Other·July 15, 2019

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 a facility reported incident conducted on 7/11/19. For Facility Reported Incident CA00641086 regarding Resident Rights, a federal deficiency was identified (see F600). A Class A citation was also issued. Inspection was limited to the specific facility reported incident investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 32398, Health Facilities Evaluator Nurse.

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

F600 07/18/2019 §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. 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: Y5O911 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 07/11/2019 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 §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure one of one resident (Resident 1) was free from abuse when Resident 1 was sexually assaulted by certified nursing assistant A (CNA A). This failure presented serious physical and emotional harm to Resident 1. Findings: Resident 1 was admitted to the facility on 5/3/19 with diagnoses of post scoliosis (sideways curvature of the spine) surgery, unsteadiness on feet, muscle weakness, other abnormalities of gait and mobility, fusion of cervical region spine and fusion of lumbar region of spine and other forms of scoliosis lumbar region, spondylolisthesis (slipping of vertebrae that occurs at the base of the spine) lumbar region, paroxysmal atrial fibrillation (quivering or irregular heartbeat), spinal stenosis (narrowing of the spaces within the spine), muscle spasm of back, flat back syndrome (lumbar region), and low back pain. During an interview with Resident 1 on 6/14/19 at 10:36 a.m. and on 6/16/19 at 2:15 p.m., she stated on 6/9/19 while CNA A massaged her feet, CNA A kissed her toes and then licked her foot. Resident 1 stated CNA A gave her a "sponge bath slowly, usually he was fast" during which he started sucking on her left nipple, she pushed him away and he came back to "suck on the right nipple" but she pushed him away. She stated CNA A "washed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Y5O911 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 07/11/2019 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 her groin area slowly" and she pushed him away for CNA A was "so slow and very sexual". Resident 1 stated CNA A opened her legs and usually CNA A "wiped one side then other then middle (one wipe)" but on 6/9/19 CNA A rubbed up and down and said it had to be cleaned. Resident 1 stated CNA A "put his head down there and started sucking on her vaginal area". Resident 1 stated CNA A "probably took advantage of her not being able to move much". Resident 1 stated "he pulled her feet over the side of the bed, he pulled down his pants with elastic waist, exposing himself, then grabbed her arm, trying to pull her hand to touch his penis, tried to penetrate her, not sure if he did". Resident 1 stated she felt safe in the facility and she did not sleep for three nights following the incident. Review of Resident 1's Progress Notes dated 6/10/19 at 3:05 p.m., indicated Resident 1 complained of "pain at private area. Resident stated that a staff member had sexually assaulted her, ..." Review of Resident 1's Change In Condition Evaluation dated 6/10/19 at 4:11 p.m., indicated "Alert and verbally responsive @1.45 pm during med pass patient approach me in the hallway and wants to talk to me. told her to go to your room then we will talk. patient stated that a staff member had sexually assaulted her yesterday (6/9/19)" Review of the facility's Interview/Investigative Record dated 6/10/19 indicated CNA A admitted he "make a gesture of biting the toe as a joke" to Resident 1. Review of the facility's CNA/HHA/CHT Report of Misconduct dated 6/10/19 indicated suspension of CNA A for allegation of inappropriate and sexual conduct. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Y5O911 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 07/11/2019 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 Review of the facility's Human Resources Manager's letter dated 6/12/19 indicated CNA A's employment ended on 6/13/19 due to the substantiation of a resident's claim of elder abuse committed by CNA A. Review of an article in a local daily newspaper dated 6/13/19 at 3:26 p.m. indicated CNA A was arrested by the local police for rape, sexual penetration, oral copulation, sexual battery and elder abuse. Review of the facility's policy and procedure, "Elder Abuse Prevention" revised 3/7/17, indicated "each resident has the right to be free from all types of abuse ... Residents must not be subjected to abuse by anyone, including, but not limited to facility staff..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Y5O911 Facility ID: CA070000008 If continuation sheet 4 of 4