Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 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.
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.
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 118 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 | — | 0 | 0 |
| Brandel Manor | 16.3 mi | — | 0 | 0 |
| Grace Home Inc. | 16.3 mi | — | 0 | 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 August 2026) and official state health department websites.