Other·May 30, 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 the ANNUAL RECERTIFICATION SURVEY from 4/10/17 through 4/17/17. Representing the California Department of Public Health: Health Facility Evaluator Nurses: 25962, 35842, 38088 and 34331. The census on the day of entry, 4/10/17 was 54 There were 14 sampled residents Entity Reported Incident (ERI) # CA00506638 was investigated during the recertification survey with no deficiencies issued. One Complaint #CA00517765 was investigated during the recertification survey: A deficiency was issued for Complaint #CA00517765 - F323. Notice of Intent to Issue a Citation was issued to the Administrator on 4/26/17

F256 SS=E ADEQUATE & COMFORTABLE LIGHTING LEVELS CFR(s): 483.10(i)(5)

F256 05/17/2017 (i)(5) Adequate and comfortable lighting levels in all areas; This REQUIREMENT is not met as evidenced by: 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: QZNA11 Facility ID: CA010000082 If continuation sheet 1 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 Based on observation, interview, and record review the facility failed to provide adequate lighting in three bathrooms used by residents when one of two light bulbs in each bathroom were burnt out. This had the potential to cause harm related to falls and traumatic injuries to residents due to poor lighting. Findings: During observations on 4/11/17 and 4/12/17, the bathrooms used by residents in Rooms 7/8, 14/15 and 21 had one of two light bulbs burnt out. During concurrent observation and interview on 4/11/17 at 4:30 p.m. and 4/12/17 at 3:40 p.m., Maintenance Manager H was shown the burnt out light bulbs in the bathrooms shared by the resident's in Rooms 7/8, 14/15, and 21. Maintenance Manager H stated he was notified when something needed to be repaired and/or replaced through the Maintenance Log located at the nurse's station or via the daily stand-up meeting, which all managers attended. Maintenance Manager H stated he checked the Maintenance Log every morning when he started work (8 a.m.) and every evening before he went home (5 p.m.). A review of the document titled, "Maintenance Log," revealed there was no indication for a maintenance request for the burnt out light bulbs in the bathrooms shared by the residents in Rooms 7/8, 14/15, and 21. During a review of the maintenance job description titled, "Job Description Maintenance Director Department: Maintenance," revised 3/1/14, indicated Maintenance Manager H was to maintain the interior light fixtures. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 2 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F323 FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 SS=G PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 05/17/2017 (d) Accidents. The facility must ensure that (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review the facility failed to follow the care plan FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 3 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 and implement the use of an assistive device (mechanical lift) to prevent avoidable accidents, for one of 14 sampled residents (Resident 14), identified by the facility as at risk for falls, when transferring the non-ambulatory (not able to walk) resident from the bed to a shower chair. Two CNA's (certified nurse assistants) transferred Resident 14 by hand. Resident 14 became too heavy for the two CNA's to hold and had to be lowered to the floor. Resident 14 sustained a right femur (long bone of the thigh) spiral fracture (a break in a bone that typically occurs when a rotating force is applied along the length of the bone.) Resident 14 required hospitalization and surgical repair of the fracture. Findings: Resident 14 was a 93 year old female originally admitted to the facility on 9/17/10. Resident 14's Face Sheet (an admission record) indicated she had multiple diagnoses which included a history of cerebral vascular accident (CVA [stroke] - loss of blood flow to the brain) with residual right sided hemiparesis and hemiplegia (weakness and paralysis-loss of muscle function), vascular dementia (loss of memory and other functions of daily living due to reduced blood flow to the brain from vascular disease within the brain) and osteoarthritis (a type of arthritis [inflammation] that occurs when the flexible tissue [cartilage] at the ends of bones wears down.) Resident 14's Care Plan for falls, dated 3/2/14, indicated Resident 14 was "at risk for falls secondary to history of fall, dementia, impaired mobility with need for extensive assist with cares." Approaches to prevent falls were to "monitor factors causing prior falls," and to place a "fall mat" beside bed to minimize impact of falls. An updated approach to prevent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 4 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 falls, dated 4/10/15, directed staff to use "two person assist with mechanical lift (use of a sling, attached to a hydraulic lift device, which is placed under the patient and once firmly secured can move a patient