San Luis Care Center

F-F692.

Findings include:

Review of Resident R41's Admission Record from the electronic medical record (EMR) Profile tab showed a facility admitted [DATE REDACTED] with medical diagnoses that included Hydronephrosis with Renal and Ureteral Calculous Obstruction, Dysphagia, Anemia and Muscle Weakness.

Review of Resident R41's quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/18/24, located in the resident's EMR under the MDS tab indicated the facility assessed Resident R41 to have a Brief

Interview for Mental Status (BIMS) score was 12 out of 15, indicating Resident R41 was cognitively alert.

Review of Resident R41's Care Plan, located in the resident's EMR section titled Care Plans, revealed the resident had a care plan with revision date of 08/01/24. The care plan identified the resident had focus for Resident R41 was at risk for altered nutrition/hydration status and/or weight fluctuations. Supplements: health shakes three times

a day and multivitamins with minerals. Review of care plan did not have any indication of Resident R41 refusing weekly weights.

Interview on 08/08/24 at 11:40 AM with Licensed Vocational Nurse (LVN) 2 revealed they have weekly meetings with the Registered Dietician to discuss any nutrition concerns. LVN2 stated Resident R41's last nutrition

review was 05/31/24 and RD recommended multi vitamins, health shake and continue weekly weights. LVN2 stated they are responsible for ensuring Resident R41's care plan was updated with all dietician recommendations. LVN2 stated Resident R41 sometimes refuses weights but confirmed there was only one note from May 2024 through July 2024 indicating Resident R41 refused to be weighed. LVN2 stated they were responsible for ensuring Resident R41's care plan was updated with interventions for refusing weekly weights.

Interview on 08/08/24 at 12:04 PM with Director of Nursing (DON), revealed LVN2 was responsible for initiating Resident R41's weekly weights and other nutrition interventions are implemented and entered on their comprehensive care plan. DON stated if a resident is refusing interventions and still triggering for weight loss then staff are to let the RD and Physician know so they can attempt to go over the risk verse benefits with resident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 10 055839 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055839 B. Wing 08/08/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

San Luis Care Center 709 N Street Newman, CA 95360

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 25490

Residents Affected - Few Based 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 Resident R25's care planned intervention to prevent further contractures of her right hand.

Findings included:

Review of the facility's policy titled, Restorative Nursing Program, undated revealed, .The Restorative Nursing Program (RNP) is designed to assist the facility team help residents to achieve and maintain their highest functional level . the RNP has two general purposes (a). the program may be used to help residents restore function . (b). to assist residents to maintain function or prevent, to the extent possible, or minimize functional declines .RNPs do not require a physician order .RNP activities may be provided by designated RNAs (Restorative Nursing Assistants, Certified Nursing Assistants (CNAs) .If the resident or representative refuses the RNP, the RNP Coordinator will document the education that was provided to include the risk and benefits .

Review of the Admission Record located in the Profile tab of the electronic medical record (EMR) revealed Resident R25 was admitted to the facility on [DATE REDACTED] and had diagnoses that included but were not limited to Parkinson's, weakness, contracture of muscle, left ankle, and foot, and cognitive communication deficit.

Review of Resident R25's Care Plan, located in the EMR under the Care Plan tab, initiated on 05/08/24, revealed, . Resident R25 has, an ADL [activities of daily living] self-care performance deficit r/t [related to] limited mobility, weakness, Parkinson's, cognitive impairment, autonomic neuropathy, left ankle contracture .Certified Nurse Aide (CNA): Splint/Brace Program: Gentle prolonged stretches with shoulders down, gentle prolonged stretches to fingers, all joints in preparation for washcloth placement to right hand to prevent further contracture of fingers 5 times a week for 12 weeks .

Review of the quarterly Minimum Data Set (MDS) located in the MDS tab of the EMR with an Assessment Reference Date (ARD) of 01/26/23 revealed a Brief Interview of Mental Status (BIMS) score of three out of a three which indicated she was severely impaired in cognition. Further review of the MDS revealed rhe resident was not coded for having a contracture or using a splint.

Review of an Occupational Therapy Note dated 05/03/24 provided by the facility revealed, .rolled washcloth, especially under the third finger .

Review of a CNA Task for Splint, dated from 07/08/24 until 08/06/24, located in the EMR under the Task tab revealed, Resident R25 had refused the placement of the rolled washcloth .

Review of a Progress Note dated for July and August 2024 located in the Progress Notes tab of the electronic medical records (EMR) revealed there were no nursing notes to indicate that Resident R25 had refused restorative aide care (RA).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 10 055839 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055839 B. Wing 08/08/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

San Luis Care Center 709 N Street Newman, CA 95360

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0688 During an observation on 08/05/24 at 12:07 PM, Resident R25 was observed in her room lying on a low bed, an

observation was made of Resident R25's right hand which was closed tightly in a fist. During the same observation, an Level of Harm - Minimal harm or interview was conducted. The surveyor asked Resident R25 to open her right hand. Resident R25 used her left hand and potential for actual harm fingers to attempt to open her right hand with great difficulty.

