Other·December 6, 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 entity reported incidents conducted on 11/28/17 and 11/29/17. For Entity Reported Incident CA00561661 regarding Resident Rights, the Department did not substantiate a violation of federal or state regulations. However, a federal deficiency unrelated to the entity reported incident was identified (see F609). A Class "B" Citation was also identified. For Entity Reported Incident CA00560931 regarding Misappropriation of Property, the Department did not substantiate a violation of federal or state regulations. Inspection was limited to the specific entity reported incidents 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.

F609 SS=D Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 12/16/2017 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown 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: 3SIP11 Facility ID: CA070000008 If continuation sheet 1 of 3 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 11/29/2017 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 source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility staff failed to report a suspected allegation of resident abuse in a timely manner for one of three residents (Resident 1), when housekeeping A (HK A) witnessed certified nursing assistant B (CNA B) slapped Resident 1 on the left lower leg between 11/2/17 and 11/4/17 but did not report it until 11/17/17. This failure had the potential to delay identification and implementation of appropriate corrective action and put the residents at risk for abuse. Findings: During an interview on 11/28/17 at 1:35 p.m. with HK A (a non-English speaking staff), with interpreter C (IPR C), she stated between FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3SIP11 Facility ID: CA070000008 If continuation sheet 2 of 3 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 11/29/2017 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 11/2/17 and 11/4/17 she witnessed Resident 1 take linen and washcloths from the linen cart. CNA B went to retrieve them from Resident 1. Resident 1 did not allow CNA B to do so and CNA B slapped Resident 1 on her left lower leg. HK A stated she did not report it to anyone until 11/17/17, which was 13 to 15 days later, when she told a CNA about it. That CNA told a nurse, and the nurse reported it to the social worker. During a telephone interview on 11/29/17 at 10:25 a. m. with IPR C, HK A acknowledged she should have reported what she had witnessed. Review of HK A's orientation document indicated HK A signed the facility's Reporting Elder Abuse on 6/26/17 stating she read the facility's Elder Abuse policy and procedure, viewed "Your Legal Duty" video and took pre and post video tests. The Department received a faxed report from the facility on 11/17/17 which indicated a housekeeping personnel reported she saw a CNA from the night shift slap Resident 1 on her lower leg. The facility's policy and procedure, "Elder Abuse Prevention" updated on 3/7/17, indicated "... all alleged violations and all substantiated incidents involving abuse, neglect, exploitation or mistreatment, ... will be reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, ... to the administrator of the community and to other officials, including to the State Survey Agency... in accordance with State law." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3SIP11 Facility ID: CA070000008 If continuation sheet 3 of 3