Health inspection·September 12, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few muscles leading to restricted movement in a joint] to right hand, and to [Bilateral (both) lower extremity] .Facility responsible for the 24-hour custodial care [assistance with daily activities like bathing, dressing, and eating, provided to individuals who cannot perform these tasks themselves] for the patient and will notify [company name] Hospice of changes in patient condition. During a review of the facility's document titled, COMPETENCY CHECK-MOVING A RESIDENT IN BED, dated January 2025, the document indicated, . Performance Criteria . MOVING RESIDENT TO SIDE OF BED . Stands on same side of bed to where resident will be moved . With a draw sheet: Rolls draw sheet up and grasps draw sheet with palms up. Puts one hand at resident's shoulders and the other at resident's hips. Applies on knee against side of bed, leans back, and pulls draw sheet and resident on the count of three. Without a draw sheet: Slides hands under head and shoulders and moves toward self. Slides hands under midsection and moves toward self. Slides hands under hips and legs and moves toward self .During a review of the document titled, [Emergency Medical Services (EMS)] Patient Care Report (3.5)x, dated 9/7/25, the document indicated, . Response Mode to Scene: Emergent (immediate response) . Lights and Sirens . Unit Arrived On Scene . 9/7/25 at 21:58 . unit left the Scene: 9/7/25 at 22:13 . Patient arrived at destination . 9/7/25 at 22:50 . arrived . patient laying supine on the linoleum floor with two pillows under her head, both saturated with blood. Per facility staff [unknown], [ Certified Nursing Assistant (CNA- a healthcare professional who provides basic patient care, such as assisting with daily activities, vital signs, and hygiene, under the supervision of a licensed nurse)] 's had patient in a standing position next to the bed when she slipped, fell, and hit her head causing a deep/ open head laceration [cut] approximately 2 [inches- unit of measurement] in length. Staff denies any LOC [loss of consciousness] but states patient immediately began vomiting and had 3 episodes of vomiting prior to EMS arrival. Manual C-spine [way to protect the person's neck and spine from moving] was held as wound was dressed with a pressure bandage and c-collar [support brace for neck and spinal cord] was placed . [Resident 1] was transported to [emergency room] .During a review of the Resident 1's History and Physical (H&P), dated 9/8/25 from Hospital A, the H&P indicated, Resident 1 was admitted on [DATE] after presenting to emergency department on transfer from care facility by EMS following a fall. The H&P indicated, .Assessment of New and Established Problems: [AGE] year-old female status post ground level fall with Scalp laceration, TBI, mild, with ICH, Left rib fracture, Left pneumothorax, Manubrial fracture . Plan and Recommendations: . Admit to ICU .During a record review on 9/12/25 at 1:42 p.m. with the Director of nursing (DON) and the Administrator of the facility (ADM), Resident 1's Medical Record (MR), with the admission date of 6/24/24 was reviewed. The review of progress note titled, Interdisciplinary Team [IDT - group of professionals including nurses, social workers, physical therapists, and others who collaborate to develop, implement, and evaluate a patient's comprehensive plan of care] note, dated 9/8/25, the IDT note indicated, . IDT for witnessed fall that occurs on 9/7/2025 around 10:00 PM. Discussed with IDT on 9/8/2025 at 9:00 AM. [CNA 1] informed Charge Nurse [CN 1]that resident had fallen in her room. Per [CNA 1], as she was performing a brief change for the resident had a bowel movement, she turned the resident on her right side, her feet dangled slightly off the bed, she stated to the resident do not move, as she pulled out the soiled brief from the resident and place it on the trash bag by her side, when she turned to resume care to the resident, she had fallen off the bed into the floor. [CNA 1] called another CNA [unknown] across the hallway to call and informed the [CN 1]. During a concurrent interview and record review on 9/12/25 at 1:55 p.m. with the DON, Resident 1's MR, dated 6/24/24 was reviewed. The DON stated she was present at the IDT meeting and the facility investigation indicated that CNA 1 was not being careful. The DON stated Resident 1 was in room [ROOM NUMBER] A, and the fall occurred on 9/7/24 at (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055839 If continuation sheet Page 2 of 7 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 09/12/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few 10:00 p.m. The