from one place to another)." The long term goal indicated, Resident 14 would remain free of injury as evidenced by being free of falls or accidents every day for 90 days. Long term goal target dates were updated and entered as 5/27/16, 9/7/16, 11/24/16, 2/3/17, and 2/22/17. Resident 14's quarterly fall risk assessment dated 11/26/16, indicated a score of 17. A score of greater than 13 indicated a high risk for falls, per the Johns Hopkins Health System Fall Risk Assessment Tool, which the facility utilized. Resident 14's quarterly Minimum Data Set (MDS - a resident assessment tool) dated 11/27/16, indicated Resident 14 did not ambulate and required "total dependence" of two or more staff persons during transfers. Resident 14 was not able to complete a Brief Interview for Mental Status (BIMS) due to her cognitive impairment and was "rarely/never understood." The nursing progress note dated 12/25/16 at 11:19 p.m., (recorded as a late entry on 12/30/16 at 3:12 p.m.) indicated the licensed nurse (LN D) was called to Resident 14's room on the evening of 12/25/16. The progress note indicated, "Staff sitting on floor with resident keeping her in semi-Fowler's position (sitting upright at a 30-45 degree angle.) Staff stated they went to the floor with resident during transfer from bed to shower chair." LN D assessed Resident 14 and no deformity of her arms, legs, spine or neck was observed. Resident 14's level of consciousness and range of motion to her legs was described as "per FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 5 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 baseline," (same as before the fall.) LN D did not observe signs or symptoms of injury or pain during subsequent "every 30 minutes" assessments. It was noted that Resident 14 was "non-ambulatory, bedbound, with limited verbalization." LN D's progress note also noted, "to be endorsed (reported) to oncoming nurse (next shift licensed nurse) for continued assessment. Will continue to monitor." The nursing progress note dated 12/29/16 at 5:57 a.m., indicated LN E was called, by a CNA, to Resident 14's room "around 4:40 a.m." on 12/29/16. Resident 14's right leg had "yellowish discoloration" on the right knee and "reddish discoloration" to the right shin. LN E noted, upon assessment of Resident 14's right leg, Resident 14's "facial reaction was in pain by moaning and grimacing." LN E documented Resident 14's right leg was shorter than the left leg. The progress note indicated Resident 14's physician and family were notified. Review of an Interdisciplinary Team (IDT) note for Resident 14, dated 12/30/16, indicated the IDT met on 12/30/16 at 10:25 a.m. to review "Events, 12/25/16 Falls / Found on Floor." The team consisted of the Administrator, DON, MDS nurse, DSD (Director of Staff Development) nurse, an Occupational Therapist, the Activities Director, and the Medical Records Director. The IDT progress note indicated Resident 14 had no significant changes noted prior to the "intercepted" (to obstruct or catch someone or something) fall on 12/25/16. The IDT note documented Resident 14 sustained a right femur acute spiral and displaced fracture of the mid femoral shaft. The "Root Cause," (the most basic cause that can be identified, and when fixed, will prevent or significantly reduce the likelihood of the problem's recurrence) evaluated by the IDT revealed, "Two CNA staff attempting to get res FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 6 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 (resident) up when res slipped during transfer, assisted to floor with R (right) leg impact." There was no mention, in the IDT's Root Cause evaluation, of the CNA staff not using the mechanical lift for Resident 14's transfer, as per her care plan. A rehab post (after) fall screen for Resident 14 was performed by Occupational Therapist F on 12/29/16 at 11:36 a.m. Details of the report revealed no assistive device was used on 12/25/16 during Resident 14's transfer from bed to shower chair. Concurrent review of Occupational Therapist F's progress note dated 12/29/16 at 11:37 a.m., (recorded as late entry on 12/30/16 at 9:40 a.m.), indicated, during the rehab post-fall screen on 12/29/16, Resident 14 had facial grimacing and cried out with "PROM" (Passive Range of Motion - moving the joints through a range of motions without help from a resident) to her "RLE" (right lower extremity). The RLE was in "external rotation" (turning outward or away from the midline of the body). During an interview on 1/25/17 at 11:55 p.m., the Director of Nursing (DON) stated, on 12/25/16, during the evening shift (typically 2:30 p.m. to 11 p.m.) Resident 14 was being transferred "manually" (by hand) from her bed to a shower chair by two CNA's. Resident 14's "knee buckled (collapsed)" and the two CNA's assisted her to the floor. A few days later, on 12/29/16, the DON stated a night shift nurse (LN E) noticed Resident 14's legs were "not even." When asked if Resident 14 indicated she was in pain, the DON stated at times it was difficult to tell if