Health inspection·May 6, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **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 behavior of physical aggression was left unsupervised on 4/23/24. This failure resulted in Resident 1 punching Resident 2. 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), major depression and anxiety. During a concurrent observation and interview on 5/6/24 at 10:00 a.m. with Resident 1, in Resident 1's room, Resident 1 was lying on his bed. Resident 1 did not recall the altercation on 4/23/24. 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 2/9/24, it indicated Resident 1's Brief Interview for Mental Status (BIMS -assessment of memory and judgment) assessment score was 0 (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 severe cognitive impairment. During a telephone interview on 5/6/24 at 11:31 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 had a history of aggression and required supervision while he was in his wheelchair. CNA 1 stated she was busy performing another residents care when Resident 1 and Resident 2's altercation took place. CNA 1 stated the altercation could have been avoided if Resident 1 was supervised per his care plan. During a review of Resident 1's Progress Notes (PN), dated 4/23/24 was reviewed. The PN indicated, . The writer was coming out of the bathroom when .nurse reported that the resident had a resident-to-resident altercation with resident [Resident 2] . The writer immediately went to assess the residents [Resident 2] . stated that [Resident 1] . was trying to pass by him and [Resident 1] . became upset and started punching him on the back and . [Resident 2] retaliated and started punching him back on the arms . (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 05/06/2024 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)