F 0600
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment,
and neglect by anybody.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Resident 2 had severe cognitive impairment (trouble
remembering, learning new things, concentrating, or making decisions) and she did not like it when her
breast was touched.
Findings:
During a review of Resident 1's admission Record (document containing resident demographic information
and medical diagnosis) undated, the admission record indicated Resident 1 was admitted to the facility on
[DATE]. Resident 1's diagnosis included Alzheimer ' s (affects memory, thinking and behavior)
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 11/16/23, it indicated Resident 1's Brief
Interview for Mental Status (BIMS -assessment of memory and judgment) assessment score was 10 (a
score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, 00-07 indicates severe
impairment, 99 severely impaired ). The BIMS assessment indicated Resident 1 had moderate cognitive
impairment.
During a concurrent observation and interview on 1/17/24 at 1:20 p.m. with Resident 2, in Resident 2 ' s
room, Resident 2 was lying in bed. Resident 2 stated she did not know the resident that touched her on her
breast and stated, I didn ' t like it one bit I am a girl.
During a review of Resident 2's admission Record undated, the admission record indicated, Resident 2 was
admitted to the facility on [DATE]. Resident 2's diagnoses included Parkinsonism (disorder affecting the
nervous system) and major depressive disorder (feeling of sadness and loss of interest).
During a review of Resident 2's MDS Assessment dated 12/27/23, indicated Resident 2's BIMS
(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 8
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
01/30/2024
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 0600
assessment score was 99. The BIMS assessment indicated Resident 2 had severe cognitive impairment.
Level of Harm - Actual harm
During an interview on 1/17/24 at 1:32 p.m. with Resident 4, Resident 4 stated she had witnessed Resident
1 act inappropriately with his genitals (sexual reproductive organs located outside the body) in front of
residents in the past. Resident 4 stated she had also seen Resident 1 touch another resident ' s breast
couple months ago.
Residents Affected - Few
During a review of Resident 4's MDS assessment dated [DATE], indicated Resident 4's BIMS assessment
score was 15. The BIMS assessment indicated Resident 4 was cognitively intact.
During an interview on 1/17/24 at 1:51 p.m. with Activities Director (AD), AD stated there was care planned
intervention developed on 6/2023 due to Residents 1 ' s inappropriate behavior with females. The plan was
to supervise Resident 1 when he left his room and that she told the activities staff to ensure Resident 1 was
not left alone in the dining room. AD stated Resident 1 could propel himself in his wheelchair but staff would
bring him to the dining room at times and that no one should bring him to the dining unless staff were
present.
During an interview on 1/17/24 at 1:58 p.m. with Activities/Certified Nursing Assistant (ACNA), ACNA stated
on 12/30/23 at 9:30 a.m. she was offering coffee to residents in their rooms and was going to have coffee in
the dining room at 10 a.m. ACNA stated Resident 1 has had past inappropriate behaviors with her such as
asking her to go to bed with him. ACNA stated on 12/30/23, Resident 2 ' s husband informed her that
Resident 1 touched his wife ' s breast. ACNA stated she was not in the dining room at the time the incident
on 12/20/23 , and that Resident 1 should not have been left unattended in the dining room due to his
inappropriate behaviors with females. ACNA stated she had witnessed Resident 1 touch another resident '
s breast couple months ago in the dining room prior to the incident on 12/30/23.
During an interview on 1/17/24 at 2:04 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated, on
12/30/23 Resident 3 informed him that Resident 1 touched Resident 2 ' s breast while Resident 2 was
sitting with her husband. CNA 1 stated he was aware of Resident 1 ' s inappropriate sexual behaviors and
that Resident 1 had touched his butt in the past. CNA 1 stated Resident 1 should be monitored when in the
dining room because Resident 1 had inappropriate sexual behaviors and does not control his impulses.
CNA 1 stated prior to the incident on 12/30/23 he knew the care planned intervention to not allow Resident
1 in the dining room unsupervised.
During an interview on 1/17/24 at 2:23 p.m. with Resident 5, Resident 5 stated Resident 2 was a pervert
[sexual behaviors that are considered particularly abnormal] and that he would make sexual comments or
expose his genitals.
