohydrate diet received an incorrect lunch tray item when mashed potatoes were served instead of the ordered rice. FSW 1 and the DM both confirmed the tray did not match the meal ticket, and facility policy stated the facility will follow menus.
A resident who was fully dependent for all care, including toileting and repositioning, suffered a serious fall and multiple injuries when a CNA failed to use a draw sheet or proper technique during pericare and did not request assistance from another staff member. The CNA turned the resident on her side, allowed her feet to dangle off the bed, and turned away to dispose of a soiled brief, resulting in the resident falling to the floor. The resident sustained a scalp laceration, traumatic brain injury, rib and manubrial fractures, and a pneumothorax, requiring ICU admission. Facility records and interviews confirmed that established protocols and training for safe repositioning were not followed.
The facility failed to provide written notification of the bed hold policy to two residents or their representatives upon hospital transfer, as required by their policy. The EMR lacked documentation of this information for both residents, and the Business Office Manager confirmed that bed hold consents were typically handled over the phone without written confirmation.
The facility failed to notify the ombudsman of hospital transfers for three residents, as required by policy. The Social Services staff mistakenly sent notifications to an incorrect fax number, resulting in the ombudsman not receiving the necessary transfer information. This oversight risked residents and their representatives having incomplete information about the transfers.
A facility failed to update a resident's care plan to include refusals for weekly weights. The resident, with medical conditions such as Hydronephrosis and Dysphagia, was assessed as cognitively alert and at risk for weight fluctuations. Despite recommendations for weekly weights, the care plan did not document the resident's refusals, as confirmed by interviews with an LVN and the DON.
A resident with Parkinson's and muscle contracture did not receive the planned range of motion care to prevent further contractures of her right hand. The care plan required placing a rolled washcloth in her hand, but observations showed this was not done. A CNA acknowledged the intervention but did not follow through, failing to notify the charge nurse of the resident's refusal, contrary to facility policy. The facility's lack of adherence to procedures led to this deficiency.
A resident experienced significant weight loss, and the facility failed to ensure weekly weight monitoring as recommended by the Registered Dietician. Despite the resident's medical conditions and dietary recommendations, there were no recorded weights for two months, and only one instance of refusal was documented. The LVN responsible did not implement the necessary interventions, as confirmed by the DON.
A resident on Enhanced Barrier Precautions did not receive proper wound care as staff failed to wear the required PPE and did not use a clean barrier for supplies. The LVN and CNA involved admitted to not following infection control protocols, which was confirmed by the Infection Preventionist and Director of Nursing.
The facility failed to ensure residents were treated with respect and dignity, as evidenced by CNA 1's rude and dismissive behavior towards four residents. The residents reported feeling disrespected by being called 'girlie' or 'girl' and being told that other 'premium people' were prioritized. The facility's policy on resident rights was reviewed, and the residents were found to be cognitively intact.
A resident with severe cognitive impairment and multiple diagnoses had a fractured finger that was not splinted until the day after the injury was identified. The delay occurred because the LVN lacked experience in applying a splint and did not question the NP's order to continue monitoring without immediate splint placement, risking further injury.
The facility failed to implement a resident-centered comprehensive care plan for a resident with severe cognitive impairment and a history of aggression, resulting in an unsupervised altercation where the resident punched another resident. Staff acknowledged the need for constant supervision but cited difficulties due to other care responsibilities.
Food Storage and Sanitation Deficiencies
Penalty
Summary
Food was not stored, prepared, distributed, and served in accordance with professional standards when the facility’s only ice machine contained a large area of white substance throughout the back of the bin. During observation, ice was also seen up to the top of the water trough in the bin, and ice from that machine was placed into a resident water pitcher and given to someone at the door. The Maintenance Director confirmed the white substance and stated the machine was cleaned and sanitized monthly. The facility’s ice machine cleaning log showed the machine was descaled and sanitized on 2/20/26, and the manufacturer’s guide stated that if more frequent de-scaling and sanitizing was needed, a qualified service company should be consulted to test water quality and recommend treatment. The facility also failed to maintain proper sanitizer concentration for food cart sanitation. A Food Service Worker was observed wiping a food cart with a rag from a red sanitation bucket, and the sanitizer tested at about 150 ppm on one test and about 100 ppm to 150 ppm on a repeat test. The worker stated the solution needed to be between 200 ppm and 400 ppm and that the bucket needed to be changed out. The Dietary Manager confirmed the red sanitation bucket should be maintained at 200 ppm to 400 ppm, and the facility’s sanitation guidance stated sanitation buckets should be kept within proper ppm and checked every 2 hours to ensure the ppm is maintained. In the staff break room, the residents’ refrigerator contained expired and improperly stored food items, including yogurts past the manufacturer’s date, an opened and unsealed meat wrapped around cheese labeled with a resident name, orange juice opened on 2/7/26, tapioca pudding dated 1/11/26, guacamole dated 2/7/26, a veggie tray with a best-by date of 2/23/26, sliced pepper jack cheese dated 2/22/26, string cheese dated 1/15/26, and frozen fruit bars dated best by 2/28/26. The freezer had no thermometer. Staff stated they were responsible for checking the dates in the residents’ fridge and freezer, and the Infection Preventionist stated the freezer had no log and that licensed nurses only monitored the refrigerator. The temperature log for the refrigerator showed multiple missed entries and repeated temperatures above 41 F across several months, and the facility’s policy stated refrigerated foods were to be maintained at or below 41 F and frozen foods kept frozen solid.
