Other·April 12, 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 an abbreviated survey regarding investigation of an entity reported incident conducted on 4/3/17 and 4/4/17. For Entity Reported Incident CA00528225 regarding Quality of Care/Treatment/Resident Safety, the Department did not substantiate a violation of federal or state regulations. However, a federal deficiency was identified for a violation unrelated to the entity reported incident (F226). In addition, a Class "B" Citation was identified. Inspection was limited to the specific entity reported incident investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 37409, Health Facilities Evaluator Nurse.

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

F226 04/22/2017 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 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: 6PX411 Facility ID: CA070000031 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: _______________ 555838 (X3) DATE SURVEY COMPLETED 04/04/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CAMDEN POSTACUTE CARE, INC. 1331 Camden Ave Campbell, CA 95008 (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 (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, the facility failed to implement their abuse policy for one sampled resident (1) when 1. The alleged abuse incident was not reported to the Department within 24 hours, 2. the alleged abuser was not immediately removed from duty, and 3. the completed investigation was not reported to the Department within five working days of the incident. These failures had the potential for continued abuse and harm to the resident by the suspected abuser. Findings: Resident 1 was admitted to the facility on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6PX411 Facility ID: CA070000031 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: _______________ 555838 (X3) DATE SURVEY COMPLETED 04/04/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CAMDEN POSTACUTE CARE, INC. 1331 Camden Ave Campbell, CA 95008 (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 2/4/17 with diagnoses included cerebral infraction, unsteadiness on feet, muscle weakness, atrial fibrillation, anxiety, and major depressive disorder. 1. Review of Resident 1's Activity Progress Notes dated 3/24/17 at 1:38 p.m., indicated Resident 1 reported to registered nurse A (RN A) and the activity director (AD) that certified nursing assistant A (CNA A) stuck his fingers in her rectum during her shower. During an interview with the director of nursing (DON) on 4/3/17 at 1:20 p.m., she stated RN A did not report the incident to anyone because Resident 1 was a frequent complainer and fabricated stories. Review of Resident 1's Nursing Progress Notes dated 3/25/17 at 10:55 a.m., indicated Resident 1 reported to licensed vocational nurse A (LVN A) that on 3/24/17 CNA A put his three fingers in her rectum during her shower. During an interview with LVN A on 4/3/17 at 2:55 p.m., she stated she only called the Ombudsman about the incident on 3/25/17. Review of the facility's form SOC 341 (form used to report an incident of suspected abuse or neglect), indicated the incident took place on 3/24/17, and the form was completed on 3/27/17. The Department received the SOC 341 via fax on 3/27/17. The facility policy and procedure titled "Abuse Policy" dated 07/2015, indicated "... If no serious bodily injury: ... Provide a written report to the local Ombudsman, the L&C Program District Office, and the local law enforcement agency within 24 hours utilizing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6PX411 Facility ID: CA070000031 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: _______________ 555838 (X3) DATE SURVEY COMPLETED 04/04/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE CAMDEN POSTACUTE CARE, INC. 1331 Camden Ave Campbell, CA 95008 (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 California Report of Suspected Dependent Adult/Elder Abuse Form (SOC 341)." 2. During an interview with the director of staff development (DSD) on 4/3/17 at 1:30 p.m., she stated CNA A worked in the facility on 3/25/17 and 3/26/17 but he was not assigned to provide care for Resident 1. Review of the facility's "CNA Nursing Assignments - Afternoon Shift" dated 3/25/17 and 3/26/17, indicated CNA A continued working in the facility after Resident 1 reported the incident on 3/24/17. The facility policy and procedure titled "Abuse Policy" dated 07/2015, indicated "The employee alleged to have committed the act of abuse will be immediately removed from duty, pending investigation." 3. During an interview with the social service director (SSD) on 4/3/17 at 12:05 p.m., she stated the facility's investigation report was not ready. The facility policy and procedure titled "Abuse Policy" dated 07/2015, indicated "The Administrator or designee will report findings of all completed investigations to the L&C Program District Office via fax and other officials in accordance with state law within five working days of the incident ...." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 6PX411 Facility ID: CA070000031 If continuation sheet 4 of 4