DON stated Resident 1's Brief Interview for Mental Status (BIMS - mandatory cognitive (the ability of the brain to think and reason) screening for residents, scored from 0-15, score of 13-15 indicating cognitively intact, score 8-12 moderate cognitive impairment, score 0-7 severe cognitive impairment ) was 0 and which indicated the resident was severely cognitive impaired. The DON stated Resident 1 was not restless, was not combative, was very light weight and was contracted [causes the joint to become stiff and fixed in a bent or flexed position, severely limiting a person's range of motion] in her extremities. The DON stated Resident 1 was fully dependent of care during toileting and repositioning. The DON stated CNA 1 cleaned Resident 1 and when CNA 1 turned to put the dirty brief in the trash, Resident 1 fell from the bed to the floor. The DON stated the facility investigation revealed CNA 1 did not have a draw sheet under the resident while turning and did not pull resident close to her as she should have based on her training and competency for repositioning of a resident in bed. The DON stated use of a draw sheet by CNA 1 and pulling Resident 1 close to her would have potentially prevented the fall. The DON stated Resident 1 was unable to hold on to assistive devices or support herself during the turning. The DON stated Resident 1's fall was preventable, and she expected CNA 1 to pay more attention, use assistance from another CNA if needed and follow her competency training (structured learning approach focused on developing specific, job-related knowledge and skills (competencies) that individuals must demonstrate before advancing). The DON stated the fall would have been potentially preventable if CNA 1 had followed the competency and training provided by the facility. The DON stated she was not sure why CNA 1 would ask the resident who was fully dependent for care and had a low BIMS score of 0 to Do not move and did not ensure safe positioning herself. The DON stated Resident 1 was also on an air pressure mattress (features a series of air cells that inflate and deflate in cycles to redistribute pressure across the body) which was provided by the Hospice company and was also one of the contributing factors to the fall. The DON stated she was unable to comment on the brand or type of mattress and since the incident, the facility notified the Hospice they were no longer using that particular air mattress and facility will arrange their own mattress. During a record review on 9/12/25 at 2:00 p.m. with the DON and the ADM, Resident 1's IDT note, dated 9/8/25 was reviewed. The IDT note indicated, . Assessment: [Licensed Vocational Nurse (CN 1)] and [Registered Nurse (RN)] immediately went into the room and found the resident on the right side of her bed, lying flat on her back with legs stretched out and arms crossed to her chest wearing only her shirt with no brief on. Upon assessment, blood was seen on the floor coming from the back of her head. There is an open laceration noted on the posterior [the back] part of her head. [CN 1] then placed a pressure dressing with gauze and bandage wrap. Resident was noted to be conscious and when asked what happened, she was able to answer and stated, I don't know. Pupils are [pupils are equal, round, reactive to light and accommodation (PERRLA)]. Vital signs checked and blood pressure was 134/75 within her normal limits. Resident was not moved due to head injury. A pillow with sheets was placed to her head to provide support. RN remained with the patient and [CN 1] called [NP] and informed him of the incident and ordered for the resident to be transferred out to acute [care hospital] for further evaluation and treatment. Per interview with the [CN 1], she stated that she was at the nurse's station doing her documentation, per her documentation, cause of fall was when the assigned CNA turned resident to her [resident 1] right side of the bed, CNA noted that resident did not have a draw sheet under her, as the CNA turned the resident, [Resident 1's] left leg fell forward [bringing] [Resident 1's] weight [down] and shifting her to fall off the bed and landed on the floor on her back. Resident's bed height was found at between waist and knee level Notification: MD notified of the incident and ordered to send resident out to [emergency room (ER)] for further (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055839 If continuation sheet Page 3 of 7 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 09/12/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few evaluation and treatment. [Responsible person (RP)] was informed and [company name] Hospice. [Resident 1] was sent to [Hospital A] later on transferred to [Hospital B] . RP called the facility and stated that [Resident 1] is in [ Intensive Care Unit (ICU - is a hospital unit that provides specialized, round-the-clock care for critically ill patients with life-threatening injuries or diseases)], she has laceration on the back of her head with multiple internal hematoma [collections of blood in or around the brain], left rib 1-3 [indicates a serious injury requiring immediate medical attention] was fractured and punctured her lungs, and lumbar fracture [break in one of the five bones (called vertebrae) of lower back, part of spine supports most of body's weight] with internal bleeding. Root Cause Analysis: Resident's cause of fall was weakness and residents positioning during [Activities of Daily Living (ADL -which are the fundamental self-care tasks necessary for independent living, including bathing, dressing, eating, using the toilet, continence, and mobility)] care. During an interview on 9/12/05 at 2:41 p.m. with CN 1, CN 1 stated she had been working at the facility for almost two years and was familiar with Resident 1. CN 1 stated at the time of the incident she was at the nursing station and heard CNA 1 calling her name. CN 1 stated she was one of the first responders to Resident 1's room right after the fall. CN 1 stated she observed Resident 1 was lying flat on the right side of the bed. CN 1 stated CNA 1 informed CN 1 that CNA 1 was changing Resident 1's brief and Resident 1 slipped out of her hand. CN 1 stated Resident 1 fell to the right side of bed, Resident 1 was not wearing a brief and had a little bit of blood on floor next to Resident 1 and there was nothing on Resident 1's face. CN 1 stated she thought it was coming from Resident 1's head, she assessed Resident 1's vital signs and called to send Resident 1 out by ambulance to ER. CN 1 stated she notified the family and assisted the Emergency Medical Technician (EMT- a trained healthcare professional who provides immediate care to patients at the scene of an incident and transports them to a hospital). CN 1 stated CNA 1 turned Resident 1 and did not have a draw sheet under the resident as she should have one for repositioning residents. CN 1 stated CNA 1 was not able to pull [Resident 1] closer and when she turned [Resident 1], she lost her grip as she had a dirty brief in her other hand that she was putting in the trash. CN 1 stated, I would personally say yes [CNA] should have second person to assist with repositioning Resident 1. CN 1 stated Resident 1 should have a draw sheet under her while in bed. CN 1 stated this fall for Resident 1 happened around 10:00 p.m. and CNA 1 started her shift at 2:30 p.m. CN 1 stated she would have expected CNA 1 to have changed Resident 1's brief at least once or twice before and CNA 1 should have been aware Resident 1 did not have a draw sheet to securely reposition Resident 1 during pericare. CN 1 stated Resident 1 would not have moved unless she was being moved, Resident 1 was not combative and dependent on care. During a concurrent interview and record review on 9/12/25 at 2:59 p.m. with the Director of Staff Development (DSD), the facility's document titled, COMPETENCY CHECK-MOVING A RESIDENT IN BED, dated January 2025 was reviewed. The DSD stated she had been working as the DSD for two years. The DSD stated she assisted with the education and training of all staff. The DSD stated all CNAs received training on turning, positioning, and transfers of residents and during the training, CNAs were educated on when to ask for a second person for assistance while repositioning. The DSD stated she was familiar with Resident 1. The DSD stated Resident 1 required maximum assistance and may have required two people for assistance, however, one staff was sufficient for toileting needs. The DSD stated the facility used draw sheets and the purpose for the use of draw sheets was to help with repositioning, helped to safely turn the residents and assisted with safe mobility of the resident in bed by the CNA. The DSD stated she had reviewed the case and spoke with CNA 1. The DSD stated CNA 1 kept saying she was talking to Resident 1. The DSD stated she was unable to understand why CNA 1 would rely on Resident 1 and said, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055839 If continuation sheet Page 4 of 7 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 09/12/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few Don't move, to Resident 1. The DSD stated Resident 1 had a low BIMS and was not physically able to assist with repositioning or ensuring safety. The DSD also stated the IDT team and the facility leadership team reviewed the