Medication carts and drug labeling were not maintained properly
Penalty
Summary
Drugs and biologicals were not consistently labeled and stored in accordance with accepted practice and facility policy. During observation of Resident 48’s medication administration, Budesonide-Formoterol Fumarate aerosol was found in the medication cart without an open date or beyond use date. Resident 48’s record showed diagnoses including COPD, shortness of breath, and muscle weakness, and the order summary listed the inhalation aerosol as two puffs by mouth twice daily for COPD. During the same observation, RN 1 left the medication cart unlocked and unsupervised while entering Resident 22’s room to administer medications. RN 1 stated the cart was left open because she was nervous and forgot to lock it, and acknowledged that residents and staff could access the medications. Facility staff and leadership stated the cart should be locked when not within sight, and the facility policy stated medication carts are to remain locked when out of sight or unattended. A second medication cart contained additional storage and labeling issues. Two Controlled Drug Record entries were not completed, one bottle of insulin had no open or expiration date, two bottles of ear wax removal drops had no resident label or open date, and open wound care supplies were stored with medications. The DON stated only medications should be stored in the medication cart, that wound care supplies had been opened and used on residents, and that medication bottles should be labeled with resident information and an opened and expiration date. The facility policy also stated that the date opened should be recorded on primary medication containers and that external use medications and biologicals should be stored separately from internal use medications and biologicals.
Inadequate Dietary Staff Competency and Recipe Compliance
Penalty
Summary
The facility failed to ensure two Food Service Workers were competent to safely and effectively carry out food and nutrition service functions. FSW 2 was observed preparing turkey sandwiches on 3/3/26 using 2 slices of cheese and 4 slices of deli turkey on wheat bread, even though the facility recipe for Turkey & Cheese Sandwich called for 1 slice of cheese and 2 oz of turkey between 2 slices of bread. During the same meal preparation review, FSW 2 was also observed preparing chicken enchiladas on 3/4/26 by placing 60 x 3 oz chicken enchiladas into hotel pans, pouring red sauce over them, and adding cheese by handfuls, while not mixing the water and vegetable base with the enchilada sauce as described in the facility recipe. FSW 2 was also observed in the kitchen with thawed Mighty Shakes stored in the refrigerator. The box of strawberry Mighty Shakes had a pull-out date of 3/1/26 and a use-by date of 3/22/26, while the manufacturer’s instruction indicated the product should be used within 14 days once thawed. FSW 2 stated she thought the product should be good for 3 weeks, then read the manufacturer’s carton and acknowledged it stated 14 days. The refrigerator information sheet posted in the kitchen listed health shakes as having a 2-week use-by date after thawing. FSW 3 was observed operating the dishwashing machine and stated she was not sure what temperature the machine needed to be, and did not know whether the temperature mattered. The dish machine temperature log indicated that a low-temperature dish machine should be maintained between 120 F and 140 F, and the machine was observed at 128 F during the survey. Record review showed both FSW 2 and FSW 3 were hired on 8/26/25 and had no documented competency or skills checks completed. The Dietary Manager stated she had only done a couple of in-services since starting at the end of December and was trying to locate prior documentation, while the Director of Staff Development stated her department had no record of kitchen competencies or training. The facility policy required sufficient staff with appropriate competencies and skill sets to carry out food and nutrition services.