During a review of Resident 5's MDS assessment dated [DATE], indicated Resident 5's BIMS assessment
scored was 13. The BIMS assessment indicated Resident 5 was cognitively intact.
During a concurrent interview and record review on 1/17/24 at 2:41 p.m. with Licensed Vocational Nurse
(LVN) 1, Resident 2 ' s Progress Notes (PN), dated 12/30/23 was reviewed. The PN indicated, .moved Male
Resident back to [room number] because he touched this resident's left breast . The husband reported to
the CNA while visibly upset that the Male Resident touched the left breast of this resident, his wife. Upon
seeing the incident, the Husband told the Male Resident to ' Stop, that is my wife ' . The Male Resident then
answered back to the husband, ' I do what I f----[profanity] please and it is not your business. ' . [Resident 2]
stated that ' that person touched me ' , while touching
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055839
If continuation sheet
Page 2 of 8
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
01/30/2024
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 0600
Level of Harm - Actual harm
her left breast . This CN [charge nurse] spoke with [Resident 2] and asked her what had happened. She
stated that ' that person touched me ' , while touching her left breast . LVN 1 stated Resident 1 has a history
of making sexual comments and that it was common for Resident 1 to make comments such as nice [butt]
and nice body.
Residents Affected - Few
During an interview on 1/17/24 at 2:49 p.m. with Resident 3, Resident 3 stated he was in the dining room
on 12/30/23 when Resident 1 touched resident 2 ' s breast in front of Resident 2 ' s husband. Resident 3
stated, it was not right I did not like seeing that at all and that Resident 1 is always doing something
perverted. Resident 3 stated as soon as Resident 1 is left unattended he will act up and do something
inappropriate such as exposing his genitals or touching females.
During a review of Resident 3's MDS Assessment, dated 12/9/23, the MDS assessment indicated,
Resident 3 ' s BIMS assessment scored was 15. The BIMS assessment indicated Resident 3 was
cognitively intact.
During an interview on 1/17/24 at 2:57 p.m. with Social Services (SS), SS stated she followed up with
Resident 2 on 1/2/24. SS stated Resident 2 was confused and did not remember the inappropriate touching
that occurred on 12/30/23.
During a concurrent interview and record review on 1/17/24 at 3:28 p.m. with Licensed Vocational Nurse
Unit Manager (LVNUM), Resident 1 ' s PN dated 5/18/23 was reviewed. The PN indicated, . Activities
notified nurse resident asking another resident to show him her breasts in the dining area. Resident was
then taken back to his room . Resident 1 ' s Psychiatric Assessment (PA) dated 6/20/23 was reviewed. The
PA indicated, .Staff reported . had inappropriate sexual behavior towards the female, but no grabbing or
touching . The PN dated 7/20/23 was reviewed, the PN indicated, .[Resident 1] was trying to grab RSA
[recreational assistant]breast and he also was trying to touch the bottom of a resident ' s family member .
LVNUM stated Resident 1 had a care plan intervention to only sit with male residents and not to be left
alone with female peers. LVNUM stated Resident 1 had known inappropriate sexual behaviors.
During a concurrent interview and record review on 1/17/24 at 3:41 p.m. with AD, Resident 1 ' s Care Plan
(CP) dated 6/5/23 was reviewed. The CP indicated, .During group programs [Resident 1] is encouraged to
sit with only males residents .[Resident 1] is not left alone with female peers when group programs are over
encouraging [Resident 1] to move to small dining room to watch his favorite tv programs westerns . AD
stated when Resident 1 had inappropriate behavior, the plan was to put him at a table by himself in the
dining room because he was inappropriate with females. AD stated she would ensure that staff were
present when she would conduct activity in the dining room and not leave Resident 1 alone.
During an interview on 1/30/24 at 9:40 a.m. with CNA 2, CNA 2 stated Resident 1 was able to propel
himself with the wheelchair around the facility. CNA 2 stated Resident 1 had inappropriate behavior and
would touch female staff. CNA 2 stated on 12/30/23 she saw Resident 1 in the dining room and without staff
in the dining room. CNA 2 stated the inappropriate touch could have been avoided if there was staff present
in the dining room. CNA 2 stated she should have ensured staff were present in the dining room but didn ' t.
