Health inspection·January 30, 2024

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 Page 1 of 8 055839 055839 01/30/2024 San Luis Care Center 709 N Street Newman, CA 95360

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 055839 Page 2 of 8 055839 01/30/2024 San Luis Care Center 709 N Street Newman, CA 95360

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 055839 Page 3 of 8 055839 01/30/2024 San Luis Care Center 709 N Street Newman, CA 95360

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 . 055839 Page 4 of 8 055839 01/30/2024 San Luis Care Center 709 N Street Newman, CA 95360

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. 055839 Page 5 of 8 055839 01/30/2024 San Luis Care Center 709 N Street Newman, CA 95360

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. 055839 Page 6 of 8 055839 01/30/2024 San Luis Care Center 709 N Street Newman, CA 95360

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 055839 Page 7 of 8 055839 01/30/2024 San Luis Care Center 709 N Street Newman, CA 95360

F 0656 Level of Harm - Actual harm Residents Affected - Few 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 . 055839 Page 8 of 8