Food Lacked Flavor and Was Improperly Prepared
Penalty
Summary
Food and drink were not maintained in a palatable, attractive, and appetizing manner when the cooked asparagus prepared for the lunch meal on 3/05/26 was found to be bland and lacking flavor. During interviews, Resident 62 stated the facility needed to upgrade its food choices and that the food did not taste like it should, and Resident 31 stated the facility's food had no flavor. During the lunch meal observation, the regular and pureed asparagus on the test trays were sampled and both were described as bland and lacking flavor, which the Dietary Manager acknowledged. The Food Service Worker stated she did not measure the seasonings, instead eyeballing salt and pepper and using margarine, and said the asparagus was cooked on the stove for about 30 minutes before being placed on the steam table at 11:00 a.m. The Dietary Manager stated food should not be on the steam table longer than 30 minutes. The facility recipe for asparagus with red pepper called for specific ingredients and recommended seasonings, and the kitchen in-services reviewed did not include topics about following recipes.
Puree asparagus contained stringy pieces
Penalty
Summary
The facility failed to ensure puree vegetables were prepared in the proper form when the lunch meal test tray contained puree asparagus with multiple strings and thin pieces throughout the food mixture. During observation of the puree and regular diet lunch meal test tray in the presence of the Dietary Manager, the puree asparagus was tasted by surveyors and the Dietary Manager, and the Dietary Manager acknowledged that the strings in the puree asparagus should not be there. The Food Service Worker stated she used frozen asparagus, cooked it for 30 minutes, then added broth to thin it to the appropriate consistency, and also stated she was looking for the food to stick to the back of a spoon and that she always has trouble with strands when making pureed asparagus. A review of the lunch meal tray tickets showed five residents were receiving a level 4 puree texture and were served the puree asparagus. The Dietary Manager stated staff should test for consistency for IDDSI. Facility documents for Level 4 pureed food stated foods are to be smooth and lump-free, not firm or sticky, require no chewing or bolus formation, fall off the spoon as an intact spoonful, and hold shape on a plate. The facility recipe for asparagus with red pepper instructed staff to blend until smooth and use the Fork Drip Test and Spoon Tilt Test to confirm IDDSI Level 4 specifications.
Infection Control Lapses With Nebulizer Equipment and Barrier Precautions
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for a safe, sanitary, and comfortable environment for three sampled residents. For two residents, handheld nebulizer masks were observed on top of their bedside tables with no date indicating when the masks were first used. One resident stated the mask was used every day for breathing, and the other resident also stated the mask was used every day for breathing problems. The masks were not stored in a bag, and staff identified that the masks should have been labeled with the date they were first used and kept in a bag rather than placed directly on the bedside table. The two residents had respiratory-related diagnoses. One resident was admitted with acute respiratory failure, heart failure, and shortness of breath. The other resident was admitted with COPD, muscle weakness, and dysphagia, and had a BIMS score of 3, indicating severe cognitive impairment. During observation, an LVN confirmed the nebulizer masks were undated and placed on the bedside tables, and stated this was an infection control issue because bacteria could build up in the masks and tubing. The DON stated licensed nurses were expected to change the masks weekly and bag them, and that the IP was responsible for making sure oxygen tubing and nebulizer masks were replaced and labeled. For the third resident, who was on enhanced barrier precautions due to a urinary catheter and a nephrostomy tube, a PTA transferred the resident from bed to wheelchair while wearing gloves but not a gown. The PTA stated they had not been informed about the EBP sign posted on the door and said the sign was sometimes not updated. Staff interviews confirmed that EBP applied to licensed nurses, CNAs, PTs, and PTAs during care activities including transfers, and that the purpose was to prevent cross-contamination and protect residents from infection. The facility policy stated EBP is used when anticipating close physical contact while assisting with transfers and mobility.
Kitchen Oven Not Maintained in Safe Operating Condition
Penalty
Summary
The facility failed to ensure essential equipment was maintained in safe operating condition when one of two kitchen ovens was not working and could not be used. During an observation, a Food Service Worker was preparing three hotel pans of chicken enchiladas with red sauce and one quarter hotel pan of chicken enchiladas with green sauce, and all pans were placed in one of the kitchen ovens. During an interview, the Food Service Worker stated only one oven was working and the nonworking oven had not worked for about five months. She stated she had been told it could not be fixed and staff had to time things and use the one oven. During an interview, the Maintenance Director stated the oven pilot had gone out the prior week but he thought everything was working since then. He stated staff used a system to let him know about maintenance issues and that he relied on kitchen staff to report problems. He also stated that two months earlier he had done the pilot assembly and it was working. A review of work order #1502 dated 12/10/25 showed the right oven was out and the pilot light was on; comments indicated the oven was checked, the switch was not on, and it was working properly, with completion documented on 12/12/25. The facility policy stated that mechanical, electrical, and patient care equipment would be maintained in safe operating condition.
