San Luis Care Center

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food and ice were stored, prepared, distributed, and served in accordance with professional standards for food service safety when:1. [NAME] substances were found inside the bin in one of one ice machines located in the facility's kitchen.2. Food Service Worker (FSW) 4 was observed utilizing the kitchen sanitation bucket to sanitize food carts that did not contain the recommended concentration levels of quaternary ammonium (a group of chemicals used for killing bacteria, fungi, and viruses) for sanitization (to reduce the number of disease-causing pathogens).3. Expired items were found in the residents' food refrigerator in the facility's break room and there was no thermometer in the residents' food in the freezer in the facility's break room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals (define) were locked and labeled in accordance with current accepted professional standards of practice and facility procedures for one of five sampled residents (Resident 48) and two of three medication carts when: 1. [NAME] wing medication cart contained Resident 48's inhaler medication (pressurized canister that delivers a precise, pre-measured puff of medication directly into the lungs) Budesonide-Formoterol Fumarate Aerosol (treatment for asthma and chronic obstructive pulmonary disease [COPD-chronic lung disease causing difficulty in breathing]) was found to not have an open date and beyond use date (BUD- the last date you can safely use a medication). [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure two Food Service Workers (FSW 2 and FSW 3) were competent to safely and effectively carry out the functions of food and nutrition services when:1. FSW 2 did not follow recipes during meal preparation of Turkey Sandwiches on 3/3/2026 and Chicken Enchiladas on 3/4/2026 and was not aware of what the use by date should be after mighty shakes (nutritional supplement) was thawed in the kitchen fridge on 3/1/26.2. FSW 3 was not aware of appropriate temperature for the dishwashing machine. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure food maintained its nutritional value when the cooked asparagus prepared for the lunch meal on 3/05/26 was not palatable and lacked flavor. This failure had the potential to result in residents having a decrease in oral intake which could lead to weight loss. The facility census was 66.

Inspectors wroteBased on observation, interviews and review of facility documents, the facility failed to ensure the puree vegetables were in proper form when there were stringy pieces of asparagus throughout the food mixture on the lunch meal test tray on Thursday, March 5, 2026. Failure to properly process the puree food can result in choking for the five residents (Residents 6, 22, 50, 55, 69) on a puree diet at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain infection prevention and control program for a safe, sanitary, and comfortable environment for three of 12 sampled residents (Residents' 46, 47, and 79) when:1. Handheld nebulizer (HHN) masks (a medical device accessory that covers the nose and mouth, allowing patients to inhale aerosolized medication directly into the lungs) for Resident 46 and Resident 47 were not labeled with the date it was first used and was observed placed directly on top of each resident's bedside table. These failures had the potential for Resident 46 and Resident 47 to be exposed to cross contamination (unintentional transfer of harmful germs or allergens from one surface or object to another) when the nebulizer masks were used by the residents.2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure essential equipment was maintained in safe operating condition when: one of two kitchen ovens were not working and unable to be used. This failure to have an operational oven could result in the food taking longer to cook resulting in delayed meal times, inconsistent food quality, and inefficient workflows. The facility census was 66.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a comfortable environment for four of 31 sampled residents (Residents 14, 41, 51, and 80), when vertical blinds had missing slats, horizontal blinds were broken, and resident room walls had scratches and missing paint. These failures created an environment that was not homelike and had the potential to decrease the residents mood and potentially lead to depression.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with dignity and respect in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for one of three sampled residents (Resident 79), when Resident 79's urinary catheter (tube inserted into the bladder through the urethra [urine tube], to drain urine freely into a connected bag) bag was not placed in a dignity bag (a bag the catheter drainage bag is placed into, to cover the resident's urine from view). This failure resulted in Resident 79's urinary catheter bag to be uncovered in full view for others to see and having the potential for Resident 79 to feel his privacy and dignity were not respected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a physician informed consent (the process in which residents are given information of the possible risk and benefits of psychoactive medications (change brain function, altering perception, mood, consciousness, and behavior) for the use of psychotropic medications (medication capable of affecting mind, emotions and behavior) was obtained for one of six sampled residents (Resident 32), when Resident 32 was administered lorazepam (medication used to treat anxiety (excessive, persistent fear or worry that interferes with daily life)) on 3/1/26 and 3/2/26 and informed consent was not obtained prior to medication administration. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a new Preadmission screening and Resident Review (PASARR- a federal requirement to ensure resident with mental disorder or intellectual disorder or intellectual disabilities are not inappropriately placed in a nursing home) level 1 screening for one of six sampled residents (Resident 6) when Resident 6's PASARR level 1 dated 9/9/24 completed prior to admission to the facility did not include diagnosis of psychosis (a severe mental condition in which thought, emotions are so affected that contact is lost with reality) and depression (a serious, persistent mood disorder) and use of psychotropic medication (drugs that affect the mind, emotions, and behavior). This failure had the potential for Resident 6 to not receive the appropriate services related to her diagnoses and medication used.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comprehensive, person-centered care plan (a plan that provides direction for individualized care of the resident) was developed and implemented to meet the identified needs for one of eight sampled residents (Resident 41), when Resident 41 did not have a care plan for their arm sling (a supportive device-usually a fabric pouch with a strap-used to hold an injured arm, wrist, or shoulder still against the body). This failure placed Resident 41 at risk for delayed healing by not identifying and monitoring for compliance with the arm sling.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care and services in accordance with professional standards of quality of care for three out of six sampled residents (Residents' 11, 48, and 65) when:1. Licensed Vocational Nurse (LVN) 3 signed the electronic Medication Administration Record (eMAR- legal record of drug administration to a patient at a facility by a health care professional) prior to administering Resident 11 and Resident 65's received their medications. These failures resulted in inaccurate charting and placed Resident 11 and Resident 65 at risk to not receive the medications ordered.2. Registered Nurse (RN) 1 did not shake the inhaler (handheld, pressurized device that delivers a specific, measured dose of medication) before he gave it to Resident 48 to self administer. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services which ensured the administration of medications to meet residents needs were met for one of 10 sampled residents (Resident 31), when Resident 31's buspirone (medication used to treat anxiety (feeling of fear, dread, and uneasiness, often accompanied by physical symptoms)) medication was not available during medication pass on 3/5/26. This failure had the potential for Resident 31's anxiety behavior to increase which could result in serious medical conditions such as worsening of anxiety, panic episodes, insomnia, irritability, dizziness, headache, and nausea.

