Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at San Luis Post Acute Center during CMS and state inspections, most recent first.
A resident with multiple pre-existing lower extremity wounds, including a necrotic foot wound, refused to wear protective foam boots as ordered. The facility did not develop a care plan with alternative interventions to address the resident's non-compliance or ensure wound protection. This omission led to the development of maggots in the resident's foot wound, which required hospital transfer for further evaluation and treatment.
A resident, a retired physician, was observed with an inhaler medication without a physician's order or a care plan for self-administration. The facility's IDT did not conduct an assessment or develop a care plan, contrary to the facility's policy requiring a prescriber's order and IDT assessment for bedside medication storage. The DON confirmed the policy was not followed.
The facility failed to adhere to food storage standards, with a nourishment refrigerator exceeding the recommended temperature and a boxed food item in the freezer past its expiration date. The refrigerator contained items like yogurt and milk at 46°F, above the 41°F standard. The Dietary Manager confirmed the expired Canadian bacon in the freezer, which should have been discarded according to the facility's policy.
A facility failed to ensure proper hand hygiene during resident care, as observed when an LN did not change soiled gloves or perform hand hygiene after cleaning a resident. The LN acknowledged the oversight, which contradicts the facility's hand hygiene policy requiring hand hygiene before moving from a soiled to a clean body site.
The facility failed to maintain the walk-in freezer in a safe condition, with excessive ice buildup observed on various surfaces. The Registered Dietitian reported the issue to administration since last year, but the Maintenance Director was unaware of recent notifications. The facility's policy requires immediate reporting of major equipment problems, yet the persistent ice buildup was not addressed.
Failure to Develop Resident-Specific Care Plan for Wound Protection
Penalty
Summary
The facility failed to develop a resident-specific care plan with measurable interventions for a resident who was non-compliant with care and refused to wear protective foam boots intended to prevent further injury to his feet. The resident was admitted with multiple pre-existing wounds, including chronic wounds on both lower extremities and a necrotic area on the left dorsal foot. Despite documentation of the resident's refusal to wear the prescribed foam boots and the subsequent discontinuation of the order by the physician, there was no evidence that the facility created a care plan to address the refusal or to implement alternative protective measures for the resident's wounds. The care plan did not include interventions tailored to the resident's non-compliance or strategies to ensure wound protection after the boots were refused. As a result of these omissions, the resident's left foot wound developed maggots, which was discovered during routine wound care. The wound was found to have a significant area of dry necrosis with maggots present, necessitating transfer to the hospital for further evaluation and treatment. Staff interviews confirmed that the resident often left his room's sliding door open, potentially allowing flies access to the wound, especially as the wound dressing could become loose or dislodged. The lack of a comprehensive care plan addressing the resident's specific needs and non-compliance directly contributed to the adverse outcome.
Failure to Assess and Plan for Self-Administration of Medication
Penalty
Summary
The facility's interdisciplinary team (IDT) failed to conduct an assessment for self-administration of medications, obtain a doctor's order, and develop a care plan for a resident, identified as Resident 30. Resident 30, a retired physician, was observed holding an inhaler medication and stated she was aware of how to self-administer it. However, there were no physician orders for her to keep the inhaler at her bedside, and no documentation of an assessment for self-administration of medication was found in her records. Further investigation revealed that there was no care plan for Resident 30 regarding self-administration of bedside medication. Licensed nurses confirmed the absence of a care plan and interventions for this purpose. The facility's policy requires a written order from the prescriber and an assessment by the IDT for residents to self-administer medications at the bedside. The Director of Nursing confirmed that the facility's policy was not followed in this case.
Food Storage Deficiencies in Refrigeration and Freezer
Penalty
Summary
The facility failed to store food in accordance with professional standards for food service safety, as observed in two separate incidents. First, the nourishment refrigerator in Station 1 was found to have a temperature of 46 degrees Fahrenheit, which is above the recommended 41 degrees Fahrenheit. This refrigerator contained items such as sandwiches, yogurts, and milk, with the yogurt and milk specifically noted to be at 46 degrees Fahrenheit and 46.2 degrees Fahrenheit, respectively. The Social Services Director confirmed these temperatures during an observation and interview. The facility's policy and procedure for food storage, dated 2022, requires refrigerators to maintain food temperatures at or below 41 degrees Fahrenheit. In a second incident, a boxed food item stored in the kitchen freezer was found to have an expired date. The Dietary Manager, during an observation and interview, acknowledged that the boxed item, which contained Canadian bacon, was labeled with a 'freeze by' date that had passed. The facility's policy and procedure for food storage indicates that all foods should be consumed by their safe use dates or discarded, and specifically notes that bacon should be stored in the freezer for no more than one month. The Dietary Manager removed the expired item from the freezer to discard it.
Failure to Follow Hand Hygiene Protocol During Resident Care
Penalty
Summary
The facility failed to ensure proper hand hygiene was followed by staff during direct resident care, which could potentially lead to the spread of infectious diseases. During an observation, a Licensed Nurse (LN) was seen performing a brief change for a resident without changing soiled gloves or performing hand hygiene after cleaning stool from the resident's buttocks. The LN acknowledged the failure to change gloves during an interview. The facility's policy on hand hygiene, dated 2001, indicates that hand hygiene should be performed before moving from a soiled body site to a clean body site on the same resident.
Failure to Maintain Walk-In Freezer in Safe Condition
Penalty
Summary
The facility failed to maintain the walk-in freezer in a safe operating condition, as evidenced by excessive ice buildup observed during a kitchen tour. The ice accumulation was noted on various surfaces, including the freezer pipes, plastic air curtains, and shelves under the fans. Additionally, ice buildup was present around the door and gasket, as well as on the outside bottom of the freezer door. This condition was identified during an initial kitchen tour and was corroborated by the Registered Dietitian (RD) who conducted monthly sanitation audits and reported the issue to the administration since the previous year. The Maintenance Director (MDIR) was unaware of recent notifications regarding the ice buildup and stated that the last preventative maintenance was conducted in February 2025, at which time no ice buildup was observed. However, the RD's Comprehensive Safety and Sanitation Audits from September 2024 to February 2025 consistently indicated ongoing ice buildup issues. The facility's policy on preventative maintenance requires that all major equipment problems be reported immediately, yet the persistent ice buildup in the freezer was not addressed, leading to potential risks in food preservation.
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Illustrative
What surveyors actually found near you
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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.
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Nursing homes near San Luis Obispo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mission View Health Center | 0.1 mi | ★★★★★ | 6 | 0 |
| San Luis Transitional Care | 0.8 mi | ★★★★★ | 0 | 0 |
| Arroyo Grande Care Center | 11 mi | ★★★★★ | 0 | 0 |
| Bayside Care Center | 12.2 mi | ★★★★★ | 4 | 0 |
| Coastal Oaks Special Care Center | 13.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.