Unrepaired blinds and damaged room walls
Penalty
Summary
The facility failed to provide a comfortable environment for four sampled residents when vertical blinds had missing slats, horizontal blinds were broken, and resident room walls had scratches and missing paint. During observation and interview, Resident 41 was lying in bed with sunlight shining directly on her face and stated that the sun reflected off cars in the parking lot and came through a hole in the blinds, causing her headaches, and that the blinds had been broken since admission. Resident 80's family member stated that they would not want so many slats missing from the blinds and would prefer complete blinds for the resident. The Maintenance Director observed the damaged blinds and room conditions in the rooms of Residents 41, 80, 14, and 51 and stated that the environment was not home-like, that blind slats should not be on the floor, and that residents should not have to look at unrepaired blinds and walls. CNA 4 and CNA 5 also stated they would not want family members or residents in rooms with damaged walls and missing blinds, and CNA 5 said that looking at scraped walls and missing blinds would make them depressed. Resident 14 had diagnoses including hemiplegia, dysphagia, and cognitive communication deficit; Resident 41 had fractures of the right femur, patella, and humerus with general weakness; Resident 51 had COPD, muscle wasting, Alzheimer's disease, and type 2 DM; and Resident 80 had a bone neoplasm, HIV, and sepsis. The facility policy stated that staff and management maximize characteristics of the facility that reflect a personalized, home-like setting, including a clean, sanitary, and orderly environment.
Uncovered urinary catheter bag left visible in resident room
Penalty
Summary
The facility failed to treat Resident 79 with dignity and respect when the resident’s urinary catheter drainage bag was not placed in a dignity bag. Resident 79 was admitted with diagnoses including acute kidney failure, obstructive and reflux uropathy, hydronephrosis with renal and ureteral calculous obstruction, and other artificial openings of the urinary tract status. The resident had an order for a Foley catheter to gravity drain, size 16, every shift. During a concurrent observation and interview, the resident’s catheter bag was seen hung on the side of the bed and uncovered, and it was visible upon entry into the room. A CNA stated the catheter bag was not covered and should be covered with a dignity bag at all times to provide privacy and dignity. An LVN, the IP, the DSD, and the DON each stated that a urinary bag should remain covered to protect privacy, maintain dignity, and prevent embarrassment. The facility’s Resident Rights policy stated that the resident has the right to be treated with respect and dignity.
Failure to Obtain Informed Consent Before Lorazepam Administration
Penalty
Summary
The facility failed to ensure informed consent was obtained before administering lorazepam to a resident with anxiety, dementia, and repeated falls. The resident was admitted with diagnoses including anxiety, dementia, and repeated falls, and was observed confused and Spanish speaking only during an initial tour. The resident’s order summary showed lorazepam 1 mg IM every 12 hours as needed, and the medication administration record showed the medication was given on two occasions. A review of the clinical record found no informed consent for lorazepam. During interviews, the LVN stated the lorazepam was ordered and that she did not find an informed consent, and said it should not have been administered without one. The UM stated the consent was not found in the record and that the licensed nurse who received the order should have ensured informed consent was signed before administration. The DON stated the lorazepam had been changed from oral to injection and that the consent should have been signed before it was administered. The ADM stated informed consent for psychotropic medications should be signed prior to administration so the resident and family can be aware of the medications and decide whether to receive them.
Failure to Complete Updated PASARR Screening for Resident with New Psychiatric Diagnoses and Psychotropic Medications
Penalty
Summary
The facility failed to complete a new PASARR Level I screening for one of six sampled residents after the resident’s prior PASARR, dated 9/9/24, did not include diagnoses of psychosis, depression, or psychotropic medication use. Resident 6 was admitted to the facility with diagnoses including unspecified psychosis, depression, hemiplegia, and hemiparesis. The resident’s order summary showed divalproex sodium sprinkles ordered for yelling out and uncontrollable sobbing, and fluoxetine ordered for sad facial expression and tearfulness. During observation, Resident 6 was sitting up in a wheelchair, appropriately dressed, and answered questions. The resident stated she was happy and had no concerns. Staff interviews and record review showed CNA 1 was familiar with the resident’s crying behaviors, and LVN 2 confirmed the resident had been admitted and later received divalproex sodium and fluoxetine orders. The UM and DON stated they reviewed admissions for PASARR completion but were unsure when a new PASARR was needed after psychotropic medication orders, and the DON stated she was told not to complete another PASARR because one had already been completed.