During a telephone interview on 1/30/24 at 10a.m. with Family (FM), FM stated he was seated in the dining
room on 12/30/23 with his wife. FM stated there was no staff present, a resident went to his wife and
touched her breast. FM stated, he told the resident, get your hands off my wife. FM stated
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055839
If continuation sheet
Page 3 of 8
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
01/30/2024
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 0600
Resident 1 responded by telling FM that Resident 1 can do as he [explicit language] pleased. FM stated
that he did not want anyone to touch his wife inappropriately.
Level of Harm - Actual harm
Residents Affected - Few
During a concurrent interview and record review on 1/30/24 at 12:30 p.m. with Administrator (ADM), the
facility policy and procedure (P&P) titled Comprehensive Care Plans dated 11/2017 was reviewed. The
policy indicated, .The facility Interdisciplinary Team (IDT) will develop and implement a comprehensive,
person-centered care plan for each resident that includes measurable objectives and timeframes to meet a
resident ' s medical, nursing, physical, mental, and psychosocial needs .Interventions identified by the
comprehensive care plan will be provided by qualified, competent persons .Resident care needs and care
plan interventions will be communicated to direct care staff . ADM stated staff should follow the care plan
and should have not left Resident 1 alone in the dining room. ADM stated she would not want this to
happen to her herself or her family member. ADM stated care planned interventions should be implemented
and Resident 1 should have been supervised because of his inappropriate behaviors with females.
During a review of the facility P&P titled Freedom From Abuse, Neglect and Exploitation, dated 11/2017 ,
the P&P indicated, The facility will provide a safe resident environment and protect residents from abuse
.Definition of Sexual Abuse: Non-consensual sexual contact of any type with a resident .Cognitive
impairment or mental disorder does not preclude a resident from being abusive .Facility will assess the
resident and care plan intervention to address resident behaviors that may indicate for abusive .sexual
.Resident outcomes that will be considered in instances of sexual abuse may include, but not limited to
.depression .anxiety .fear of being alone .fear of the dark .nightmares .disturbed sleep .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055839
If continuation sheet
Page 4 of 8
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
01/30/2024
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 0656
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Resident 2 had severe cognitive impairment (trouble
remembering, learning new things, concentrating, or making decisions) and she did not like it when her
breast was touched.
Findings:
During a review of Resident 1's admission Record (document containing resident demographic information
and medical diagnosis) undated, the admission record indicated Resident 1 was admitted to the facility on
[DATE]. Resident 1's diagnosis included Alzheimer ' s (affects memory, thinking and behavior)
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 11/16/23, it indicated Resident 1's Brief
Interview for Mental Status (BIMS -assessment of memory and judgment) assessment score was 10 (a
score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, 00-07 indicates severe
impairment, 99 severely impaired ). The BIMS assessment indicated Resident 1 had moderate cognitive
impairment.
During a concurrent observation and interview on 1/17/24 at 1:20 p.m. with Resident 2, in Resident 2 ' s
room, Resident 2 was lying in bed. Resident 2 stated she did not know the resident that touched her on her
breast and stated, I didn ' t like it one bit I am a girl.
During a review of Resident 2's admission Record undated, the admission record indicated, Resident 2 was
admitted to the facility on [DATE]. Resident 2's diagnoses included Parkinsonism (disorder affecting the
nervous system) and major depressive disorder (feeling of sadness and loss of interest).
During a review of Resident 2's MDS Assessment dated 12/27/23, indicated Resident 2's BIMS
assessment score was 99. The BIMS assessment indicated Resident 2 had severe cognitive impairment.
During an interview on 1/17/24 at 1:32 p.m. with Resident 4, Resident 4 stated she had witnessed Resident
1 act inappropriately with his genitals (sexual reproductive organs located outside the body) in front of
residents in the past. Resident 4 stated she had also seen Resident 1 touch another resident ' s breast
couple months ago.