staffing for the day and the facility had sufficient staffing to accommodate another CNA to assist CNA 1 with turning Resident 1 safely. The DSD stated the document indicated the use of a draw sheet or following the process of positioning resident, without a draw sheet: Slides hands under head and shoulders and moves [resident] toward self [to avoid the potential for fall], as outlined in the competency would have potentially avoided the fall. The DSD stated it appeared Resident 1 was turned away instead of moving toward self by the CNA. The DSD stated she had provided in-services and training to all CNAs to ensure patient safety and avoid falls after Resident 1's fall. During an interview on 9/12/25 at 3:14 p.m. with the ADM, the ADM stated she had been at the facility in her role for two and half years. The ADM stated she was notified about Resident 1's fall by the DON the same day around 10:30 p.m. The ADM stated the following day, the DON and the ADM had a meeting with CNA 1 and also notified the family of Resident 1. The ADM stated the facility had an IDT meeting to discuss the root cause analysis (RCA - systematic approach to identifying the foundational causes of problems, rather than just addressing symptoms, to develop long-term solutions and prevent recurrence) and reported the incident to the regulatory authorities as required. The ADM stated CNA 1 should have positioned the patient closer to her during repositioning using a draw sheet or followed the process for repositioning residents without a draw sheet closer to her as mentioned in the competency and training. The ADM also stated the mattress topper should not have been used. The ADM stated the facility would be auditing and monitoring to ensure all residents' safety and reeducation was provided to CNAs. The ADM stated she expected staff to follow the facility policies, competency, and training and CNA 1 failed to follow facility competency and training and steps when moving Resident 1 safely. During a concurrent phone interview and record review on 9/15/25 at 1:45 p.m. with the DON, Resident 1's MDS RESIDENT ASSESSMENT AND CARE SCREENING, dated May 12, 2025, was reviewed. The MDS indicated . Section GG - Functional Abilities - . Coding: Safety and Quality of Performance - If helper assistance is required because resident's performance is unsafe or of poor quality, score according to amount of assistance provided . 01. Dependent - Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity . 01 C. Toileting hygiene: The ability to maintain perineal hygiene, adjust clothes before and after voiding or having a bowel movement. If managing an ostomy [define], include wiping the opening but not managing equipment . 01 G. Lower body dressing: The ability to dress and undress below the waist, including fasteners; does not include footwear . The DON stated the assessment was the most recent assessment for Resident 1. The DON stated she was familiar with the MDS assessment. The DON stated the MDS assessment was completed quarterly and yearly assessment for change and to see any condition changes. The DON stated assessment was for the overall resident condition and different areas were assessed to address any change in resident condition and to make sure resident care needs were met. The DON stated the MDS looked at what residents required and the MDS assessment was done by the facility. The DON further stated the care plan and goals were established based on the residents assessment. The DON stated she reviewed and was familiar with Resident 1's assessment. The DON stated the MDS assessment for Resident 1 indicated Resident 1 scored dependent which indicated, helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 people for toileting need. The DON stated she was unable to explain whether Resident 1 required two people for toileting needs and would have to defer to the MDS consultant. The DON stated she would assist with arranging a call with the MDS (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055839 If continuation sheet Page 5 of 7 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 09/12/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few consultant to explain the scoring, however, at times, the facility did have two staff helping with Resident 1. The DON stated Resident 1 was dependent and one CNA was sufficient at times, depending on the care needs. The CNO stated Resident 1 was dependent on CNA 1 and CNA 1 should not have relied on Resident 1 to assist during repositioning. During a concurrent phone interview and record review on 9/15/25 at 2:03 p.m. with the Clinical Reimburse Specialist consultant (CRS), Resident 1's MDS RESIDENT ASSESSMENT AND