Missing Care Plan for Arm Sling
Penalty
Summary
The facility failed to ensure a comprehensive, person-centered care plan was developed and implemented for one resident who had an order to monitor sling placement to the right upper extremity every shift and for proper placement. The resident was admitted with diagnoses that included fractures of the right femur, right patella, and humerus, as well as unsteadiness on her feet. The resident’s MDS assessment showed a BIMS score of 15, indicating no cognitive deficit. During observation, the resident was lying in bed without her arm sling and stated she was in the facility for therapy after falling and having surgery on her fractured right leg and right shoulder. The resident also stated she was supposed to have her sling on but frequently took it off. Record review and staff interviews showed the resident did not have a care plan for the right arm sling when the order was in place. An LVN reviewed the EMR and stated a care plan for the sling was not found. The LVN stated that a care plan provides nursing direction for resident care and that missing information could result in the resident not receiving needed care to heal. The UM later reviewed the care plan and stated it had been placed earlier that day, adding that the intervention should have been placed in the care plan right after the order was written to give staff directions for care. The DON also stated the resident did not have a care plan for the sling and that the resident should have had one to alert nurses that she should be wearing it.
Medication Documentation and Inhaler Preparation Errors
Penalty
Summary
LVN 3 documented medication administration in the eMAR before actually giving medications to Resident 11 and Resident 65. During observation, LVN 2 was seen preparing Resident 11's medications, leaving the room, and then pulling medication for Resident 65, while stating she had already documented Resident 11's medication as given before administration. She also stated she had prepared Resident 65's medications earlier and documented them as administered even though Resident 65 did not take them, and that she later had to return to administer them. LVN 2 stated this practice was not acceptable and could lead to a medication error. Resident 11 had diagnoses including atrial fibrillation, muscle weakness, rheumatoid arthritis, and skin carcinoma, and Resident 65 had diagnoses including DM, COPD, and muscle weakness. RN 1 did not shake Resident 48's budesonide-formoterol MDI before handing it to the resident for self-administration. During the observation, RN 1 administered the medication and gave the inhaler to Resident 48 without shaking it, then allowed the resident to take two puffs. RN 1 stated she did not shake the MDI because she believed it had already been shaken earlier in the day, and she was not sure whether the resident was self-administering because she had always given the inhaler to the resident. Resident 48's record showed diagnoses including COPD, shortness of breath, and muscle weakness, and the order was for budesonide-formoterol inhalation aerosol, 2 puffs twice daily for COPD. Interviews with staff and the DON confirmed that medications should be documented after administration and that MDI medications should be shaken well before use. LVN 3, LVN 2, LVN 1, the DON, and the ADM all stated that signing or saving the eMAR before giving the medication was not acceptable practice. The DON also stated the MDI should be shaken well to ensure the medication was thoroughly mixed, and the ADM stated it was not acceptable to sign the eMAR before administering medications.
Medication Not Available for Resident With Anxiety
Penalty
Summary
The facility failed to provide pharmaceutical services to ensure that medications were available to meet a resident’s needs when buspirone was not available during medication administration. During a medication pass in the west wing, the RN prepared the resident’s medications but did not administer the buspirone because it was not available, and stated she would call the pharmacy after finishing medication administration for the wing. The RN also stated it was the responsibility of licensed nurses to make sure routine medications were available to administer to residents. The resident involved had diagnoses including dementia, depression, and anxiety, and the order summary showed buspirone 7.5 mg by mouth twice daily for feeling nervous and restless. Interviews with an LVN, the DON, and the ADM confirmed that licensed nurses were responsible for ensuring medications were available and that the facility practice was to reorder medications before they ran out. Facility policies on reordering medications, routine deliveries, and pharmacy medication management were reviewed during the investigation.
Lack of RD Oversight and Food Service Competency
Penalty
Summary
The facility failed to ensure the Dietary Manager received frequently scheduled consultation from the Registered Dietitian. The report states the RD worked remotely for 8 hours per week, had only limited onsite visits, and did not have formal or documented frequent consultation with the DM. The RD also stated she did not have any formal or documentation to show frequently scheduled consultation to the DM. The facility policy required that if the RD was not employed full-time, the designated director of food and nutrition services would receive frequently scheduled consultation from a RD. During meal service observations, surveyors identified multiple food service problems. On 3/3/26, Resident 15’s lunch ticket called for a renal, consistent carbohydrate diet with regular texture and thin liquids, and the ticket listed pot roast, white rice, and mixed vegetables. The tray observed for the resident instead contained pot roast, mashed potatoes, and mixed vegetables. A Food Service Worker and the DM both confirmed the tray was incorrect and needed rice instead of mashed potatoes. On 3/5/26, surveyors observed a puree and regular lunch test tray with the DM present. The puree asparagus contained multiple strings and thin pieces, and the DM acknowledged the strings should not have been there. The Food Service Worker stated she cooked frozen asparagus, then added broth to thin it, and said she often had trouble with strands in the puree asparagus. The DM stated she would expect staff to test for IDDSI consistency. The facility’s IDDSI Level 4 guidance required foods to be smooth, lump-free, and to meet spoon and fork tests, and the recipe for puree asparagus required blending until smooth and confirming texture with the Fork Drip Test and Spoon Tilt Test. The report also documented food preparation and staff competency concerns. On 3/4/26, a Food Service Worker prepared chicken enchiladas by placing 60 enchiladas in hotel pans, pouring enchilada sauce over them, and adding cheese by handfuls while stating she guessed the quantity of cheese to use. The recipe required specific sauce preparation and measured amounts of cheese. The worker’s personnel file showed no documentation of job competency. The DSD stated dietary training and competency records were not available, and the DM stated she had only done a couple of in-services since starting and was trying to locate prior documentation. The report also noted bland asparagus served on the lunch meal, with the DM acknowledging the food lacked flavor and the Food Service Worker stating she eyeballed seasoning amounts and was unsure of the quantities used.