Residents Affected - Few During an observation on 08/06/24 at 9:11 AM, revealed Resident R25 resting peacefully in her room. Resident R25's right hand was closed tightly in a fist. No rolled towel was observed in Resident R25's hand.

During an interview on 08/06/24 at 10:31AM with the CNA1, revealed, she was familiar with Resident R25 and acknowledged the right-hand contracture. The surveyor asked CNA1 was there any intervention in place to prevent further damage to the resident's hand. CNA1 stated, Yes, to place a rolled towel in the right hand.

This surveyor informed CNA1 that several observations were made of Resident R25, and no gauze or towel was placed in the right hand. CNA1 stated she did not place the towel in the resident hand per care plan. This surveyor asked CNA1 what was facility policy when a resident refused care. CNA1 stated, to document on

the Task form located in the EMR and to notify the charge nurse. CNA1 did document in EMR, however, she did not inform the charge nurse that the towel was not placed.

During an interview on 08/06/24 at 11:00 AM with the facility Infection Preventionist (IP) revealed, Resident R25 is care planned for RA. The IP continued to share that the facility no longer has an RA department, so the responsibility has transitioned to the CNAs to complete. The IP further stated, if a resident refuses RA care

the CNA is to document in the EMR under the task tab along with informing the charge nurse. Once the charge nurse has been notified, the nurse will document in the EMR that the resident has refused care, and when the resident refuses care multiple times, the RA will be discontinued, or the resident will be reassessed by the therapy department. The IP informed this surveyor that CNA1 did not follow proper facility policies.

During an interview on 08/06/24 at 3:33 PM the Administrator revealed that the purpose of notifying the nursing staff of any care refusal is to ensure that nursing staff are aware of any care issues residents are not receiving along with monitoring CNAs are following through with their duties and responsibilities. The Administrator further stated that her expectation of all staff is that they follow facility policies and procedures when it comes to refusal of care.

During an interview on 08/08/24 at 11:39 AM, the Director of Nursing (DON) revealed nursing competencies are done annually and as needed. The DON stated for all refusals of care, CNAs are to document in the EMR along with informing the nursing staff of the refusal. Once the nursing staff is notified, the nurse will document in the EMR that a resident has refused care. The DON continued to share that the purpose of notifying nursing staff of refusals is to monitor and track care and to ensure that staff are performing their responsibilities and duties.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 10 055839 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055839 B. Wing 08/08/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

San Luis Care Center 709 N Street Newman, CA 95360

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38517 potential for actual harm Based on interview, medical record review, and policy review, the facility failed to ensure one of five Residents Affected - Few 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.

Findings include:

Review of Resident R41's Admission Record from the electronic medical record (EMR) Profile tab showed a facility admitted [DATE REDACTED] with medical diagnoses that included Hydronephrosis with Renal and Ureteral Calculous Obstruction, Dysphagia, Anemia and Muscle Weakness.

Review of the NSG Skin and Nutrition Review, located under the Evaluations tab of the EMR, dated 05/31/24stated the reason for the review was significant/grad weight loss/gain. Comments section stated Resident R41 weight history: 05/22/24: 136 lbs (-5#/-3.7% x 1 week, not sig), 5/10/24:145 lbs and 4/27/24: 148 lbs (-17#/-11.5% x 1 mon, sig) Significant weight loss noted in the past 1 month likely related to poor intake secondary to food consistency. PO intake is 25-100% with 1-2 meals refusal daily. Further weight loss is not encouraged due to advanced age. No edema noted at this time Recommend Health shake 120mL three times a day. Recommend Multivitamin with minerals and continue weekly weight monitoring.

Review of Resident R41's weights form the Vitals/Weights tab indicated:

05/10/24 145 lbs.

05/22/24 136 lbs.

05/31/24 131 pounds (lbs.)

No June or July 2024 weight

Revie of Resident R41's Nursing Progress Note, located under the progress notes tan, dated 07/29/24 documented, Resident R41 refused to be weighed this week for weekly review. The Medical Director notified of Resident R41's refusal with no new orders, continue to encourage residents to allow weight. Further review of Resident R41's EMR revealed there was no other documentation of Resident R41 refusing to be weighed.

Interview on 08/08/24 at 11:40 AM with Licensed Vocational Nurse (LVN) 2, LVN2 revealed they have weekly meeting with the Registered Dietician to discuss any nutrition concerns. LVN2 stated Resident R41's last nutrition review was 05/31/24 and RD recommended multi vitamins, health shake and continue weekly weights. LVN2 stated they are responsible for ensuring Resident R41 was put on weekly weights and LVN2 confirmed Resident R41 was not placed on weekly weights. LVN2 stated Resident R41 sometimes refuses weights but confirmed there was only one note from May 2024 through July 2024 indicating Resident R41 refused to be weighed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 10 055839 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055839 B. Wing 08/08/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

San Luis Care Center 709 N Street Newman, CA 95360

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Interview on 08/08/24 at 12:04 PM with Director of Nursing (DON), DON stated LVN 2 was responsible for initiating Resident R41's weekly weights and other nutrition interventions are implemented. DON stated if a resident is Level of Harm - Minimal harm or refusing interventions and still triggering for weight loss then staff are to let the RD and Physician know. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 10 055839 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055839 B. Wing 08/08/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

San Luis Care Center 709 N Street Newman, CA 95360

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 25490 potential for actual harm Based on record review, observation, interview, and review of the facility policies., the facility failed to ensure Residents Affected - Few 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 Resident R19. This facility failure had the potential to cause further infection to the resident's wounds.

