Health inspection·December 19, 2023

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Residents Affected - Few This failure placed Resident 1 at risk to experience anxiety, irritability, difficulty in sleeping, and possibly nightmares. Findings: During on observation on [DATE] at 5:33 p.m. in Resident 1 ' s room, Resident 1 was seated in her wheelchair. Resident 1 stated she has not received duloxetine for three days because the facility ran out of her medication. Resident 1 stated the medication was working well and since she stopped taking the medication, she experienced nightmares. During a review of Resident 1's Face Sheet (FS, a document with demographic, personal and medical information) undated, the FS indicated Resident 1 had diagnoses which included anxiety and major depression. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], the MDS indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 15 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment). The BIMS assessment indicated Resident 1 was cognitively intact. During a review of Resident 1's Physician Order(PO) dated [DATE], the PO indicated, . 20 MG [milligram-unit of measure] (Duloxetine) Give 2 capsule by mouth two times a day for irritability, general discontent . During a concurrent interview and record review on [DATE] at 6:08 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1 ' s Medication Administration Record (MAR) dated 12/2023 was reviewed. The MAR indicated, duloxetine was unavailable from [DATE] - [DATE]. LVN 1 stated there was no documentation in Resident 1 ' s clinical record to indicate that pharmacy was contacted to ensure the medication order went through. LVN 1 stated if pharmacy was notified, they would have received the medication the same day. LVN 1 stated the Licensed Nurse (LN) should have ensured the medication was ordered timely to prevent the medication from running out. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055839 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055839 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/19/2023 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)