Other·March 24, 2017

F000 INITIAL COMMENTS

F000 DEFICIENCY) COMPLETE DATE The following reflects the findings of the California Department of Public Health during the investigation of a complaint: CA00524765 Representing the California Department of Public Health: 15335, HFEM I The inspection was limited to the specific complaint and does not represent the findings of a full inspection of the facility. The Department identified Immediate Jeopardy, see F226. Census 28 ______________________________________ ______________________________________ ________________________CLCLASS _B___ CITATION 02-1477-0013073-F Complaint Number: CA00524765 Representing the Department of Public Health: Surveyor ID # 1477, HFEN 483.12(b)(1)-(3), 483.95(c)(1)-(3) DEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES 483.12 (b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, and (3) Include training as required at paragraph §483.95, 483.95 (c) Abuse, neglect, and exploitation. In addition to the freedom 555914 03/02/2017 WE CARE SKILLED NURSING FACILITY 21863 Vallejo Street Hayward, CA 94541 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE from abuse, neglect, and exploitation requirements in § 483.12, facilities must also provide training to their staff that at a minimum educates staff on- (c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at § 483.12. The facility violated the aforementioned regulation by failing to implement their policies and procedures for the protection of residents and for the investigation, and reporting of abuse. After Resident 1's report of Certified Nursing Assistant (CNA 2) placing a finger in Resident 1's anus, the facility continued to allow CNA 2 to provide hands on care to the residents, did not investigate the allegation of abuse that was documented on a grievance form and placed in the Grievance/Complaint book, and did not report the allegation of abuse to the local police or ombudsman, and the California Department of Public Health (CDPH). (c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property (c)(3) Dementia management and resident abuse prevention. During an interview with the Social Service Designee (SSD), who worked for the Temporary Manager (TM), on 3/2/17, at 1:50 p.m., SSD stated she found a grievance form dated 9/23 in the back of the grievance binder. A review of the facility document titled, "Concerns/Grievance Registration Form," dated 9/23, indicated that Resident 1 made a grievance to CNA 1 which CNA 1 wrote as follows: "(Resident 1) informed (CNA 1) that CNA (CNA 2) put his finger in (Resident 1's) anus while changing him. He informed CNA (CNA 1) that the finger was placed in the anus intentionally to cause pain..." During an interview with Resident 1 on 3/2/17, 555914 03/02/2017 WE CARE SKILLED NURSING FACILITY 21863 Vallejo Street Hayward, CA 94541 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE at 2 p.m., Resident 1 stated CNA 2 deliberately put his finger in Resident 1's anus, and it happened 3 or 4 times. Resident 1 stated that when it happened he told CNA 2 "Stop doing that!" and CNA 2 replied, "I'm not hurting you," to which Resident 1 said, "You are or I wouldn't tell you that, if you don't stop I will report this." Resident 1 stated that he felt that CNA 2 was being deliberately cruel. Resident 1 told the Director of Nurses (DON) on the date it happened around 9/23/16, but he could not be sure. Resident 1 also stated he told the DON "Don't schedule him (CNA 2) to work with me I don't want him!" During an interview with the DON on 3/2/17, at 2:30 p.m., the DON stated that around 9/23/16 Resident 1 asked him to take CNA 2 off his assignment. The DON stated he did not ask Resident 1 why, he just took CNA 2 off Resident 1's assignment. During a telephone interview with CNA 1 on 3/7/17, at 4:20 p.m., CNA 1 stated that Resident 1 told her on the night shift (couldn't remember the date) that CNA 2 put his finger in Resident 1's anus when giving care. CNA 1 stated "I thought that was serious and I told him I would let the charge nurse know." CNA 1 stated she couldn't recall who the charge nurse was, but Resident 1 told her, "Make sure...don't tell (CNA 2) because I don't want him mad at me." CNA 1 stated she told the charge nurse and filled out a grievance form. CNA 1 tried to give it to the charge nurse who told her to put it in the grievance book. CNA 1 stated she then put the form in the book of grievances and "I put it in the front so the next day when they open the book they can see it." CNA 1 further stated that nobody had ever asked her about the report and she quit her job a couple of weeks before Thanksgiving. CNA 1 stated that today was the first time anybody had asked her 555914 03/02/2017 WE CARE SKILLED NURSING FACILITY 21863 Vallejo Street Hayward, CA 94541 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE about the report she made. During an interview with the Facility Social Service