Other·August 1, 2017

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 an entity-reported incident. Entity-reported incident number: CA00538741 Representing the Department: Health Facility Evaluator Nurse 36737 The investigation was limited to the specific entity-reported incident investigated and does not represent the finding of a full inspection of the facility.

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

F223 07/06/2017 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 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 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: 33DS11 Facility ID: CA020000125 If continuation sheet 1 of 4 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: _______________ 05A396 (X3) DATE SURVEY COMPLETED 06/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARFIELD NEUROBEHAVIORAL CENTER 1451 28th Avenue Oakland, CA 94601 (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 by: Based on interview and record review the facility failed to keep one of three sampled residents (Resident 1) free from sexual abuse. Resident 1 was identified by the facility as being at risk for sexual victimization due to prior history of sexual abuse, mental illness, posttraumatic stress (a psychological reaction occurring after experiencing a highly stressing event), and dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities. Resident 1 was sexually abused by a facility housekeeper (HK) on 6/3/17 when HK was found in Resident 1's room with his penis in the resident's mouth. This failure resulted in Resident 1 being sexually violated. Findings: According to the undated medical record "Resident Information", Resident 1 was admitted on 1/26/2012 with diagnoses of, Dementia, Psychiatric Disorder (mental illness), and Post-Traumatic Stress. Review of the quarterly psychiatry report dated 3/20/17 indicated Resident 1 had a history of severe childhood abuse, sexual exploitation, and rape. The psychiatry report further indicated Resident 1's insight and judgement were poor and her memory was grossly impaired. Review of the Minimal Data Set (MDS), (A set of screening, clinical assessment, and functional status tools, providing a comprehensive assessment for residents of long term care facilities), Cognitive Patterns section C, dated 5/25/17, indicated the brief interview of mental status (BIMS) reflected a score of 5 of 15 or severely impaired. Review of Resident 1's care plan for, "At risk for altercations with others," initiated 12/19/14 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 33DS11 Facility ID: CA020000125 If continuation sheet 2 of 4 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: _______________ 05A396 (X3) DATE SURVEY COMPLETED 06/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARFIELD NEUROBEHAVIORAL CENTER 1451 28th Avenue Oakland, CA 94601 (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 and revised 6/23/16 indicated Resident 1 was at risk of being victimized by others given her history of abuse, mental illness, post-traumatic stress, and dementia. The care plan interventions indicated Resident 1 was to attend activities with increased supervision to decrease the risk of victimization. Review of Resident 1 care plan for, "At risk for sexually inappropriate behavior," initiated 12/19/14 and revised 6/23/16 indicated a history of initiating sexual relationships due to poor judgment. The care plan interventions were to redirect resident when she was observed to be sexually provocative or inappropriate with peers; encourage Resident 1 to say "No!" when receiving unwanted attention from male peers. In an interview with Certified Nursing Aide (CNA) on 6/13/17, at 12 p.m., CNA stated on 6/3/17 at about 1 p.m. she walked into the residents room and saw (HK) with his pants pulled down to his mid thighs and Resident 1 was on her knees facing HK. CNA stated she was shocked and said "what are you doing?", HK replied, "you didn't see anything" and quickly left the room. CNA stated she asked Resident 1 if she was having sex with HK, Resident 1 replied no she was "just sucking his d***". During an interview with the Medical Records Technician (MRT) on 6/13/17, at 12:30 p.m., the MRT stated she was assigned manager of the day 6/3/17. CNA came to MRT's office at about 1 p.m. to report the incident she just witnessed between Resident 1 and HK. The MRT stated when she found HK in the break room, the MRT requested his key and escorted him from the building. The MRT stated Resident 1 was then brought to MRT's office and when questioned about what had FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 33DS11 Facility ID: CA020000125 If continuation sheet 3 of 4 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: _______________ 05A396 (X3) DATE SURVEY COMPLETED 06/16/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE GARFIELD NEUROBEHAVIORAL CENTER 1451 28th Avenue Oakland, CA 94601 (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 happened, Resident 1 said she "sucked HK's d***". According to the facility's Policy and Procedure on Abuse reporting dated 9/20/98 and revised 4/10/13: "Purpose... Residents must not be subjected to abuse by anyone, including but not limited to facility staff...Definition 3) Sexual Abuse - sexual harassment, sexual coercion, and sexual assault are examples..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 33DS11 Facility ID: CA020000125 If continuation sheet 4 of 4