Health inspection·May 29, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure residents were treated with respect and dignity for four of six sampled residents (Resident 1, 2, 3 and 5) when Certified Nursing Assistant (CNA) 1 disrespectfully responded to Resident 1, 2, 3 and 5. This failure resulted in Resident 1, 2, 3 and 5 feeling disrespected. Findings: During a concurrent interview and record review on 5/24/24 at 2:48 p.m. with the Social Services (SS), Resident 1's Grievance Form (GF) dated 4/11/24 was reviewed. The GF indicated, .[Resident 1] complain that CNA [1] is rude, calls me girlie and not with respect. Resident request to go to bed right after dinner and CNA stated I have to care for other people you are not the only one . The SS stated CNA 1 was re-educated on customer service. During a concurrent interview and record review on 5/24/24 at 2:50 p.m. with the SS, Resident 2's Grievance Form (GF) dated 5/15/24 was reviewed. The GF indicated, .[Resident reported that CNA [1] made a comment during care that she needed to hurry to care for the premium people . The SS stated she interviews the resident when a grievance is filed and that the Director of Staff Development (DSD) follows up with the grievance. During a concurrent observation and interview on 5/24/24 at 3:19 p.m. with Resident 2, in Resident 2's room, Resident 2 was lying in bed. Resident 2 stated CNA 1 was in a rush when she needed assistance and responded to her request for assistance by stating that she had to care for the premium people . Resident 2 asked CNA 1 what she meant and CNA 1 responded that she was refereeing to the residents that paid more than her. Resident 2 stated she felt lousy and disrespected from CNA 1's comment. During a review of Resident 2's Minimum Data Set (MDS- a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment dated [DATE], the MDS indicated Resident 2's Brief Interview for Mental Status (BIMS - screening tool used to assess resident cognitive level) assessment score was 15 out of 15 (0-7 indicated severe cognitive impairment - [memory loss, poor decision making-skills] 8-12 moderate cognitive impairment, 13-15 cognitively intact). During a concurrent observation and interview on 5/24/24 at 3:39 p.m. with Resident 3, in Resident 3's room, Resident 3 was lying in bed. Resident 3 stated she has contracture (tightening of the muscles) to her left side of the body and that CNA 1 did not know how to position her causing her discomfort. Resident 3 stated when she informed CNA 1 regarding her discomfort CNA 1 responded by telling (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 4 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 05/29/2024 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)