Designee (FSSD) on 3/2/17, at 3 p.m., the FSSD stated that if there was a concern any staff member can fill out the grievance form and place it in the grievance book. FSSD stated, "Sometime when I come I check it. I work here three times a week. I check the front of the book and if nothing is there then that's it." During an interview with the ADM on 3/2/17, at 3:05 p.m., the ADM stated "FSSD is responsible for checking the book, nobody checks the book if FSSD is not here. The ADM also stated the DON did not tell him that Resident 1 did not want CNA 2 to take care of him. A review of the Facility's undated document titled, "Policy and Procedure: Abuse Prevention" indicated the following: "...Abuse...will not be tolerated in this facility at any time...Protection...If a resident incident is reported...this facility will take the following steps: Provide a safe environment for resident (s)...Remove employee immediately from the care or vicinity of the resident. Suspend employee during the investigation...Investigation...All incidents of suspected or alleged abuse will be investigated by the assigned staff...Reporting...All mandated reporters are required by law to report incident of known or suspected abuse...By telephone immediately or as soon as practically possible, to the local ombudsman or the local law enforcement agency...First responder or first staff member informed will be responsible for informing immediate supervisor and initiating incident report. Administrator or designee, and Director of Nursing must be notified as soon as possible but no later than 24 hours after the 555914 03/02/2017 WE CARE SKILLED NURSING FACILITY 21863 Vallejo Street Hayward, CA 94541 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE incident report. The Licensed Nurse shall be responsible for completing a physical assessment of the resident(s) involved and documenting all findings on an Incident Report...Administrator/DON shall investigate all suspected or alleged abuse...Administrator shall report all incidents of alleged abuse or suspected abuse to CDPH within 24 hours...and the results of the investigation to CDPH within 5 working days of the incident, and if the alleged violation is verified appropriate corrective must be taken...." Therefore, the facility violated the aforementioned regulation by failing to implement their policies and procedures for the protection of residents and for the investigation, and reporting of abuse. After Resident 1's report of Certified Nursing Assistant (CNA 2) placing a finger in Resident 1's anus, the facility continued to allow CNA 2 to provide hands on care to the residents, did not investigate the allegation of abuse that was documented on a grievance form and placed in the Grievance/Complaint book, and did not report the allegation of abuse to the local police or ombudsman, and the California Department of Public Health (CDPH).

F223 SS=G FREE FROM ABUSE/INVOLUNTARY SECLUSION CFR(s): 483.12(a)(1)

F223 03/09/2017 483.12 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 555914 03/02/2017 WE CARE SKILLED NURSING FACILITY 21863 Vallejo Street Hayward, CA 94541 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident’s symptoms. 483.12(a) The facility must(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on interview, and record review, for one of four sampled residents (Resident 1) the facility failed to protect Resident 1 from physical abuse when one Certified Nursing Assistant (CNA 2) put his finger in Resident 1's anus. This failure resulted in pain to Resident 1 and made him angry and afraid of CNA 2. Findings: During an interview with the Social Service Designee (SSD) who worked for the Temporary Manager (TM) on 3/2/17, at 1:50 p.m., SSD stated she found a grievance form dated 9/23 (year not indicated) in the back of the grievance binder. A review of the facility document titled, "Concerns/Grievance Registration Form," dated 9/23, indicated that Resident 1 made a grievance to CNA 1 which CNA 1 wrote as follows: "(Resident 1) informed (CNA 1) that CNA (CNA 2) put his finger in (Resident 1's) anus while changing him. He informed (CNA 1) that the finger was placed in the anus intentionally to cause pain..." During an interview with Resident 1 on 3/2/17, at 2 p.m., Resident 1 stated CNA 2 deliberately put his finger in Resident 1's anus, and it happened 3 or 4 times. Resident 1 stated that 555914 03/02/2017 WE CARE SKILLED NURSING FACILITY 21863 Vallejo Street Hayward, CA 94541 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE when it happened he told CNA 2 "Stop doing that!" and CNA 2 replied, "I'm not hurting you," to which Resident 1 said, "You are or I wouldn't tell you that, if you don't stop I will report this." Resident 1 stated that he felt that CNA 2 was being deliberately cruel. Resident 1 told the Director of Nurses (DON) on the date it happened around 9/23/16, and he told the DON "Don't schedule him (CNA 