Other·October 15, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during the investigation of a facility-reported incident. Facility-reported incident number: CA00637045 Representing the Department: HFEN 40747. The inspection was limited to the specific facility-reported incident investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for facility-reported incident number CA00637045.

F600 SS=G Free from Abuse and Neglect CFR(s): 483.12(a)(1)

F600 10/18/2019 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G1WC11 Facility ID: CA020000053 If continuation sheet 1 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 05A427 (X3) DATE SURVEY COMPLETED 09/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CRESTWOOD MANOR - FREMONT 4303 Stevenson Boulevard Fremont, CA 94538 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to prevent physical abuse for one of three residents (Resident 1), when Certified Nursing Assistant 1 (CNA 1) hit, choked, and verbally abused Resident 1. This failure resulted in Resident 1 having a bloody nose, bruising and redness to the face and neck, pain, and emotional distress. Findings: Review of Resident 1's face sheet, dated 2/12/18, indicated Resident 1 was admitted to the facility in 2002 and had a conservator (a person who is responsible for making decisions about the care, living arrangements, and finances of another person because that person is consistently unable to make reasonable decisions.) Review of the Minimum Data Set (MDS - an assessment tool used to guide care), dated 3/18/19, showed Resident 1's short and long term memory were intact, there were no hearing difficulties, her speech was clear, she made herself understood, and that Resident 1 was able to understand others. During an observation and concurrent interview on 5/10/19 at 12:10 p.m., Resident 1 was lying on her bed in her room. Resident 1's neck and left eye was bruised on the left side and her nose was bruised and swollen. Resident 1 stated that on the evening of 5/9/19 she asked CNA 1 for something, he said no, and so she felt angry and spit into the mask he was wearing. Resident 1 stated she then went to her room and CNA 1 followed her at which time she apologized to him for spitting onto his mask. Resident 1 then stated CNA 1 said he FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G1WC11 Facility ID: CA020000053 If continuation sheet 2 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 05A427 (X3) DATE SURVEY COMPLETED 09/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CRESTWOOD MANOR - FREMONT 4303 Stevenson Boulevard Fremont, CA 94538 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE did not accept her apology and proceeded to hit her face ten to twenty times with his hand. Resident 1 stated that CNA 1 also put his hands around her neck and choked her hard. Resident 1 stated that CNA 1 was yelling at her and called her a, "Ho." Resident 1 stated CNA 1 then said he would come back and kick her face in if she told the police what he had done. Resident 1 stated CNA 1 told her to change her shirt because it was bloody, which she did, then she left her room and told staff what CNA 1 had done. Resident 1 stated she could not sleep that night, had pain, and felt unsafe at the facility. In an interview on 5/10/19 at 12:30 p.m., the Administrator (ADM) stated the facility had video of the incident showing footage of the community room and of the hallway outside of the community room on the date of 5/9/19 at approximately 4:00 p.m. The ADM stated that Resident 1 had referred to CNA 1 by a name that was unknown to the facility and that two other residents also indicated that they knew CNA 1 by this other name, so staff initially attempted to identify who Resident 1 was referring to. Review of the facility's closed circuit surveillance footage while in the presence of the ADM, showed the following of the community room and of the hallway outside of the community room: 4:00 p.m. until 4:07 p.m. " CNA 1 walked in the hallway towards the community room, stopped, and appeared to unlock the door. CNA 1 wore a face mask over his mouth and nose. Resident 1 was directly behind CNA 1. " CNA 1 stepped into the community room and faced the partially opened door. Resident 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G1WC11 Facility ID: CA020000053 If continuation sheet 3 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 05A427 (X3) DATE SURVEY COMPLETED 09/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CRESTWOOD MANOR - FREMONT 4303 Stevenson Boulevard Fremont, CA 94538 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE was still in the hallway, outside of the door. " Resident 1 then left the community room doorway and walked towards her room (as confirmed by the ADM). " The community door closed with CNA 1 still inside the community room. CNA 1 then opened the