Incorrect Therapeutic Diet Tray Served
Penalty
Summary
The facility failed to ensure menus were followed for a resident on a renal, consistent carbohydrate diet during the lunch meal service. During observation of the meal cart, Resident 15’s lunch meal ticket showed a renal, consistent carbohydrate diet with regular texture and thin liquids, and the ticket specified three ounces of pot roast, 1/2 cup white rice, and 1/2 cup mixed vegetables. However, the tray observed for Resident 15 contained a scoop plate with three ounces of pot roast, 1/2 cup mashed potatoes, and 1/2 cup mixed vegetables instead of the ordered rice. During concurrent interview, Food Service Worker 1 confirmed the tray had the incorrect food item and stated it needed rice, not mashed potatoes. The Dietary Manager also confirmed the tray was incorrect and needed rice instead of mashed potatoes. Facility policy titled Food and Nutrition Services Menus and Therapeutic Diets stated the facility will follow menus.
Failure to Provide Adequate Supervision and Safe Repositioning During Pericare
Penalty
Summary
Facility nursing staff failed to provide adequate supervision and utilize proper turning techniques during pericare for a fully dependent, bedridden resident with severe cognitive impairment and multiple comorbidities, including Parkinson's disease, hypothyroidism, hyperlipidemia, depression, dysphagia, coronary artery disease, and a pacemaker. The resident required total assistance for all activities of daily living, including toileting and repositioning, and was assessed as dependent, meaning all effort for these activities was to be provided by staff. Despite this, a certified nursing assistant (CNA) attempted to change the resident's brief without using a draw sheet or proper positioning technique, and did not request assistance from another staff member, even though staffing levels were sufficient to allow for a second helper. During the incident, the CNA turned the resident on her side, allowing her feet to dangle off the bed, and then turned away to dispose of a soiled brief. At this point, the resident fell from the bed to the floor, sustaining a scalp laceration, traumatic brain injury with intracranial hemorrhage, left rib fracture, left pneumothorax, and a manubrial fracture, requiring urgent transfer to an acute care hospital and admission to the ICU. The CNA did not pull the resident close or use a draw sheet as required by facility competency and training, and instead relied on verbal instructions to the resident, who was unable to assist or follow commands due to her cognitive and physical limitations. Interviews and record reviews confirmed that the CNA did not follow established protocols for safe repositioning, and that the resident's care plan and assessments clearly indicated the need for full assistance. The facility's own policies and competency checklists required the use of draw sheets or proper manual techniques for moving dependent residents, and staff were trained to seek assistance when needed. The failure to implement these interventions and provide adequate supervision directly resulted in the resident's avoidable fall and serious injuries.
Failure to Provide Written Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notification of the bed hold policy to two residents or their representatives upon transfer to the hospital, as required by their policy. The policy, revised in November 2018, mandates that residents or their representatives receive written information about the duration of the state bed-hold policy before or upon transfer for hospitalization or therapeutic leave. However, for two residents, identified as R47 and R62, there was no evidence in the electronic medical records (EMR) that such information was provided during their transfers to the hospital. Resident R47 was transferred to the hospital on two occasions, and in both instances, the EMR lacked documentation of the bed hold policy being provided. Similarly, for Resident R62, the EMR did not show evidence of the bed hold policy being communicated upon their transfer to the hospital. An interview with the Business Office Manager revealed that the facility typically handled bed hold consents over the phone and did not document or confirm the provision of written bed hold information upon transfer, which was confirmed for Resident R62.