2) to work with me I don't want him!" A review of Resident 1's "Minimum Data Set (MDS) Resident Assessment and Care Screening" dated 1/25/17, indicated Resident 1 had no problems with memory or recall, had no problems with mood or behavior. He was continent of both his bowels and bladder but needed extensive assistance with the physical assistance of two persons to use the toilet. During an interview with the DON on 3/2/17, at 2:30 p.m., the DON stated that around 9/23/16 Resident 1 asked him to take CNA 2 off his assignment. The DON stated he did not ask Resident 1 why, he just took CNA 2 off Resident 1's assignment. During a telephone interview with CNA 1 on 3/7/17, at 4:20 p.m., CNA 1 stated that Resident 1 told her on the night shift (couldn't remember the date) that CNA 2 put his finger in Resident 1's anus when giving care. CNA 1 stated "I thought that was serious and I told him I would let the charge nurse know." CNA 1 couldn't recall who the charge nurse was, but Resident 1 told her, "Make sure...don't tell (CNA 2) because I don't want him mad at me." CNA 1 stated she told the charge nurse and filled out a grievance form. CNA 1 tried to give it to the charge nurse who told her to put it in the grievance book. CNA 1 stated she then put the form in the book of grievances and "I put it in the front so the next day when they open the 555914 03/02/2017 WE CARE SKILLED NURSING FACILITY 21863 Vallejo Street Hayward, CA 94541 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE book they can see it." CNA 1 further stated that nobody had ever asked her about the report and she quit her job a couple of weeks before Thanksgiving. CNA 1 stated that today was the first time anybody had asked her about the report she made. CNA 2 was unavailable for interview and did not return phone calls to messages left on 3/6/17, 3/7/17 and 3/8/17. Review of the facility's undated policy and procedure titled, "Abuse Prevention" indicated "...Abuse...will not be tolerated in this facility at any time. Every Resident has the right to be free from...physical abuse. Residents must not be subjected to abuse by anyone..." Cross-reference F 226.

F226 SS=L DEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES CFR(s): 483.12(b)(1)-(3), 483.95(c)(1)-(3)

F226 03/09/2017 483.12 (b) The facility must develop and implement written policies and procedures that: (1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, (2) Establish policies and procedures to investigate any such allegations, and 555914 03/02/2017 WE CARE SKILLED NURSING FACILITY 21863 Vallejo Street Hayward, CA 94541 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE (3) Include training as required at paragraph §483.95, 483.95 (c) Abuse, neglect, and exploitation. In addition to the freedom from abuse, neglect, and exploitation requirements in § 483.12, facilities must also provide training to their staff that at a minimum educates staff on(c)(1) Activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth at § 483.12. (c)(2) Procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property (c)(3) Dementia management and resident abuse prevention. This REQUIREMENT is not met as evidenced by: Based on interview and record review for one of four sampled residents (Resident 1) the facility failed to implement their policies and procedures for protection of residents and for the investigation, and reporting of abuse. After Resident 1's report of Certified Nursing Assistant (CNA 2) placing a finger in Resident 1's anus, the facility continued to allow CNA 2 to provide hands on care to the residents, did not investigate the allegation of abuse that was documented on a grievance form and placed in the Grievance/Complaint book, and did not report the allegation of abuse to the local police or ombudsman, and the California Department of Public Health (CDPH). The failure to protect Resident 1 and all residents residing in the facility from physical abuse by removing CNA 2 from resident care, to investigate the allegation that CNA 2 555914 03/02/2017 WE CARE SKILLED NURSING FACILITY 21863 Vallejo Street Hayward, CA 94541 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE physically abused Resident 1, and to report to the police or ombudsman and CDPH, resulted in the potential for substandard quality of care which affected the 28 residents in the facility. Immediate Jeopardy (IJ) was called on 3/2/17, at 7 p.m. The Administrator (ADM), the Director of Nursing (DON), and the Temporary Manager were verbally notified of the IJ regarding failure to protect residents, investigate and report an allegation of physical abuse. The IJ was not lifted on 3/2/17, at 6:20 p.m. The Administrator was not able to provide an acceptable plan of correction to the Department (CDPH). Findings: During an interview with the Social Service Designee (SSD), who worked for the Temporary Manager (TM), on 3/2/17, at 1:50 p.m., SSD stated she found a grievance