During a review of Resident 4's MDS assessment dated [DATE], indicated Resident 4's BIMS assessment
score was 15. The BIMS assessment indicated Resident 4 was cognitively intact.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055839
If continuation sheet
Page 5 of 8
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
01/30/2024
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 0656
Level of Harm - Actual harm
Residents Affected - Few
During an interview on 1/17/24 at 1:51 p.m. with Activities Director (AD), AD stated there was care planned
intervention developed on 6/2023 due to Residents 1 ' s inappropriate behavior with females. The plan was
to supervise Resident 1 when he left his room and that she told the activities staff to ensure Resident 1 was
not left alone in the dining room. AD stated Resident 1 could propel himself in his wheelchair but staff would
bring him to the dining room at times and that no one should bring him to the dining unless staff were
present.
During an interview on 1/17/24 at 1:58 p.m. with Activities/Certified Nursing Assistant (ACNA), ACNA stated
on 12/30/23 at 9:30 a.m. she was offering coffee to residents in their rooms and was going to have coffee in
the dining room at 10 a.m. ACNA stated Resident 1 has had past inappropriate behaviors with her such as
asking her to go to bed with him. ACNA stated on 12/30/23, Resident 2 ' s husband informed her that
Resident 1 touched his wife ' s breast. ACNA stated she was not in the dining room at the time the incident
on 12/20/23 , and that Resident 1 should not have been left unattended in the dining room due to his
inappropriate behaviors with females. ACNA stated she had witnessed Resident 1 touch another resident '
s breast couple months ago in the dining room prior to the incident on 12/30/23.
During an interview on 1/17/24 at 2:04 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated, on
12/30/23 Resident 3 informed him that Resident 1 touched Resident 2 ' s breast while Resident 2 was
sitting with her husband. CNA 1 stated he was aware of Resident 1 ' s inappropriate sexual behaviors and
that Resident 1 had touched his butt in the past. CNA 1 stated Resident 1 should be monitored when in the
dining room because Resident 1 had inappropriate sexual behaviors and does not control his impulses.
CNA 1 stated prior to the incident on 12/30/23 he knew the care planned intervention to not allow Resident
1 in the dining room unsupervised.
During an interview on 1/17/24 at 2:23 p.m. with Resident 5, Resident 5 stated Resident 2 was a pervert
[sexual behaviors that are considered particularly abnormal] and that he would make sexual comments or
expose his genitals.
During a review of Resident 5's MDS assessment dated [DATE], indicated Resident 5's BIMS assessment
scored was 13. The BIMS assessment indicated Resident 5 was cognitively intact.
During a concurrent interview and record review on 1/17/24 at 2:41 p.m. with Licensed Vocational Nurse
(LVN) 1, Resident 2 ' s Progress Notes (PN), dated 12/30/23 was reviewed. The PN indicated, .moved Male
Resident back to [room number] because he touched this resident's left breast . The husband reported to
the CNA while visibly upset that the Male Resident touched the left breast of this resident, his wife. Upon
seeing the incident, the Husband told the Male Resident to ' Stop, that is my wife ' . The Male Resident then
answered back to the husband, ' I do what I f----[profanity] please and it is not your business. ' . [Resident 2]
stated that ' that person touched me ' , while touching her left breast . This CN [charge nurse] spoke with
[Resident 2] and asked her what had happened. She stated that ' that person touched me ' , while touching
her left breast . LVN 1 stated Resident 1 has a history of making sexual comments and that it was common
for Resident 1 to make comments such as nice [butt] and nice body.
During an interview on 1/17/24 at 2:49 p.m. with Resident 3, Resident 3 stated he was in the dining room
on 12/30/23 when Resident 1 touched resident 2 ' s breast in front of Resident 2 ' s husband. Resident 3
stated, it was not right I did not like seeing that at all and that Resident 1 is always doing something
perverted. Resident 3 stated as soon as Resident 1 is left unattended he will act up and do something
inappropriate such as exposing his genitals or touching females.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055839
If continuation sheet
Page 6 of 8
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
01/30/2024
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 0656
Level of Harm - Actual harm
Residents Affected - Few
During a review of Resident 3's MDS Assessment, dated 12/9/23, the MDS assessment indicated,
Resident 3 ' s BIMS assessment scored was 15. The BIMS assessment indicated Resident 3 was
cognitively intact.
During an interview on 1/17/24 at 2:57 p.m. with Social Services (SS), SS stated she followed up with
Resident 2 on 1/2/24. SS stated Resident 2 was confused and did not remember the inappropriate touching
that occurred on 12/30/23.