Failure to Notify Ombudsman of Resident Transfers
Penalty
Summary
The facility failed to provide timely notification to the ombudsman for three residents who were transferred to the hospital. The facility's policy requires notifications to the Office of the State LTC Ombudsman to occur before or as close as possible to the actual time of a facility-initiated transfer or discharge. However, the facility did not adhere to this policy for three residents, identified as R41, R47, and R62, who were transferred to the hospital on various dates. The lack of notification placed the residents and their representatives at risk of having incomplete information and misunderstanding the reason for transfer or discharge, as well as the discharge appeal process. During an interview, the Social Services (SS) staff confirmed that the facility failed to provide the written notice of transfer or discharge to the ombudsman for the three residents after their hospital transfers. The SS staff had been sending notifications to a fax number they believed belonged to the local ombudsman, but the ombudsman confirmed they had not received any transfer notifications. The SS staff acknowledged that they thought the ombudsman was receiving the notifications through fax but confirmed they never received any confirmation forms.
Failure to Update Care Plan for Weight Refusal
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as R41, to include refusals for weekly weights. R41 was admitted with medical diagnoses including Hydronephrosis with Renal and Ureteral Calculous Obstruction, Dysphagia, Anemia, and Muscle Weakness. The resident's quarterly Minimum Data Set (MDS) indicated a Brief Interview for Mental Status (BIMS) score of 12 out of 15, showing cognitive alertness. Despite being at risk for altered nutrition/hydration status and weight fluctuations, the care plan, last revised on 08/01/24, did not document any refusals of weekly weights by the resident. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) revealed that the LVN was responsible for updating the care plan with all dietician recommendations, including weekly weights. The LVN acknowledged that R41 sometimes refused weights, but only one refusal was documented from May 2024 through July 2024. The DON stated that if a resident refuses interventions and is still at risk for weight loss, staff should inform the Registered Dietician and Physician to discuss the risks and benefits with the resident. However, this process was not reflected in R41's care plan, leading to the deficiency.
Failure to Provide Range of Motion Care for Resident
Penalty
Summary
The facility failed to provide appropriate range of motion (ROM) care and treatment for a resident, identified as R25, who was part of a sample of 30 residents. R25 was admitted with diagnoses including Parkinson's, weakness, and contracture of muscle, among others. The care plan for R25 included a specific intervention to prevent further contractures of her right hand, which involved placing a rolled washcloth in her hand five times a week. However, observations revealed that this intervention was not consistently implemented, as R25's right hand was observed tightly closed in a fist without the washcloth in place. Interviews with facility staff, including a CNA and the Infection Preventionist, revealed that the responsibility for restorative aide care had transitioned to CNAs after the facility no longer maintained a dedicated restorative aide department. The CNA acknowledged awareness of the intervention but admitted to not placing the towel in R25's hand as per the care plan. The CNA documented the resident's refusal in the electronic medical record (EMR) but failed to notify the charge nurse, which was against facility policy. Further interviews with the Administrator and the Director of Nursing (DON) highlighted the importance of notifying nursing staff of any care refusals to ensure proper monitoring and adherence to care plans. The DON confirmed that CNAs are required to document refusals in the EMR and inform nursing staff, who would then document the refusal and reassess the care plan if necessary. The failure to follow these procedures contributed to the deficiency in providing the necessary ROM care for R25.
Failure to Monitor Resident's Weight After Significant Loss
Penalty
Summary
The facility failed to ensure that a resident, identified as R41, had weekly weights obtained after experiencing significant weight loss. R41 was admitted with medical diagnoses including hydronephrosis with renal and ureteral calculous obstruction, dysphagia, anemia, and muscle weakness. A review of R41's medical records indicated a significant weight loss over a month, with a decrease from 148 lbs to 136 lbs, and further to 131 lbs by the end of May. The Registered Dietician recommended health shakes, multivitamins, and weekly weight monitoring. However, there were no recorded weights for June or July, and only one documented instance of R41 refusing to be weighed. Interviews with facility staff revealed that the Licensed Vocational Nurse (LVN) responsible for R41's care did not ensure the resident was placed on weekly weights, despite the recommendation. The Director of Nursing confirmed that LVN 2 was responsible for initiating weekly weights and implementing other nutrition interventions. The failure to monitor R41's weight as recommended had the potential for the resident to lose a significant amount of weight without appropriate interventions, which could have adverse health effects.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to ensure staff followed enhanced barrier precautions and standard nursing precautions while providing wound care to a resident, identified as R19. The resident had a history of type 2 diabetes, contracture of muscle, venous insufficiency, and anemia, and was on Enhanced Barrier Precautions (EBP) as per physician's orders. During an observation, a Licensed Vocational Nurse (LVN) was seen providing wound care without wearing the required yellow gown and using a clean barrier for wound care supplies. The supplies were placed directly on the resident's breakfast tray, which was not a clean surface, and the HELIX stick used for measuring wounds was placed on an uncleaned surface before use. Interviews with the Infection Preventionist, CNA, LVN, and the Director of Nursing confirmed the breach in infection control protocols. The Infection Preventionist stated that a clean barrier should always be used, and staff must wear masks, gloves, and gowns for residents on EBP. The CNA and LVN admitted to not wearing the yellow gown and not using a clean barrier. The Director of Nursing expressed that nursing competencies are reviewed annually and expected all staff to follow standard precautions to prevent infection control breaches.
