Health inspection·September 21, 2023

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement written policies and procedures (P&P) that prevent abuse, neglect, and exploitation of residents when registry Certified Nursing Assistants (CNAs) were not given abuse training/orientation prior to working with residents. Residents Affected - Few This failure had the potential to result in abuse of residents. Findings: During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was re-admitted to the facility on [DATE] with diagnoses that included muscle weakness, end stage kidney disease, and high blood pressure. During a review of Resident 1's Progress Notes, dated 9/4/23, the Progress Notes indicated Resident 1 complained of eight of 10 (0 for no pain and 10 as the most painful) pain on the back of her head after being transferred from the chair to the bed by CNA 1 and she hit her head on the headboard. The Progress Notes indicated Resident 1 had a round contusion at the back of the head that measured half an inch, Resident 1's daughter requested for Resident 1 to be transferred to the hospital for further evaluation. During a review of the History & Physical (H&P), printed 9/7/23, the H&P indicated Resident 1 had a closed head trauma from the incident. During an interview on 9/21/23 at 11:10 a.m. with Director of Nursing (DON), DON stated CNA 1 was assigned to Resident 1 on 9/4/23. DON stated CNA 1 was interviewed and gave a version of the incident that was different from Resident 1's account. DON stated CNA 1 was a registry staff and not a regular employee of the facility. During another interview on 9/21/23 at 11:50 a.m. with DON, DON stated the registry does not provide documentation of abuse training for the registry staff that they send to the facility. DON stated registry staff are given orientation on abuse prevention before they start their first shift. DON stated an Orientation Binder for Registry Nurses and CNAs where orientation acknowledgment forms were filed. During a review of the facility's undated Orientation Acknowledgement, the Orientation Acknowledgement indicated I .with staffing agency have reviewed the Registry Orientation Binder with a [facility staff] which include abuse, hoyer lift (mobility tool used to help seniors with mobility challenges get out of bed or the bath) and resident profiles . The Orientation Acknowledgment form would have Page 1 of 2 055715 055715 09/21/2023 Kyakameena Care Center 2131 Carleton Street Berkeley, CA 94704

F 0607 the registry staff signature and facility staff signature. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 9/21/23 at 11:59 a.m. with Staff Scheduler (SS), the Staffing Schedule was reviewed. SS stated CNA 1, CNA 2 and CNA 3 worked the morning shift, all three CNAs were registry staff who worked on 9/4/23. SS stated CNA 4, also a registry staff who was on the schedule for 9/21/23, was at the facility during the investigation. Residents Affected - Few During an interview on 9/21/23 at 12:01 p.m. with CNA 4, CNA 4 stated being told where to find things and equipment during the first time at the facility but was not given abuse training. During an interview on 9/21/23 at 12:33 p.m. with DON, DON stated there was no documentation that indicated CNA 1, CNA 2, CNA 3, and CNA 4 had abuse training/orientation in the Orientation Binder for Registry Nurses and CNAs. During a review of the facility's P&P titled Abuse Prevention Program, last revised, December 2016, the P&P indicated for resident abuse prevention, the administration will protect the residents from abuse by anyone including, but not limited to, facility staff and staff from other agencies. The administration will require training/orientation that include abuse prevention, identification, and stress management. 055715 Page 2 of 2