During a concurrent interview and record review on 1/17/24 at 3:28 p.m. with Licensed Vocational Nurse
Unit Manager (LVNUM), Resident 1 ' s PN dated 5/18/23 was reviewed. The PN indicated, . Activities
notified nurse resident asking another resident to show him her breasts in the dining area. Resident was
then taken back to his room . Resident 1 ' s Psychiatric Assessment (PA) dated 6/20/23 was reviewed. The
PA indicated, .Staff reported . had inappropriate sexual behavior towards the female, but no grabbing or
touching . The PN dated 7/20/23 was reviewed, the PN indicated, .[Resident 1] was trying to grab RSA
[recreational assistant]breast and he also was trying to touch the bottom of a resident ' s family member .
LVNUM stated Resident 1 had a care plan intervention to only sit with male residents and not to be left
alone with female peers. LVNUM stated Resident 1 had known inappropriate sexual behaviors.
During a concurrent interview and record review on 1/17/24 at 3:41 p.m. with AD, Resident 1 ' s Care Plan
(CP) dated 6/5/23 was reviewed. The CP indicated, .During group programs [Resident 1] is encouraged to
sit with only males residents .[Resident 1] is not left alone with female peers when group programs are over
encouraging [Resident 1] to move to small dining room to watch his favorite tv programs westerns . AD
stated when Resident 1 had inappropriate behavior, the plan was to put him at a table by himself in the
dining room because he was inappropriate with females. AD stated she would ensure that staff were
present when she would conduct activity in the dining room and not leave Resident 1 alone.
During an interview on 1/30/24 at 9:40 a.m. with CNA 2, CNA 2 stated Resident 1 was able to propel
himself with the wheelchair around the facility. CNA 2 stated Resident 1 had inappropriate behavior and
would touch female staff. CNA 2 stated on 12/30/23 she saw Resident 1 in the dining room and without staff
in the dining room. CNA 2 stated the inappropriate touch could have been avoided if there was staff present
in the dining room. CNA 2 stated she should have ensured staff were present in the dining room but didn ' t.
During a telephone interview on 1/30/24 at 10a.m. with Family (FM), FM stated he was seated in the dining
room on 12/30/23 with his wife. FM stated there was no staff present, a resident went to his wife and
touched her breast. FM stated, he told the resident, get your hands off my wife. FM stated Resident 1
responded by telling FM that Resident 1 can do as he [explicit language] pleased. FM stated that he did not
want anyone to touch his wife inappropriately.
During a concurrent interview and record review on 1/30/24 at 12:30 p.m. with Administrator (ADM), the
facility policy and procedure (P&P) titled Comprehensive Care Plans dated 11/2017 was reviewed. The
policy indicated, .The facility Interdisciplinary Team (IDT) will develop and implement a comprehensive,
person-centered care plan for each resident that includes measurable objectives and timeframes to meet a
resident ' s medical, nursing, physical, mental, and psychosocial needs .Interventions identified by the
comprehensive care plan will be provided by qualified, competent persons .Resident care needs and care
plan interventions will be communicated to direct care staff . ADM stated staff should follow the care plan
and should have not left Resident 1 alone in the dining room. ADM
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055839
If continuation sheet
Page 7 of 8
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
01/30/2024
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 0656
Level of Harm - Actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
stated she would not want this to happen to her herself or her family member. ADM stated care planned
interventions should be implemented and Resident 1 should have been supervised because of his
inappropriate behaviors with females.
During a review of the facility P&P titled Freedom From Abuse, Neglect and Exploitation, dated 11/2017 ,
the P&P indicated, The facility will provide a safe resident environment and protect residents from abuse
.Definition of Sexual Abuse: Non-consensual sexual contact of any type with a resident .Cognitive
impairment or mental disorder does not preclude a resident from being abusive .Facility will assess the
resident and care plan intervention to address resident behaviors that may indicate for abusive .sexual
.Resident outcomes that will be considered in instances of sexual abuse may include, but not limited to
.depression .anxiety .fear of being alone .fear of the dark .nightmares .disturbed sleep .
Event ID:
Facility ID:
055839
If continuation sheet
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