Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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.
The facility failed to update its facility-wide assessment, omitting current resident diagnoses such as schizophrenia and MRSA, and lacking details on staff competencies and training programs. Specific care needs, like two-person lifts and specialized diets, were also not included. The NHA acknowledged these deficiencies and the need for an updated assessment.
The facility failed to ensure that three CNAs received required annual training in dementia management and abuse prevention. Two CNAs did not receive dementia management training, one did not receive abuse training, and one did not complete the required 12 hours of annual training. This was confirmed through record reviews and interviews with the DON and SDC, who could not provide documentation of the training.
A facility failed to inform a resident with memory impairments of changes in their Medicare-covered services in a timely manner. The facility did not obtain a signature from the resident's authorized representative on liability notices and failed to provide written notification of Medicare Non-Coverage letters to the resident's representative. The social services director admitted to not documenting the notification process adequately, which led to the deficiency.
A resident with Alzheimer's, depression, and mobility issues did not have a comprehensive activity care plan developed to address their recreational needs. Despite participating in group activities, the Activities Director did not create a specific care plan, as they believed it was unnecessary unless residents isolated themselves. The Nursing Home Administrator acknowledged that all residents should have an activities care plan, highlighting a lapse in policy adherence.
The facility failed to provide effective pain management for two residents, as non-pharmacological interventions were inconsistently offered and pain locations were not always documented when administering medications. One resident, with multiple diagnoses including lupus and hemiplegia, reported constant pain but did not consistently receive non-pharmacological interventions. Another resident, with kidney cancer and end-stage renal disease, experienced pain in her fingers but lacked consistent non-pharmacological pain management strategies. Staff interviews revealed a lack of awareness regarding these inconsistencies.
A facility failed to provide dialysis care consistent with professional standards for a resident with end-stage renal disease. The resident's fistula care was not managed according to the physician's order, which included applying antibiotics and a band-aid. The LPN did not follow the order, believing a scab was sufficient, and failed to notify the physician. The DON was unaware of the oversight, and care plans lacked interventions for fistula site monitoring.
Facility Assessment Deficiency
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during day-to-day operations. The assessment, last updated on February 27, 2023, did not include current diagnoses of residents such as intermittent explosive disorder, schizophrenia, anxiety, seizures, and MRSA. Additionally, it lacked information on staff competencies and training programs required to meet the care needs of the resident population. Specific resident care needs, such as those requiring a two-person lift, respiratory care, insulin administration, and specialized diets, were also omitted from the assessment. During staff interviews, the Nursing Home Administrator (NHA) acknowledged the deficiencies in the facility assessment, admitting unawareness of its outdated status. The NHA confirmed that the assessment did not reflect the current diagnoses of residents or the specific training and competencies needed by staff to provide adequate care. The NHA recognized the importance of a complete assessment to ensure the facility's ability to meet the residents' needs and indicated that the interdisciplinary team would review and update the assessment accordingly.
Deficiency in CNA Training for Dementia and Abuse Prevention
Penalty
Summary
The facility failed to provide required in-service training for certified nurse aides (CNAs) in areas critical to resident care, specifically dementia management and abuse prevention. Three out of five CNAs reviewed did not receive the mandated annual training. CNA #3 and CNA #5 did not receive annual dementia management training, while CNA #1 did not receive annual abuse training. Additionally, CNA #5 did not complete the required 12 hours of annual training. These deficiencies were confirmed through record reviews and interviews with the Director of Nursing (DON) and the Staff Development Coordinator (SDC), who acknowledged the lack of documentation for the required training sessions for these CNAs over the past 12 months.
Failure to Timely Notify Resident's Representative of Medicare Coverage Changes
Penalty
Summary
The facility failed to inform a resident with memory impairments of changes in their Medicare-covered services in a timely manner. Specifically, the facility did not obtain a signature from the resident's authorized representative on liability notices and failed to provide written notification of Medicare Non-Coverage letters to the resident's representative when Medicare-covered services ended. The facility's policy requires that the Notice of Medicare Non-Coverage (NOMNC) be given to all Medicare beneficiaries at least two days before the end of a Medicare-covered Part A stay or when all of Part B therapies are ending. However, the NOMNC notice was signed by the resident's representative on the same day the resident's Medicare Part A benefits ended, which was not in compliance with the policy. The social services director (SSD) acknowledged that she and the minimum data set coordinator (MDSC) were responsible for notifying the resident or resident's representative when Medicare benefits were ending. The SSD admitted to not documenting when she contacted the family to schedule meetings, the outcome of the meetings, or if the NOMNC and SNF ABN were provided and signed by the resident or resident's representative. The SSD also stated that she needed to improve documentation of the NOMNC process to ensure clarity that the resident or resident's representative was notified, options were explained, and the outcome was determined. The SSD was familiar with the resident's Medicare Part A services and had the resident sign the NOMNC and ABN, but did not document when the representative was notified or if the forms were provided to the representative.