Findings include:

Review of the facility's policy titled, Infection Control Enhanced Barrier Precautions, not dated, revealed, Enhanced Barrier Precautions (EBP) are an infection control intervention used to reduce transmission of multi drug-resistant organisms . EBP is an extension of standard precautions utilized for resident .

Review of the facility undated policy titled, Infection Prevention and Control Program, revealed, .facility staff will use standard precautions during resident care activities, .staff will use PPE as indicated by the identified precautions .

Review of Resident R19 Face Sheet located in the electronic medical record (EMR) under the Profile tab revealed, that Resident R19 was originally admitted to the facility on [DATE REDACTED] with the following diagnoses but not limited to, type 2 diabetes, contracture of muscle, venous insufficiency, and anemia.

Review of Resident R19's Physicians Order, located in the EMR under the Oorders tab, dated 08/06/24 revealed, .on Enhanced Barrier Precautions [EBP] .

Review of Resident R19's Physicians Order, located in the EMR under the Oorders tab revealed, Treatment of bilateral lower extremities: Cleanse with soap and water, apply non-adherent dressing and wrap with Kerlix .

Observation on 08/05/24 at 11:13 AM revealed Licensed Vocational Nurse (LVN)1 was already in the room providing wound care to Resident R19 with gloves, and a mask but no yellow gown per doctor orders and EPB sign located on the outside of Resident R19's room. LVN1 was observed spraying Resident R19's lower right and left legs with a cleaning solution and wiping with a white 2-inch by 2-inch gauze which was located on the resident's bedside table resting on Resident R19's breakfast tray. There was no clean barrier cloth on the resident tray to prevent cross-contamination. LVN1 then proceeded to call a Certified Nurse Aide (CNA) into the room to assist with holding the HELIX stick with a blue tip (a HELIX stick is used to measure wounds) to obtain photos of Resident R19 lower extremities wounds. CNA1 walked into the room with only a mask and gloves, CNA1 did not wear a yellow gown. Once CNA1 was at the bedside to assist LVN1. LVN1 retrieved the HELIX stick, which was resting on a black IPAD, the IPAD was resting on a dresser drawer located against the wall. LVN1 handed

the HELIX stick to CNA1. CNA1 placed the HELEX stick directly on Resident R19's leg and LVN1 preceded to take images. Observation of Resident R19's door revealed Everyone must: clean their hands before entering and leaving ., Providers and staff must also: Wear gloves and gown for the following high contact resident care .dressing, bathing, transferring, wound care .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 10 055839 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055839 B. Wing 08/08/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

San Luis Care Center 709 N Street Newman, CA 95360

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an interview on 08/06/24 at 11:03 AM the Infection Preventionist (IP) revealed, that when providing wound care or any care and supplies are used a clean barrier (drop cloth) is placed on the bedside table or Level of Harm - Minimal harm or at the foot of the resident's bed. At no time are supplies to be placed on the resident's food tray or any potential for actual harm uncleaned surfaces. The IP further stated that for any residents on e EBP precautions, staff must wear their masks, gloves, and yellow gowns. Residents Affected - Few

During an interview on 08/06/24 at 10:41 AM, CNA1 recalled assisting LVN1 with Resident R19's wound care. The CNA1 was asked to share the proper procedures for providing care for a resident on EBP. CNA1 stated, You wear a mask, gloves, and a yellow gown. T. CNA1 stated, No we [she and LVN1] were not [wearing yellow gowns]. The CNA1 was asked did she recall where the supplies were placed. CNA1 stated, On the bedside table. The CNA1 was asked did she recall the supplies being placed on a clean surface barrier. CNA1 stated, No they were not.

During an interview on 08/06/24 at 12:07 PM, LVN1 revealed, that when providing wound care all supplies should be placed on a clean barrier. LVN1 acknowledged he did not place Resident R19's supplies on a clean barrier nor did he wear a yellow gown while performing care. LVN1 continued to share that by not wearing his yellow gown and placing Resident R19's supplies on a clean barrier he did not follow proper infection control policies and procedures.

During an interview on 08/06/24 at 3:38 PM, the Administrator revealed she expects all nursing staff providing care should follow standard precautions of care to prevent any infection control breaks.

During an interview on 08/08/24 at 11:39 AM, the Director of Nursing (DON) revealed nursing competencies are done annually and as needed, this surveyor informed the DON of the infection-control break which was observed. The DON stated, That is nursing 101 and I expect all staff to follow proper standard precautions of care at all times.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 10 055839