Failure to Treat Residents with Respect and Dignity
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity, as evidenced by the actions of Certified Nursing Assistant (CNA) 1 towards four residents. Resident 1 reported that CNA 1 was rude, called her 'girlie,' and dismissed her request to go to bed after dinner by stating she had to care for other people. Resident 2 reported that CNA 1 made a comment about needing to hurry to care for 'premium people,' implying that other residents who paid more were prioritized. Resident 3, who has contractures, stated that CNA 1 did not know how to position her properly and suggested that her daughter should change her instead. Resident 5 also reported being disrespected by CNA 1, who called her 'girl' instead of using her name or addressing her respectfully as 'ma'am.' All four residents felt disrespected by these interactions. The grievances were documented and reviewed by the Social Services (SS) and the Administrator (ADM). The facility's policy on resident rights, which emphasizes treating residents with respect and dignity, was reviewed during the investigation. The Minimum Data Set (MDS) assessments for Residents 1, 2, 3, and 5 indicated that they were cognitively intact, with Brief Interview for Mental Status (BIMS) scores of 15 out of 15. Despite this, the residents experienced disrespectful treatment from CNA 1, which was corroborated by their consistent accounts during interviews and observations. The facility acknowledged the issue and stated that CNA 1 had been re-educated on customer service.
Delay in Splint Placement for Fractured Finger
Penalty
Summary
The facility failed to meet professional standards of quality for Resident 4, who had a fractured left fifth finger on 5/19/24. Despite the fracture being identified and an X-ray confirming the injury, a splint was not placed until 5/20/24. The delay occurred because the Licensed Vocational Nurse (LVN) did not have experience applying a splint and did not question the Nurse Practitioner's (NP) order to continue monitoring the resident without immediate splint placement. This inaction placed Resident 4 at risk for further damage to the fractured finger. Resident 4, who has severe cognitive impairment and diagnoses including muscle wasting, muscle weakness, and seizures, was found with a swollen and discolored left fifth finger during routine nail care. The facility's Director of Nurses (DON) confirmed that it is a professional standard of practice to place a splint when a fracture is identified to immobilize and prevent further injury. The facility's policy also mandates consulting with the resident's physician for significant changes in health status, which was not adequately followed in this case.
Failure to Implement Resident-Centered Comprehensive Care Plan
Penalty
Summary
The facility failed to implement a resident-centered comprehensive care plan for Resident 1, who had a known history of physical aggression and severe cognitive impairment. On 4/23/24, Resident 1, who was diagnosed with Alzheimer's, major depression, and anxiety, was left unsupervised, resulting in an altercation where Resident 1 punched Resident 2. The incident occurred while the assigned Certified Nursing Assistant (CNA) was busy performing care for another resident, and the altercation could have been avoided if Resident 1 had been supervised as per his care plan. The care plan specifically required visual supervision at all times, especially when Resident 1 was in his wheelchair to prevent such incidents. During interviews, both the CNA and the Licensed Vocational Nurse (LVN) acknowledged that Resident 1 required constant supervision to ensure safety, but they also noted the difficulty in providing one-on-one observation due to the need to care for other residents. The Director of Nursing (DON) confirmed that the care plan interventions, which included maintaining visual supervision and keeping Resident 1's path clear, were not implemented. The facility's policy on comprehensive care plans emphasized the need for measurable objectives and timeframes to meet residents' needs, but these were not adhered to in this case, leading to the altercation between the two residents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 172 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Newman
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Main West Postacute Care | 14.7 mi | ★★★★★ | 1 | 0 |
| North Starr Postacute Care | 15.5 mi | ★★★★★ | 14 | 0 |
| Brandel Manor | 16.3 mi | — | 0 | 0 |
| Grace Home Inc. | 16.3 mi | ★★★★★ | 3 | 0 |
| Covenant Village Care Center | 16.4 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for San Luis Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.