Resident 14 had pain due to her dementia. The DON stated an X-ray of Resident 14's right leg/hip was taken on 12/29/16 which revealed "an acute (sudden onset) spiral and displaced fracture (the bone snaps into two or more parts and moves so that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 7 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 the two ends are not lined up straight) of the right femur." The DON confirmed Resident 14 was sent to the hospital on 12/29/16. Review of the hospital's surgery notes titled, Surgery and Procedure Reports, dated 12/31/16 at 12:02 p.m., indicated on 12/30/16, Resident 14 underwent an open reduction and internal fixation (ORIF) of the right femur. ORIF is surgery to fix the broken bone. Open reduction means the bone is moved back into the right place with surgery. Internal fixation means that hardware (such as rods or pins) is used to hold the broken bones together (www.allinahealth.org). Resident 14's surgery to repair and stabilize the fractured right femur required surgical placement of a plate, screws, and cables. During an interview on 1/25/17 at 2 p.m., when asked if all two-person transfers utilized a mechanical lift, Licensed Nurse S (LN S) stated, "Yes, but therapy [physical or occupational] determines the level of transfer and it depends on the resident [condition/diagnosis]." During an interview on 1/25/16 at 2:15 p.m., when asked when a mechanical lift was used, CNA A stated, "when a resident is not able to stand or bear weight." During an interview and observation on 2/8/17 at 3:15 p.m., CNA B stated she was assigned to take care of Resident 14 on the evening shift of 12/25/16. CNA B stated it was Resident 14's shower day and CNA B pressed the call light for help to transfer Resident 14 from her bed to the shower chair. CNA C responded to the call light. When asked what type of transfer the two CNA's performed, CNA B stated, "we do it manually" (by hand). CNA B stated she and CNA C had Resident 14 "under her arms" FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 8 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 during the transfer, when CNA B stated Resident 14 was "too heavy." CNA B stated, "so we lowered her [Resident 14] to the floor." When asked if Resident 14's knee's "buckled," CNA B stated, "No, she was just heavy so we slowly let her down and one of us stayed with her and the other one called for the nurse." When asked if Resident 14 showed any signs of being in pain, CNA B stated, "No, she seemed as usual ... she didn't hit the ground." CNA B demonstrated the position that Resident 14 was in after being lowered to the floor: a sitting position with both legs bent or folded to one side. During an interview on 3/9/17 at 11:15 a.m., when asked why a mechanical lift was not used on 12/25/16 when transferring Resident 14 to the shower chair, the DON stated she consulted with the Director of Staff Development (DSD), who interviewed CNA B and CNA C after the fall, and the CNA's stated, "because it was quicker to do it manually." During a subsequent interview on 4/11/17 at 9:30 a.m., the DSD confirmed no mechanical lift was used to transfer Resident 14 because CNA B and CNA C told her it was faster to do it manually. When asked if Resident 14 was always transferred "manually" the DSD stated, "If it was with those two (CNA's), probably." During an interview on 3/13/17 at 3:30 p.m., Resident 14's nursing progress notes, dated between 12/26/16 and 12/28/16, were requested of the DON. The DON stated there were no nursing progress notes for this time period (except for a weekly summary dated 12/28/16 at 3:51 a.m. that did not mention Resident 14's fall.) The DON stated she became aware of Resident 14's "assisted" fall of 12/25/16 when, on 12/29/16, Resident 14 "showed bruising" and licensed staff had FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 9 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 obtained a physician's order for an X-ray of the right hip. The DON stated she asked her nursing staff, "What happened?" The DON stated that was when LN D informed her of Resident 14's "intercepted" fall on 12/25/16. The DON stated she told LN D to document the event in the progress notes (refer to progress note above, dated 12/25/16 at 11:19 p.m., recorded as a late entry on 12/30/16 at 3:12 p.m.) During concurrent review of Resident 14's nursing progress notes, the DON confirmed it was on 12/29/16 that the progress notes reflected the development of pain and bruising to Resident 14's right leg with the subsequent order for an X-ray which revealed an acute fracture of the right femur. During an interview on 3/14/17 at 8:19 a.m., LN E stated she was called into Resident 14's room on 12/29/16 "between 4:30 and 5 a.m." by a CNA who asked her to check the resident's right leg. LN E stated she discovered "discoloration" to Resident 14's right knee and shin and "the right leg was shorter than the left leg." LN E stated she assessed Resident 14 with PROM to her right leg and Resident 14's face grimaced and she moaned. LN E stated Resident 14 did not have a response to PROM to her left leg. LN E stated she faxed a report to Resident 14's physician and requested an Xray be taken. LN E also informed Resident 14's family. When asked if any staff reported Resident 14's fall on 12/25/16, LN E stated, "No, I had no knowledge she had a fall." During an interview on 3/14/17 at 3:20 p.m., LN D stated she was called into Resident 14's room by a CNA on the evening of 12/25/16 (exact time unknown). LN D stated there were three to four CNA's in Resident 14's room, to help, but Resident 14 was "on the lap" (the flat area between the waist and the knees) of one of the CNA's and they were sitting on the floor. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 10 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 LN D described Resident 14's position as "a sitting position with her knee's bent to one side." LN D stated Resident 14's position did not look malformed. LN D stated a CNA's told her, "she gave out," referring to Resident 14's transfer, and the CNA's "went down with her" and "she never hit the floor." LN D stated she assessed Resident 14, while still on the floor, for any deformity of extremities, bruising, pain and her level of consciousness and there were no indications of injury. Resident 14 was then lifted to the shower chair, given a shower, and LN D stated she checked Resident 14 "visually and physically" every 30 minutes and "no changes" were observed. When asked if she documented the incident, LN D stated, "No ... I didn't chart on time" and confirmed she wrote a "late entry" note dated 12/30/16 of the incident that occurred on 12/25/16. When asked if she documented Resident 14's "every 30 minute assessments" after the fall on 12/25/16, LN D stated, "No, not documented ..." LN D stated she did not inform the DON or Resident 14's physician at the time of the incident on 12/25/16. When asked if she reported the event to the oncoming night shift nurse (LN E), LN D stated, "I want to say yes 100% but I can't recall the conversation ... I can't imagine not telling the next nurse." When asked if the CNA's used a mechanical lift when transferring Resident 14 from the bed to the shower chair, LN D stated the CNA's did not use the mechanical lift. According to Potter and Perry's Fundamentals of Nursing, ninth edition, 2017, Principles of Safe Patient Transfer and Positioning, "Mechanical lifts and lift teams are essential when a patient is unable to assist." During a telephone interview on 4/12/17 at 8:40 a.m., when asked if she assessed Resident 14 as requiring a mechanical lift for transfers, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 11 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 Occupational Therapist F stated "Not previously [before the fall], it was used after [the fall]. Review of the hospital's examination report, titled "History and Physicals," dated 12/29/19, indicated Resident 14 was brought to the Emergency Department (ED) on 12/29/16 due to "severe right leg pain" after a "mechanical fall." Upon physical examination, Resident 14's right hip was painful to palpation (touch) and had swelling. There were "ecchymoses (bruises) over her upper body." Concurrent review of the orthopedic surgeon's Consultation, dated 12/30/16, indicated "Prior to the fracture, the patient (Resident 14) did not ambulate." Review of the acute care hospital's interfacility (from one facility to another) transfer record dated 1/3/17 (the date Resident 14 was discharged from the hospital and re-admitted to the skilled nursing facility) indicated Resident 14's prior level of function (before being admitted to the hospital) was documented as "Dependent" and she was "Unable" to transfer independently. The facility's policy titled, "Safety and Supervision of Residents," revised 12/07, indicated a policy statement, "Resident safety and ... assistance to prevent accidents are facility-wide priorities." The "Resident-Oriented Approach to Safety," indicated "#4. Implementing interventions to reduce accident risks and hazards shall include ... communicating specific interventions to all relevant staff," and "#5. Monitoring the effectiveness of interventions shall include ... ensuring that interventions are implemented correctly and consistently." The facility's policy and procedure titled, "Falls FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 12 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 and Fall Risk, Managing," revised 12/07, indicated a Policy Statement, "Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling." The "Policy Interpretation and Implementation/Prioritizing Approaches to Managing Falls and Fall Risk," indicated, "The staff ... will identify appropriate interventions to reduce the risk of falls," and " ... staff will identify and implement relevant interventions ... to try to minimize serious consequences of falling." The section of the policy and procedure subtitled, "Monitoring Subsequent Falls and Fall Risk," indicated "The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling."

