Other·December 13, 2018

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 represents the findings of the California Department of Public Health as a result of an investigation for one Facility Reported Incident (FRI). The inspection was limited to the specific FRI investigated and does not represent a full inspection of the facility. Facility Reported Incident: CA00599761 Representing the Department: Health Facilities Evaluator Nurse, 36087 One deficiency was cited for Facility Reported Incident: CA00599761

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

F600 11/29/2018 §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 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: Q18L11 Facility ID: CA020000125 If continuation sheet 1 of 5 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 11/16/2018 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 involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide an environment free of physical abuse for one (Resident 1) of three sampled residents, when Certified Nursing Assistant (CNA 1) pushed, pulled, and yelled at Resident 1 multiple times. This failure resulted in Resident 1 being physically and verbally abused. Findings: Review of Resident 1's Admission Record indicated Resident 1 was admitted to the facility on 6/10/14 with diagnoses that included Dementia (a general term for loss of memory and other mental abilities severe enough to interfere with daily life) due to traumatic brain injury, with behavioral disturbance, and Obsessive-Compulsive Disorder (a mental disorder where people feel the need to check things repeatedly and perform certain routines/tasks repeatedly). Review of the quarterly Minimum Data Set (MDS - An assessment tool used to direct resident care) assessment dated 7/26/18, showed a Brief Interview of Mental Status (BIMS) score of 14 out of 15; which represents an intact cognition (ability to understand and make one's own decisions daily) . During a review of the surveillance video recordings, from cameras 3 and 7, dated 8/13/18 from 12:02 p.m. to 12:04 p.m., showed that three food carts were parked in the middle of the dining room. CNA 1 walked back towards the food cart; Resident 1 was seen approaching the food carts as well. CNA 1 and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q18L11 Facility ID: CA020000125 If continuation sheet 2 of 5 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 11/16/2018 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 Resident 1 met in front of food cart 1. As Resident 1 attempted to open the first food cart, CNA 1 pushed the Resident 1's right hand away. As Resident 1 walked behind food cart 1, CNA 1 grabbed Resident 1's right wrist and pushed Resident 1 away from the cart. CNA 1 grabbed Resident 1's right arm again and pushed him, this time to stop Resident 1 from opening the middle cart. CNA 1 was shaking his finger at Resident 1. CNA 1 grabbed Resident 1's right wrist and pushed him while still holding Resident 1's wrist. CNA 1 grabbed both of Resident 1's lower arms. CNA 1 pushed Resident 1 towards the window while still holding Resident 1's right wrist. CNA 1 pulled Resident 1 away, grabbed Resident 1's left hand and then pushed Resident 1 away. CNA 1 then pushed Resident 1 in the back. CNA 1 walked away from Resident 1. When Resident 1 was charging towards CNA 1, CNA 1 tried to push Resident 1 away. CNA 1 then pushed Resident 1's left arm away. Resident 1 lost his balance and another CNA (CNA 5) tried to brace Resident 1's fall to the floor, but was unsuccessful. Resident 1 fell to the floor. During a telephone interview with CNA 1 on 8/30/18 at 10:10 a.m., CNA 1 began by stating that one day in August 2018, CNA 1 was trying to serve coffee to another resident when Resident 1 walked into the dining room asking for his lunch tray. CNA 1 instructed Resident 1 to sit and CNA 1 would bring Resident 1's tray to his table. When Resident 1 insisted to get his tray, CNA 1 blocked the food cart because he did not want the other trays to get contaminated. When Resident 1 came close to CNA 1, CNA 1 pushed Resident 1. CNA 1 admitted he pushed Resident 1 more than once. During an interview with Resident 1 on 8/29/18, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q18L11 Facility ID: CA020000125 If continuation sheet 3 of 5 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 11/16/2018 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 at 12:30 p.m., Resident 1 stated when he asked if he can have his tray served, CNA 1 told him to wait, as CNA 1 was busy serving coffee to the other residents. When Resident 1 told CNA 1 that he could get his tray for himself, CNA 1 hit him to keep him from touching the cart. Resident 1 stated CNA 1 pushed him out of the way and he landed on the floor, on his bottom. Resident 1 continued stating that one of his slippers came off so he tried to pick it up, but when CNA 1 thought he was going to the cart again, CNA 1 pushed him two more times. In an interview on 8/29/18 at 11:59 a.m. with CNA 2 (who was also present in the dining room during the incident) CNA 2 stated when Resident 1 walked to the food cart to look for his tray, CNA 1 followed him and the two went around the food cart. CNA 1 pushed Resident 1 and then Resident 1 fell on the floor. CNA 2 stated she told CNA 1 to stop pushing Resident 1, but CNA 1 would not listen. In an interview on 8/29/18, at 11:35 a.m., CNA 4 stated that when she stopped by the dining room, CNA 4 saw CNA 1 and Resident 1 talking by the food cart. CNA 1 walked away but Resident 1 followed CNA 1 so CNA 1 turned around, came back, and with his two hands, pushed Resident 1 in his chest, making Resident 1 fall to the floor on his bottom. Then CNA 4 stated she heard somebody call, "Code Green". According to facility's Policy and Procedure titled, "Abuse Reporting", dated 9/20/98 and revised on 4/10/13, showed that, "Each resident has the right to be free from abuse...Residents must not be subjected to abuse by anyone, including but not limited to facility staff...Definitions: 1) Physical Abuse hitting, slapping, pinching, kicking and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q18L11 Facility ID: CA020000125 If continuation sheet 4 of 5 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 11/16/2018 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 controlling behavior through corporal punishment, and non-accidental use of physical force that results in bodily injury, pain or impairment (including but not limited to bruising, skin tears or fractures) are physically abusive actions...pushing and shoving are also physically abusive behaviors". FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Q18L11 Facility ID: CA020000125 If continuation sheet 5 of 5