Inspectors wroteBased on observation, interviews and review of facility documents, the facility failed to ensure the Dietary Manager (DM) received frequently scheduled consultation from the Registered Dietitian (RD). Failure to have the RD provide frequent oversight and consultation with the DM of food and nutrition services can result in a lack of the RD identifying system issues regarding menus and recipes not being followed, food not in the proper form, and lack of competent staff and ensuring development of a prompt action plan to resolve the issues for the health and safety of the 66 residents admitted to the facility. Cross Reference F802, F803, F804, F805.

Inspectors wroteBased on observation, interviews, and review of facility documents, the facility failed to ensure menus were followed for a renal diet for one sampled resident (Resident 15) during the lunch meal service on Tuesday, March 3, 2026. This failure had the potential to result in the resident exceeding the micronutrients in the physician's prescribed therapeutic diet order which may compromise the nutritional and medical status of the resident. During an observation of the lunch meal service on 3/3/26 at 12:01 p.m., in the meal cart, a concurrent review of Resident 15's lunch meal ticket showed a renal, consistent carbohydrate diet, regular texture and thin liquids with a scoop plate as the adaptive equipment. During a further review of Resident 15's meal ticket at the same time, indicated three ounces of pot roast, 1/2 cup white rice, 1/2 cup mixed vegetables. [...]

Inspectors wroteBased on interviews and record review, the facility nursing staff failed to use the proper turning technique and ensure one of three sampled residents (Resident 1), received adequate supervision and assistance during pericare (cleaning a patient's genital and anal areas) to prevent falls when Resident 1 who was deemed fully dependent for toileting hygiene, experienced a fall on 9/7/25. The certified nursing assistant did not ensure implementation of effective intervention as the use of a draw sheet (sheet placed underneath a patient to assist with repositioning and transferring in a healthcare setting) or proper technique and positioning without draw sheet for Resident 1 in accordance with facility competency, training consistent with Resident 1's care's need. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide two of three residents (Resident (R)47 and R62) or their responsible party, reviewed for hospital transfers out of a total sample of 36 residents a written bed hold when R47 and R62 was transferred to the hospital. This failure had the potential to cause confusion or distress regarding return to the same room after hospitalization.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide three of three residents (Resident (R)41, R47 and R62) reviewed for hospital transfers out of a total sample of 36 residents' notification to the ombudsman when R41, R47 and R62 transferred to the hospital. This failure placed the resident and their representative at risk of having incomplete information, misunderstanding the reason of transfer/discharge, and the discharge appeal process.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise the care plan to include refusals for weekly weights for one resident (Resident (R)41) out of a sample of 36 residents. Refer to F692.