Failure to Develop Comprehensive Activity Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as Resident #18, to address their recreational needs and goals. The resident, who is over 65 years old, was admitted with diagnoses including Alzheimer's disease, depression, anxiety, and difficulty in walking. The resident was cognitively impaired with a BIMS score of five out of 15 and was dependent on showering while using a walker. A review of the resident's initial baseline care plan from December 2023 and the comprehensive care plan revised in March 2024 revealed that an activity focus area was not included, and there were no person-centered activity preferences and interventions documented. Interviews with facility staff highlighted the oversight in care planning. The Activities Director, responsible for creating recreation care plans, admitted to not creating an activity-specific care plan for the resident because the resident participated in group activities and interacted with others. The Activities Director had only implemented two activity care plans since starting in January 2024. The Nursing Home Administrator confirmed that all residents should have an activities care plan, indicating a lapse in adherence to facility policy and procedure regarding comprehensive care planning.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to provide effective pain management for two residents, as observed through a lack of consistent non-pharmacological interventions and inadequate documentation of pain location when administering medications. Resident #3, a 75-year-old with multiple diagnoses including systemic lupus erythematosus and hemiplegia, reported constant pain rated as an 8 out of 10. Despite having a care plan that included non-pharmacological interventions such as repositioning and use of pillows, these were not consistently offered, as evidenced by the electronic medical record (EMR) review. Additionally, the location of her pain was not consistently identified when administering acetaminophen. Resident #25, a 79-year-old with conditions including kidney cancer and end-stage renal disease, also experienced deficiencies in pain management. Although her care plan included pharmacological interventions, it lacked non-pharmacological strategies. She reported pain in her fingers and had a history of surgery related to her dialysis port, yet non-pharmacological interventions were not consistently offered prior to administering acetaminophen. The EMR review showed that the location of her pain was not always documented, and non-pharmacological interventions were not consistently attempted. Interviews with staff, including an LPN and the DON, revealed a lack of awareness regarding the inconsistency in offering non-pharmacological interventions. The LPN acknowledged the use of Tylenol and repositioning as pain relief methods but did not consistently document these interventions. The DON confirmed that pain assessments were conducted regularly but was unaware of the lapses in non-pharmacological intervention offerings for the residents. This lack of adherence to the facility's pain management policy contributed to the deficiency in providing comprehensive pain management for the residents.
Failure to Follow Dialysis Care Protocols
Penalty
Summary
The facility failed to provide dialysis care consistent with professional standards for a resident who required such services. The resident, a 79-year-old with diagnoses including malignant neoplasm of the left kidney, end-stage renal disease, and type II diabetes mellitus, was receiving dialysis while residing at the facility. The facility's policy required immediate monitoring and documentation of the resident's access site upon return from dialysis treatment. However, the facility did not follow the physician's order for the resident's fistula care, which included applying antibiotics and a band-aid until healed. The physician's orders did not specify which antibiotic to use, and the treatment was not completed on several occasions as documented in the medication administration record. Additionally, the facility failed to notify the physician when the fistula site healed, as required by the facility's policy. The licensed practical nurse (LPN) responsible for the resident's care did not follow the physician's order because she believed a scab was nature's version of a band-aid and did not notify the physician when she did not use the antibiotic cream and band-aid. The director of nursing (DON) was unaware that the physician was not notified when a scab appeared on the resident's fistula site. The facility's care plans for dialysis and chronic renal failure did not include interventions for the skin treatment and monitoring of the fistula site, contributing to the deficiency.
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 20 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — 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 Alamosa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Evergreen Nursing Home | 0.6 mi | — | 2 | 0 |
| Colorado Veterans Community Living Ctr At Homelake | 13.3 mi | — | 0 | 0 |
| Rock Creek Rehabilitation And Healthcare Center | 14.4 mi | — | 3 | 0 |
| Rio Grande Rehabilitation And Healthcare Center | 15.4 mi | — | 15 | 1 |
| River Valley Rehabilitation And Healthcare Center | 28.7 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.