Other·August 18, 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 a standard abbreviated survey regarding investigation of an entity reported incident conducted on 8/9/17 and 8/10/17. For Entity Reported Incident CA00547513 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 (see F226). In addition, a Class "B" Citation was issued. 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: 34432, 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 08/28/2017 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 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: D2IK11 Facility ID: CA070000008 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: _______________ 555156 (X3) DATE SURVEY COMPLETED 08/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WEBSTER HOUSE 437 Webster St Palo Alto, CA 94301 (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 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 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 observation, interview and record review, the facility failed to follow their abuse policy when an injury of unknown origin for one of three residents (Resident 1) was not reported to the immediate supervisor, to the administrator, and to the appropriate agencies in a timely manner. This failure had the potential to affect the resident's safety and protection from harm. Findings: Review of Resident 1's record was initiated on 8/9/17. Resident 1 had diagnoses of cerebral infarction (stroke) and muscle weakness. Review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 5/30/17 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D2IK11 Facility ID: CA070000008 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: _______________ 555156 (X3) DATE SURVEY COMPLETED 08/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WEBSTER HOUSE 437 Webster St Palo Alto, CA 94301 (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 indicated a Brief Interview for Mental Status (BIMS) score of 9 (scores of 9 to 12 indicate the person has moderate impairment of cognition and memory). Review of Resident 1's "Non-Pressure Skin Condition Report", dated 8/8/17, indicated a three centimeter (cm., a unit of measure) by three cm. yellowish and purple skin discoloration was located on Resident 1's front right jawline close to the chin. Review of Resident 1's nurses notes dated 8/7/17 indicated Resident 1 reported the yellowish discoloration on her right jaw to her physician on 8/7/17. The nurses notes indicated Resident 1 reported another resident had caused the discoloration on her right jaw. During an observation and interview of Resident 1 on 8/9/17 at 11:30 a.m., a yellowgreen with purple center round bruise was located on the right jaw area close to the chin. Resident 1 stated a man who she did not recognize held her face with a cupped hand and caused the bruise located on her right jawline. Resident 1 stated the man did not grab her chin in violence but it was "like a joke". Resident 1 stated she did not have a good memory of the incident. During an interview with Licensed Nurse A (LN A) on 8/9/17 at 11:55 a.m., she stated the physician reported Resident 1's bruise to her on 8/7/17 at around 2 p.m. LN A stated the police and administrator were notified immediately. During an interview with certified nursing assistant B (CNA B) on 8/9/17 at 12:15 p.m., she stated she noticed the bruise on Resident 1's right jaw area on the morning of 8/5/17 and did not, but should have, report this to her FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D2IK11 Facility ID: CA070000008 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: _______________ 555156 (X3) DATE SURVEY COMPLETED 08/10/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WEBSTER HOUSE 437 Webster St Palo Alto, CA 94301 (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 supervisor. During an interview with CNA C on 8/10/17 at 2:25 p.m., he stated he first saw the bruise on Resident 1's right jaw area on 8/6/17 during the evening shift. CNA C stated he did not, but should have, report the bruise to his supervisor. During an interview with the director of nursing (DON) on 8/10/17 at 3:25 p.m., she stated CNA B and CNA C should have reported the bruise to their supervisors immediately upon discovery of Resident 1's bruise. On 8/8/17 at 3:46 p.m., the California Department of Public Health (CDPH) received a faxed report containing form SOC 341, "Report of Suspected Dependent Adult/Elder Abuse." The report indicated on 8/7/17 Resident 1 was observed to have a bruise on the right jaw line, discovered on 8/7/17. Review of the facility's undated policy, "Elder Abuse Prevention", indicated incidents including injuries of unknown source must be reported no later than 24 hours to the administrator of the community and to other officials, including the State Survey Agency, in accordance with State law. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: D2IK11 Facility ID: CA070000008 If continuation sheet 4 of 4