Inspectors wroteBased on interviews, observations, and a review of the facility policies, the facility failed to ensure one resident (Resident (R)25) in a total sample of 30, received a range of motion care and treatment. Specifically, the facility failed to provide restorative aide care per R25's care planned intervention to prevent further contractures of her right hand.

Inspectors wroteBased on interview, medical record review, and policy review, the facility failed to ensure one of five residents (Resident (R) 41) reviewed for nutrition had weekly weights obtained after a significant weight loss. This failure had the potential for residents to lose a significant amount of weight without interventions which could have adverse health effects.

Inspectors wroteBased on record review, observation, interview, and review of the facility policies., the facility failed to ensure staff followed enhanced barrier precautions and standard nursing precautions while providing wound care for one of one resident (Resident (R)19) out of a sample size of 30. Specifically, facility staff failed to follow personal protective equipment (PPE) guidelines properly and did not use a clean barrier surface for wound care supplies when providing bilateral wound care to R19. This facility failure had the potential to cause further infection to the resident's wounds.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were treated with respect and dignity for four of six sampled residents (Resident 1, 2, 3 and 5) when Certified Nursing Assistant (CNA) 1 disrespectfully responded to Resident 1, 2, 3 and 5. This failure resulted in Resident 1, 2, 3 and 5 feeling disrespected.

Inspectors wroteBased on observation, interview and record review, the facility failed to meet professional standards of quality, for one of four sampled residents (Resident 4), when Resident 4 had a fractured (break or crack) left fifth finger (pinky) on 5/19/24 and a splint (immobilizer) was not placed until 5/20/24. This failure placed Resident 4 at risk for further damage to his fractured left fifth finger.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a resident-centered comprehensive care plan for one of three sampled residents (Resident 1), when Resident 1 with known behavior of physical aggression was left unsupervised on 4/23/24. This failure resulted in Resident 1 punching Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safety and protection for one of three sampled residents (Resident 2) was free from abuse and neglect when Resident 1 had a known history of sexual behaviors that was care planned and interventions were not implemented for Resident 1. On 12/30/23, Certified Nursing Assistant (CNA) 2 noticed Resident 1 in the dining room unsupervised, CNA 2 neglected to implement care planned intervention leaving Resident 1 unattended. Resident 1 touched Resident 2 ' s breast in front of her husband during a visit. This failure resulted in the lack of supervision of Resident 1 in the dining room with a female resident present and resulted in the violation of Resident 2 ' s dignity, which could have resulted in humiliation, and psychosocial harm for a reasonable person. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a resident-centered comprehensive care plan for one of three sampled residents (Resident 1) when Resident 1 with known inappropriate sexual behaviors was left unattended on 12/30/23 in the dining room. On 12/30/23, Certified Nursing Assistant (CNA) 2 noticed Resident 1 in the dining room unsupervised, CNA 2 did not implement care planned intervention to not leave Resident 1 alone with female peers. CNA 2 left Resident 1 unattended, Resident 1 touched Resident 2 ' s breast. This failure resulted in the lack of supervision of Resident 1 in the dining room with a female resident present and resulted in the violation of Resident 2 ' s dignity, which could have resulted in humiliation, and psychosocial harm for a reasonable person. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to meet professional standards of quality, for one of three sampled residents (Resident 1) when Resident 1 did not have duloxetine (medication for depression) available for three days and licensed nurses did not follow up with pharmacy to check the order status. This failure placed Resident 1 at risk to experience anxiety, irritability, difficulty in sleeping, and possibly nightmares.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure grooming needs were met for one of three sampled residents (Resident 1) when Certified Nursing Assistants (CNAs) and Licensed Nurses (LNs) failed to provide Resident 1 with fingernail care to keep nails groomed as indicated in the facility's policy titled, Quality of Life Activities of Daily Living. This failure resulted in Resident 1's care needs unmet and placed Resident 1 at risk for developing injury and/or infections.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a fall risk care plan for one of three sampled residents (Resident 352) when: Resident 352's fall risk was determined to be high risk for falls on 4/5/19 and care plan interventions were not developed to keep her safe, free from falls and fall related injuries. This failure resulted in Resident 352's fall, a laceration to the bridge of her nose, a hematoma [a solid swelling of clotted blood within the tissues], discoloration to the left side of her head, pain and a left hip fracture which required surgical repair for the hip fracture and a nine-day hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food in accordance with professional standards for food service safety when: 1. An undated opened whole milk 2 percent (% - a unit of measurement) gallon was placed in a plastic container containing ice and ready for use in the food preparation counter. 2. An undated with no use by date bag of hamburger patties were stored and ready for use in freezer 2 of the kitchen. 3. Two undated and open plastic bags of white bread, one bottle of ground spice pimiento, and one bottle of salt were stored and ready for use in the condiments shelves in the kitchen. These failures to ensure effective dietetic service operations placed residents that received meals from the kitchen at risk for food borne illness and the growth of microorganisms.