F364 SS=E NUTRITIVE VALUE/APPEAR, PALATABLE/PREFER TEMP CFR(s): 483.60(d)(1)(2)

F364 05/17/2017 (d) Food and drink Each resident receives and the facility provides(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance; (d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature; This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 13 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 by: Based on food production and distribution observation, interview, and dietary record review, the facility failed to ensure meals were prepared and served in a manner to maintain palatability and nutrient content as evidence by stabilizer, instant potatoes, not being measured in accordance to the pureed recipes for peanut butter cookies, pureed Italian green beans, pureed casserole (Lasagna) and pureed garlic bread. Failure to ensure food distribution and food production systems that ensured food palpability and nutritional content may result in decreased dietary intake and implementation of menus that did not meet individual resident nutritional requirement, which may result in weight loss and further compromise resident medical status for 11 of 11 residents on pureed diets. Findings: During observation of tray line on 4/11/17 at 11:30 a.m., Cook X used instant potatoes to thicken the pureed peanut butter cookies, Italian green beans, pureed casserole (Lasagna), and garlic bread located at the steam table. Cook X did not measure the instant potatoes in accordance to the recipes. Cook X poured the instant potatoes into the pureed foods until he obtained the consistency of applesauce (pudding like texture). During a review of the pureed recipes titled, "Pureed Breads, Cakes, Pancakes, French Toast, Sweet Rolls, Waffles, Tortillas and Other Bread Products" "Pureed Vegetables," and "Pureed Casserole," undated, indicated the stabilizer instant potatoes or commercial instant food thickener was to be used as needed; puree should reach a consistency of applesauce. The stabilizer needed to be measured: Six servings required 0 to 6 Tbsp FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 14 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 (tablespoons) and 12 servings required 6 to 12 Tbsp. During review of the dietary document titled, Master Resident By Name," dated 4/13/17, indicated there were 11 residents on a pureed diet. During an interview on 4/12/17 at 11:10 a.m., and 4/13/17 at 2:50 p.m., Dietary Supervisor U stated instant potatoes used as a thickener would add more starch to a resident's diet, especially if the instant potatoes were not measured. She stated instant potatoes could change the flavor of the food as well. Dietary Supervisor U stated she always used the instant food thickener to thicken the pureed foods when she cooked. Dietary supervisor could not find any dietary in-services on preparing pureed foods. During an interview on 4/14/17 at 11:20 a.m., Cook W stated she tried to puree the regular recipe thick, so she would not have to use a stabilizer (instant potatoes or commercial instant food thickener). Cook W stated if she had to use a stabilizer she would use the commercial instant food thickener. During an interview on 4/14/17 at 2:30 p.m., Cook X stated he never measured the powdered potatoes, which he always used to thicken the pureed foods. Cook X stated he poured powdered potatoes into the pureed foods to reach a consistency of applesauce. Cook X stated he was taught by the previous dietary supervisor / dietician / cook the preparation for the pureed foods needed to reach a consistency of applesauce or hold its shape (not runny). Cook X stated the previous dietary supervisor / dietician / cook explained to him it was better to add calories to the resident's diet and the recipes for pureed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 15 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 texture was only an estimate. Review of the instant potatoes container label, indicated two Tbsp of powdered instant potato mix equaled 100 calories.

F367 SS=E THERAPEUTIC DIET PRESCRIBED BY PHYSICIAN CFR(s): 483.60(e)(1)(2)

F367 05/17/2017 (e) Therapeutic Diets (e)(1) Therapeutic diets must be prescribed by the attending physician. (e)(2) The attending physician may delegate to a registered or licensed dietitian the task of prescribing a resident’s diet, including a therapeutic diet, to the extent allowed by State law. This REQUIREMENT is not met as evidenced by: Based on tray line observation, interview, and record review the facility failed to ensure meals were plated per physicians' order for 8 out of 15 residents on a (CCHO) Consistent Carbohydrate Diet for Diabetes Mellitus (persistent high blood sugar) when sampled residents (Resident 6 and 9) and unsampled residents (Resident 15, 16, 17, 18, 19, and 20) received a peanut butter cookie instead of two small diet cookies or four vanilla wafers during the noon meal on 4/11/17. Failure to ensure physicians' orders were followed may put residents at risk of further compromising nutritional and medical status. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 16 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 Findings: During a lunch tray line observation on 4/11/17 at 12:00 p.m. and review of residents' profile menu cards on 4/12/17 at 5:20 p.m. and the "Master Resident by Name" profile dated 4/13/17, indicated sampled residents (Resident 6 and 9) and unsampled residents (Resident 15, 16, 17, 18, 19, and 20) were on a CCHO diet. Resident 6, 9, 15, 16, 17, 18, 19, and 20 were given a peanut butter cookie by Dietary Aide T. During a review of the facility's "Spring Therapeutic Menu" cooks' spread sheet for 4/11/17 residents on a CCHO diet were to receive two small diet cookies (approximately 2 inches) or 4 vanilla wafers. During an interview on 4/11/17 at 12:40 p.m., when Dietary Aide T was asked what type of cookie a resident on a CCHO diet received, Dietary Aide T stated a peanut butter cookie. During an observation on 4/11/17 at 12:40 p.m. and an interview on 4/12/17 at 3:30 p.m., RD M observed Dietary Aide T place a peanut butter cookie on the residents' trays that were on a CCHO diet. When RD M was asked what type of cookie residents on a CCHO diet were to receive on their lunch meal tray for 4/11/17, RD M stated diet cookies or vanilla wafers as indicated on the therapeutic spread sheet. RD M stated Dietary Aide T should have followed the therapeutic spread sheet. During an interview on 4/11/17 at 12:45 p.m. and 4/12/17 at 11:10 a.m., Dietary Supervisor U stated the cooks' spread sheet indicated residents on a CCHO diet were to receive two small diet cookies (approximately 2 inches) or 4 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 17 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 vanilla wafers. Dietary Supervisor U stated the dietary aide who prepared the resident's meal tray after the cook plated the food was supposed to make sure the resident received the right diet in accordance with the resident's menu card. Dietary Supervisor U stated Dietary Aide T had a language barrier and stated there was no excuse for giving the residents the wrong therapeutic diet. Dietary Supervisor stated any of the residents on a CCHO diet whose tray was located in the first three meal carts were given the wrong cookies. During observation and interview on 4/11/2017 at 12:45 p.m., Resident 6 was seen eating lunch at a table in the facility dining room with another resident and CNA K. CNA K confirmed Resident 6's lunch was vegetarian tofu pasta, green beans, garlic bread and a peanut butter cookie. When asked where the cookie was CNA K stated "She ate her cookie first." During concurrent interview and record review on 4/13/17 at 2:50 p.m., Dietary Supervisor U stated Dietary Aide T had worked in the kitchen at the facility for several years. Dietary Supervisor U stated Dietary Aide T had a language barrier, but worked with another dietary aide, who was bilingual, when prepping the resident's meal trays. When Dietary Supervisor U was asked if Dietary Aide T knew how to read the "Cook Therapeutic Spread Sheet" (detailed what the residents were to receive according to the resident's diet), Dietary Supervisor U stated, "I thought so, but now I don't know. I have only been working here since February. Review of the "Dietary InService" binder with Dietary Supervisor U, there was no documentation dietary staff were in-serviced on the various therapeutic diets. During an interview on 4/14/17 at 11:20 a.m. with Cook W translating, Dietary Aide T stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 18 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 she learned how to read the therapeutic spread sheets and resident menu cards via way of inservices, books, and studying the recipes. Dietary Aide T stated she could read English better than she could speak English and she had prepared the residents' meal trays for many years at the facility. Dietary Aide T stated the residents on a CCHO diet should not have received a peanut butter cookie, the residents should have received the cookies detailed on the cooks spread sheet. Dietary Aide T stated if a resident's meal card did not make sense, she would ask for clarification. During an interview on 4/17/17 at 11:35 a.m., LN Y stated the certified nursing assistant (CNA) checked the resident's meal tray against the resident's meal card before passing out the meal trays to the residents. LN Y stated if the CNA saw a discrepancy in the resident's meal plated verses the resident's meal card, the CNA should bring the tray back to the kitchen and get the correct tray. During a review of the dietary aide job description titled, "Job Description Dietary Aide Department: Dietary" revision date 3/1/14, indicated the dietary aide was supposed to: 1. Make sure correct food and texture as ordered by the diet with attention to serving modified and therapeutic diets, 2. Recheck items on tray with tray card to insure resident receives correct diet, 3. Have exceptional communication skills, and 4. Be able to read, analyze, and interpret common scientific and technical information, and to be easily understood through verbal communication in the English language. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 19 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 