CARE SCREENING, dated May 12, 2025, was reviewed. The CRS stated she reviewed the assessment for Resident 1 and for toileting needs, Resident 1 was scored as dependent. The CRS stated if one helper did all the effort required to reposition Resident 1, then one person was sufficient, otherwise assistance of two or more helpers was required to complete the activity. The CRS stated the MDS assessment was used to establish resident care needs and plan of care. During a phone interview on 9/16/25 at 10:40 a.m. with CNA 1, CNA 1 stated she had been working at the facility for two years. CNA 1 stated she was working with Resident 1 when Resident 1 had a fall at the facility. CNA 1 stated Resident 1 was her last patient of the night to be checked if a brief change was required. CNA 1 stated she knocked on Resident 1's door and explained she was there to change Resident 1. CNA 1 stated, I closed the curtain, I gathered my stuff, bags, wipes, and brief. I checked her, she had a bowel movement. I explained I am going to change her. I proceeded with her, her foot was dangling. I began to turn her, and I pivoted to turn to throw away the soiled brief and next thing she fell to the floor. CNA 1 stated she was working by herself with Resident 1. CNA 1 stated she did not recall pulling Resident 1 closer to herself. CNA 1 stated she was still in shock and could not recall all the details, however, she did recall changing Resident 1's brief earlier in the day around 4:30 p.m. CNA 1 stated she recalled turning Resident 1 away from herself before the fall, and she fell while turning. CNA 1 stated she was on the opposite side [away from the side resident was facing] of Resident 1 and Resident 1 was facing the wall and the sliding door away from her. CNA 1 stated Resident 1 was very stiff and was not moving at all. CNA 1 stated Resident 1 did not have chucks [disposable absorbent under pads to protect the bed from spills or leakage often due to incontinence] or a draw sheet under her. CNA 1 stated Resident 1 should have chucks or a draw sheet as she was dependent. CNA 1 stated she did not recall seeing Resident 1 earlier without a draw sheet. CNA 1 stated Resident 1 was also on an inflatable bubbly mattress and it was set to a certain pressure. CNA 1 stated she should have called for help. CNA 1 stated if another person was present during repositioning, it would have helped to prevent the fall. CNA 1 stated the use of a draw sheet during repositioning would have helped prevent the fall for Resident 1. CNA 1 stated the facility normally had one person assisting Resident 1 with repositioning. CNA 1 stated she never had any residents fall during her care and this was the first time any resident under her care experienced a fall and she had learned from this experience. During a review of the facility's policy and procedure (P&P) titled, QUALITY OF CARE Accident Hazards / Supervision / Devices, dated 7/2018, the P&P indicated, .Purpose .To provide an environment that is free from controllable accident hazards and provision of supervision and devices needed to prevent avoidable accidents .The facility will provide an environment that is as free of accident hazards as is possible and provide supervision and assistance devices to residents to avoid preventable accidents .Efforts to minimize risk to residents will include individualized, resident-centered interventions to reduce individual risks related to hazards in the environment .interventions will be modified when necessary .individualized interventions will be developed to reduce the potential for accidents .Staff will be trained on the use of assistive devices and transfer equipment .The devices and transfer techniques will be reflected in the resident's comprehensive care plan .During a review of the facility's document titled, JOB DESCRIPTION NURSING ASSISTANT - CERTIFIED, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055839 If continuation sheet Page 6 of 7 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 09/12/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete undated, the document indicated, . Essential Functions . Observe and practice safety according to facility policy and procedure . Demonstrate and able to explain proper body mechanics in all patient handling interactions & processes . Perform the following according to policy and procedure . Apply proper lifting and transferring techniques . Safety: Know and follow all Company policies, regulations and requirements . Demonstrate safe practices in regard to resident's comfort and safety by applying knowledge of proper body alignment for self and resident . Event ID: Facility ID: 055839 If continuation sheet Page 7 of 7