Inspectors wroteBased on interview and record review, the facility failed to have an effective Quality Assessment and Performance Improvement (QAPI- a program that enables the facility to evaluate and improve the quality of resident care and services through data collection, staff input, and other information) program when: 1. Four out of five staff which included: Licensed Vocational Nurse (LVN) 6, Certified Nursing Assistant (CNA) 5, CNA 6 and LVN 2 were unable to identify the purpose of the QAPI program or the current facility QAPI projects. These failures resulted in an ineffective QAPI program necessary to improve quality of care provided to residents and ensure adequate staff knowledge of the facility QAPI program and QAPI project improvements plans.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were treated with respect and dignity and in an environment that prootes and enhances the quality of life for two of three sampled residents (Resident 17 and Resident 15) when: 1. Certified Nursing Assistant (CNA) 1 stopped assisting Resident 17 during lunch and Resident 17 waited to be fed while watching other residents to be fed. This failure violated Resident 17's right to a dignified existence and had the potential to result in Resident 17 to experienced weight loss. 2. Resident 15's upper body parts and brief were exposed while resting in bed. This failure violated Resident 15 right to be treated with respect and dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodations for one of 51 sampled residents (Resident 353) when Resident 353's call light was not within reach and hung on the wall outlet. This failure had the potential to result in Resident 51's needs to go unmet.

Inspectors wroteBased on observation, interview, and record review the facility failed to protect the privacy of personal information for one of three sampled residents (Resident 51) when Licensed Vocational Nurse (LVN) 1 left the protected health information (PHI) exposed to public view. This failure resulted in the potential for unauthorized access to personal information and violated Resident 51's rights to confidentiality.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were administered in accordance with professional standard of practice for one of three sampled residents (Resident 39) when Licensed Vocational Nurse (LVN) 5 did not follow the facility's medication administration policy and procedures and administered an incorrect dosage of ascorbic acid (vitamin c) to Resident 39. This failure resulted in Resident 39 not receiving the appropriate dosage of ascorbic acid as prescribed by the Medical Director (MD).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 30 and Resident 51) received treatment and care in accordance with professional standards of practice, comprehensive person centered care and the residents' choices to enable residents to maintain their highest practicable level when: 1. For Resident 30, the facility failed to assess, document and inform the Medical Doctor (MD) when Resident 30's Carvedilol (tablet 3.125 mg [milligrams - unit of measurement] a medication to treat high blood pressure) medication was not given 13 times in January 2019, 14 times in February 2019, 16 times in March 2019, 11 times in April 2019 and seven times in May 2019 for low blood pressure. 2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 7 followed the facility policy and procedure titled, Medication Administration for two of two sampled residents (Residents 26 and 21) when LVN 7 administered physician ordered medications two hours before medications were due for administration for Resident 26 and Resident 21. These failures resulted in Resident 26 and Resident 21's sleep interruption and caused Resident 26 and Resident 21 to feel tired and frustrated.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their policy and procedure titled, Medication Storage Guidance when the medication refrigerator temperature which stored drugs and biologicals was not monitored and documented on 5/21/19 on the morning shift temperature log. This failure had the potential for drugs and biologicals stored inside the medication refrigerator to decreased its effectiveness.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were accurately documented in accordance with the facility policy and procedure and accepted professional standards of practice for one of one sampled residents (Resident 30) when Licensed Vocational Nurse (LVN) 4 did not document the accurate diagnosis for Resident 30's laboratory (lab) orders. This failure resulted in an inaccurate medical record for Resident 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain an effective infection control program for 1of 2 sampled residents (Resident 47) when Resident 47's urinal was unlabeled, undated, had yellow, sticky substance on the handle and hung on the side of the garbage can. These failures had the potential to place the Residents 47 at risk for cross contamination and exposure to infectious organisms.