Health inspection·July 20, 2023

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure prompt efforts were made to resolve a grievance for one of two residents (Resident 1). For Resident 1 the facility did not acknowledge the receipt of or actively work toward a resolution of Resident 1's complaint/grievance. This failure had the potential to adversely affect Resident 1's health, safety, welfare, and rights. Review of Resident 1's face sheet (a single page document containing essential information, e.g. contact details) indicated she was admitted to the facility on [DATE] and had a diagnosis of fibromyalgia (a chronic disorder characterized by widespread pain and other symptoms such as fatigue, muscle stiffness, and insomnia). Review of Resident 1's Minimum Data Set (MDS, an assessment tool), dated 4/20/23 indicated Resident 1 was cognitively intact. Review of Resident 1's care plan (document summarizing a person's health conditions, specific care needs and current treatments), dated 5/1/2020, indicated she preferred to use messages distributed by electronic means (email, messages distributed by electronic means from one computer user to one or more recipients via a network) to communicate her concerns and grievances to interdisciplinary team members (IDT, team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities), to specific departments and to Cc: Executive Director and Social Service. Further review of the care plan indicated the intervention was to respond to resident emails with resolutions of her concerns and grievances. During an interview on 7/20/23 at 10:27 a.m., with the social service director (SSD), SSD stated it was her responsibility to respond to resident concerns and grievances. SSD further stated Resident 1 had repeated complaints about staff entering her room. During a concurrent interview and record review on 7/20/23 at 11:24 a.m., with the SSD, an email sent by Resident 1 to IDT members, dated 7/10/23 at 1:59 p.m. was reviewed. The email indicated, at 12:05 p.m. today, a black female unknown to me, wearing civilian clothes, not wearing any identification badge, suddenly appeared at my bedside, and began asking me questions about what kind of insurance I had and if I wanted to buy some kind of insurance. The SSD stated she did not read the email clearly and she got busy the next day. SSD further stated she should have followed up and she missed it. Review of the social service director job description, last updated 5/2021, indicated reviews Skilled Nursing .complaints and grievances; makes necessary oral/written reports to the Administrator. (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555156 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555156 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Webster House 437 Webster Street Palo Alto, CA 94301 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)