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 Page 1 of 4 055839 055839 05/29/2024 San Luis Care Center 709 N Street Newman, CA 95360

F 0550 Level of Harm - Minimal harm or potential for actual harm her to have her daughter change her. Resident 3 stated it was CNA 1's responsibility to care for her not her daughters. Resident 3 stated she felt angry from CNA 1's comment. During a review of Resident 3's Minimum Data Set and physical functional level assessment dated [DATE], the MDS indicated Resident 3's Brief Interview for Mental Status assessment score was 15 out of 15. Residents Affected - Some During a review of Resident 3's admission Record (document containing resident demographic information and medical diagnosis) undated, the admission record indicated Resident 3 was admitted to the facility on [DATE]. Resident 3's diagnosis included muscle weakness, contracture of left hand, contracture of muscle left upper arm, stiffness of left knee and muscle wasting. During a concurrent observation and interview on 5/24/24 at 3:48 p.m. with Resident 1, in Resident 1's room, Resident 1 was seated in her wheelchair. Resident 1 stated CNA 1 disrespected her by calling her Girlie while providing care. Resident 1 stated, I could be her grandmother, I am not a girl . During a review of Resident 1's Minimum Data Set and physical functional level assessment dated [DATE], the MDS indicated Resident 1's Brief Interview for Mental Status assessment score was 15 out of 15. During a concurrent telephone interview and record review on 5/28/24 at 11:37 a.m. with the Administrator (ADM), the facility policy titled RESIDENT RIGHTS Respect and Dignity dated 09/20/2022 was reviewed. The policy indicated, .The resident has a right to be treated with respect and dignity . The ADM stated that all residents should be treated with dignity and respect. During a concurrent observation and interview on 5/29/24 at 11:46 a.m. with Resident 5, in Resident 5's room, Resident 5 was lying in bed. Resident 5 stated CNA 1 disrespected her by calling her Girl while providing care. Resident 5 stated CNA 1 should call her by her name or mam and not talk down to her calling her girl. During a review of Resident 5's Minimum Data Set and physical functional level assessment dated [DATE], the MDS indicated Resident 5's Brief Interview for Mental Status assessment score was 15 out of 15. 055839 Page 2 of 4 055839 05/29/2024 San Luis Care Center 709 N Street Newman, CA 95360

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 four sampled residents (Resident 4), when Resident 4 had a fractured (break or crack) left fifth finger (pinky) on 5/19/24 and a splint (immobilizer) was not placed until 5/20/24. Residents Affected - Few This failure placed Resident 4 at risk for further damage to his fractured left fifth finger. Findings: During a concurrent interview and record review on 5/24/24 at 2:35 p.m. with Licensed Vocational Nurse (LVN) 2, Resident 4's Interdisciplinary Notes (IDT) dated 5/21/24 was reviewed. The IDT indicated, .On 5/19/2024, during routine nail care, the C N A [Certified Nursing Assistant] noted that resident's left 5th digit [finger] is swollen with blackish discoloration. Charge Nurse assessed the affected site right away . Notified MD and ordered X-ray [picture of bone] to be done on the left fingers. Result came with findings . Fracture .left fifth middle NP [Nurse Practitioner] on call was notified on 5/19/2024 and ordered to continue to monitor the resident and inform her of any increase in pain . Stated she will come in AM and assess the resident .5/20/2024 .NP .Ordered for resident to be sent out to acute for splint placement on the left 5th digit . LVN 2 stated she did not have experience applying a splint and that Resident 4 needed to be sent out to the hospital for splint placement. LVN 2 stated the purpose of the splint was to immobilize and prevent further injury. LVN 2 stated she didn't question the NP's order to continue to monitor Resident 4 and did not call the primary physician for second opinion. During a concurrent observation and interview on 5/24/24 at 3:44 p.m. with Resident 4 in the facility hallway, Resident 4 was seated in his wheelchair. Resident 4 was asked regarding how he sustained the left fifth digit fracture, Resident 4 shrugged his shoulders expressing he didn't know. During a review of Resident 4's Face Sheet (FS, a document with demographic, personal and medical information) undated, the FS indicated Resident 4 had diagnoses which included muscle wasting, muscle weakness and seizures (uncontrolled movement). During a review of Resident 4's Minimum Data Set (MDS - a resident assessment tool used to identify resident cognitive and physical function) assessment dated [DATE], the MDS indicated Resident 4's Brief Interview for Mental Status (BIMS -assessment of cognitive status for memory and judgment) assessment score was 0 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 4 had severe cognitive impairment. During a review of Resident 1's Radiology Results Report (RRR) dated 5/19/24 was reviewed. The RRR indicated, .Reason for Study .swelling .fracture .left fifth middle phalanx [finger] .recent trauma [injury] . During a review of Resident 4's Progress Note (PN) dated 5/20/24 was reviewed. The PN indicated, .Resident came back with splint of tongue depressor stick [wooden stick] to left pinky attached to 4th digit [ring finger] secured with . wrap . During an interview on 5/28/24 at 12:02 p.m. with the Director of Nurses (DON), the DON stated the 055839 Page 3 of 4 055839 05/29/2024 San Luis Care Center 709 N Street Newman, CA 95360

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few purpose of the splint was to immobilize and prevent further injury. The DON stated it was professional standard of practice to place a splint when a fracture was identified. During a review of the facility Policy and Procedure (P&P) titled RESIDENT RIGHTS Notification of Changes of Condition and Room Changes dated 7/2018 was reviewed. The P&P indicated, .The facility will keep the resident, and the resident representative (consistent with his or her authority) informed of significant changes in health status and accidents resulting in injury. The facility will consult with the resident's physician related to accidents resulting in injury and with significant changes in health status . During a review of Cleveland Clinic Professional Reference titled, Broken Finger dated 8/12/21, (found at https://my.clevelandclinic.org/health/diseases/21784-broken-finger ) indicated, . The splint keeps your finger straight and protects it while it heals. You'll usually keep the splint for three to four weeks as your fractured finger heals . 055839 Page 4 of 4