community room door and left the community room, letting the door close behind him. " Resident 1 walked into her room and out of view " CNA 1 1 walked out of the community room and entered Resident 1's room; out of view. 4:08 p.m. until 4:10 p.m. " Other residents and staff members are in the hallway near the community room and near Resident 1's room. " Resident 1 steps into the hallway and then immediately steps back into her room. " Resident 1 walks back into the hallway, out of her room and walks into the community room. She walks up to the office window (located in the community room) of the Program Director (PD). She then walks away from the office window and towards the door, back into the hallway and back into her room. " CNA 1 then walks out of Resident 1's room and into the shower room. 4:10 p.m. until 4:11 p.m. " CNA 1 leaves the shower room and re-enters Resident 1's room. " CNA 1 then leaves Resident 1's room, walks down the hallway and is out of view of the video cam. 4:12 p.m. " Resident 1 walks out of her room and walked out of view of the video cam. The Activity FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G1WC11 Facility ID: CA020000053 If continuation sheet 4 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 05A427 (X3) DATE SURVEY COMPLETED 09/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CRESTWOOD MANOR - FREMONT 4303 Stevenson Boulevard Fremont, CA 94538 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Director (AD) walks into view and appears to talk to someone. 4:13 p.m. " Resident 1 seen on video speaking with the AD. The AD takes Resident 1 by the hand and walks her into the PD's office. During an interview on 5/10/19 at 1:24 p.m., the Activity Director (AD) stated that on the previous afternoon (5/9/19), he saw Resident 1 in the hallway with blood on her face and she looked very upset. The AD stated Resident 1 told him that CNA 1 (from the night shift) had attacked her. The AD then stated he took Resident 1 to the Program Director (PD) to determine who CNA 1 was because the name provided by Resident 1 did not match any other staff names. In an interview on 5/10/19 at 2:11 p.m. the Director of Staff Development (DSD) stated that the AD brought Resident 1 to her office on 5/9/19 as well. The DSD stated Resident 1 had a bloody nose and that Resident 1 stated CNA 1(a night shift CNA) had attacked her. The DSD stated she then determined that CNA 1 was the person Resident 1 attempted to identify. Review of a nursing progress note dated on 5/9/19 at 4:50 p.m., showed Resident 1 had dried blood on her nostril. Review of a nursing progress note dated on 5/9/19 at 5:00 p.m., showed Resident 1 had a bruise on the left side of her temple and redness on her neck. Further review of a nursing progress note dated on 5/9/19 at 5:35 p.m., showed Resident 1 was still shaken up, the reddened area on her neck FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G1WC11 Facility ID: CA020000053 If continuation sheet 5 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 05A427 (X3) DATE SURVEY COMPLETED 09/16/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CRESTWOOD MANOR - FREMONT 4303 Stevenson Boulevard Fremont, CA 94538 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE was darker, she had an abrasion near her left eye, bruising and swelling of her nose, and redness on her right cheek. In a telephone interview on 5/14/19 at 11:55 a.m., Registered Nurse (RN 1) stated Resident 1 was taken by ambulance to the Acute Care Hospital's Emergency Department for her injuries on 5/9/19 at approximately 9:00 p.m. Review of the Acute Care Hospital records, dated 5/9/19 at 9:47 p.m., showed Resident 1 stated she was attacked by one of the facility staff, while the facility stated Resident 1 had a spontaneous nose bleed and a history of spontaneous nose bleeds. The record also indicated Reisdent 1 had neck bruised, blood in her nose and mouth, redenss near her left eye, and a bruised left nostril. Further review of photographs taken on 5/9/19 by the Acute Care Hospital's Emergency Department showed Resident 1 had a bruised and swollen nose, a bruise near her left eye, redness on her neck, and bruising on the left side of her neck. Review of a Police Report (Number 190509028), showed that CNA 1 was arrested on 5/9/19 for cruelty to an elder/dependent. Further review showed CNA 1 stated to the police department (PD) that he was not assigned to Resident 1 on the date and time in question; that he was assigned to a different hallway, and he had no work related business in Resident 1's room. Review of the facility's Elder and Dependent Adult Abuse/Suspicion of a Crime policy and procedure, revised 1/10/19, showed every resident had the right to free of physical abuse. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: G1WC11 Facility ID: CA020000053 If continuation sheet 6 of 6