form dated 9/23 in the back of the grievance binder. A review of the facility document titled, "Concerns/Grievance Registration Form," dated 9/23, indicated that Resident 1 made a grievance to CNA 1 which CNA 1 wrote as follows: "(Resident 1) informed (CNA 1) that CNA (CNA 2) put his finger in (Resident 1's) anus while changing him. He informed CNA (CNA 1) that the finger was placed in the anus intentionally to cause pain..." During an interview with Resident 1 on 3/2/17, at 2 p.m., Resident 1 stated CNA 2 deliberately put his finger in Resident 1's anus, and it happened 3 or 4 times. Resident 1 stated that when it happened he told CNA 2 "Stop doing that!" and CNA 2 replied, "I'm not hurting you," to which Resident 1 said, "You are or I wouldn't 555914 03/02/2017 WE CARE SKILLED NURSING FACILITY 21863 Vallejo Street Hayward, CA 94541 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE tell you that, if you don't stop I will report this." Resident 1 stated that he felt that CNA 2 was being deliberately cruel. Resident 1 told the Director of Nurses (DON) on the date it happened around 9/23/16, but he could not be sure. Resident 1 also stated he told the DON "Don't schedule him (CNA 2) to work with me I don't want him!" During an interview with the DON on 3/2/17, at 2:30 p.m., the DON stated that around 9/23/16 Resident 1 asked him to take CNA 2 off his assignment. The DON stated he did not ask Resident 1 why, he just took CNA 2 off Resident 1's assignment. During a telephone interview with CNA 1 on 3/7/17, at 4:20 p.m., CNA 1 stated that Resident 1 told her on the night shift (couldn't remember the date) that CNA 2 put his finger in Resident 1's anus when giving care. CNA 1 stated "I thought that was serious and I told him I would let the charge nurse know." CNA 1 stated she couldn't recall who the charge nurse was, but Resident 1 told her, "Make sure...don't tell (CNA 2) because I don't want him mad at me." CNA 1 stated she told the charge nurse and filled out a grievance form. CNA 1 tried to give it to the charge nurse who told her to put it in the grievance book. CNA 1 stated she then put the form in the book of grievances and "I put it in the front so the next day when they open the book they can see it." CNA 1 further stated that nobody had ever asked her about the report and she quit her job a couple of weeks before Thanksgiving. CNA 1 stated that today was the first time anybody had asked her about the report she made. During an interview with the Facility Social Service Designee (FSSD) on 3/2/17, at 3 p.m., the FSSD stated that if there was a concern any staff member can fill out the grievance form 555914 03/02/2017 WE CARE SKILLED NURSING FACILITY 21863 Vallejo Street Hayward, CA 94541 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE and place it in the grievance book. FSSD stated, "Sometime when I come I check it. I work here three times a week. I check the front of the book and if nothing is there then that's it." During an interview with the ADM on 3/2/17, at 3:05 p.m., the ADM stated "FSSD is responsible for checking the book, nobody checks the book if FSSD is not here. The ADM also stated the DON did not tell him that Resident 1 did not want CNA 2 to take care of him. A review of the Facility's undated document titled, "Policy and Procedure: Abuse Prevention" indicated the following: "...Abuse...will not be tolerated in this facility at any time...Protection...If a resident incident is reported...this facility will take the following steps: Provide a safe environment for resident (s)...Remove employee immediately from the care or vicinity of the resident. Suspend employee during the investigation...Investigation...All incidents of suspected or alleged abuse will be investigated by the assigned staff...Reporting...All mandated reporters are required by law to report incident of known or suspected abuse...By telephone immediately or as soon as practically possible, to the local ombudsman or the local law enforcement agency...First responder or first staff member informed will be responsible for informing immediate supervisor and initiating incident report. Administrator or designee, and Director of Nursing must be notified as soon as possible but no later than 24 hours after the incident report. The Licensed Nurse shall be responsible for completing a physical assessment of the resident(s) involved and documenting all findings on an Incident Report...Administrator/DON shall investigate all suspected or alleged abuse...Administrator 555914 03/02/2017 WE CARE SKILLED NURSING FACILITY 21863 Vallejo Street Hayward, CA 94541 PREFIX TAG ID PREFIX TAG DEFICIENCY) COMPLETE DATE shall report all incidents of alleged abuse or suspected abuse to CDPH within 24 hours...and the results of the investigation to CDPH within 5 working days of the incident, and if the alleged violation is verified appropriate corrective must be taken..." Cross-reference F 223.