F371 SS=E FOOD PROCURE, STORE/PREPARE/SERVE F371 - SANITARY CFR(s): 483.60(i)(1)-(3) 05/17/2017 (i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. (i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. (i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 20 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 Based on food storage observation, dietary staff interview, and dietary document review, the facility failed to ensure safe dietetic services as evidence by: 1. Food products were not sealed 2. Food products had no opened date and/or use by date 3. Expired food products were not thrown out 4. Meat was not fully submerged under water when being thawed. These failures had the potential to increase the risk of residents' exposure to foodborne illnesses, which might result in compromised medical status and in severe instances may result in death. Findings: During the initial tour of the kitchen refrigerators / freezers on 4/10/17 at 10:05 a.m., the following concurrent observations, interviews, and dietary document review occurred: 1. A bag of sausage was not sealed. Review of the dietary policy titled, "Procedure for Refrigerated Storage," dated 3/2013, indicated food should be covered. 2. Food products did not have an open date or dates were inconsistent. a. Mixed frozen vegetables (five pound bag) was not dated. b. Loaf of frozen wheat bread was not dated. During an interview on 4/10/17 at 10:20 a.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 21 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 Dietary Supervisor U stated all food products should have a received date and an opened date. Review of the dietary policy titled, "Procedure for Refrigerated Storage," dated 3/2013, indicated food should be: 1. Labeled and dated and 2. Individual packages of refrigerated frozen food taken from the original packing box need to be labeled and dated. 3. Expired refrigerated food products were not discarded. a. Beef base (a paste used to add flavor to gravy, sauces, etc.) received 7/26/16 and opened 2/2/17. b. Sour Cream received 3/17/17 had no opened date; best use by date was not legible. During an interview on 4/10/17 at 10:25 a.m., Dietary Supervisor U stated she could not read the best by date on the container of sour cream and was unable to state when the beef base expired once opened. Review of the dietary policy titled, "Procedure for Refrigerated Storage," dated 3/2013, indicated milk, cottage cheese, cream and soft cheese were to be used by the pull date on the carton unless a written policy is provided by the milk supplier stating otherwise. Review of the dietary document titled, "Refrigerated Storage Guide," dated 2015, indicated sour cream's refrigerated storage guidelines were: 1. Follow expiration date or 2. Sour cream expired seven days after being opened, which ever came first. 4. During concurrent observation and interview on 4/11/17 at 8:50 a.m., a frozen ground turkey roll was not completely submerged under cold FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 22 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 running water during the thawing process. Cook X stated the reason the turkey roll was not completely submerged in the water was because the tub was too small. Dietary Supervisor U stated the turkey roll should have been totally submerged in the cool water and needed to be in a larger tub. Review of the dietary policy titled, "Food Preparation: Thawing of Meats," undated, indicated one of the processes for thawing meat was as follows: Submerge meat under running, potable water at a temperature of 70º F (Fahrenheit) or lower, with a pressure sufficient to flush away loose particles.

F431 SS=E DRUG RECORDS, LABEL/STORE DRUGS & BIOLOGICALS CFR(s): 483.45(b)(2)(3)(g)(h)

F431 05/17/2017 The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g) of this part. The facility may permit unlicensed personnel to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 23 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 administer drugs if State law permits, but only under the general supervision of a licensed nurse. (a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. (b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who-(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and (3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. (g) Labeling of Drugs and Biologicals. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. (h) Storage of Drugs and Biologicals. (1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. (2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 24 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, staff interview, record and policy review, the facility failed to ensure proper storage, disposition or of medications when: 1. One staff (Licensed Nurse S) placed medication in a resident's room trash can after the resident refused to take the medication. This failure could result in medication that was accessible for residents resulting in possible ingestion and side effects of the medication. 2. One expired bottle of probiotic (supplement used to replenish beneficial bacteria in the body) and six intravenous antibiotic bags (medications used to treat infections administered through a vein) were in the medication refrigerator which could result in the use of medication or supplements which were no longer effective or harmful to the residents. 3. One bottle of controlled medication (drug with the potential for abuse or addiction, held under strict governmental control) was not labeled with the resident's name, and had an inaccurate measurement system on the bottle to ensure proper accounting of medication left in the bottle. The failure to accurately account for the medication could lead to medication which was misused or could result in the diversion of a controlled substance. Findings: 1. During an observation on 4/12/17 at 4:50 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 25 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 p.m., a staff member informed LN S, who was in the hallway with the medication cart, that Unsampled Resident 22 needed some pain medication. LN S went into Unsampled Resident 22's room with two tablets of Tylenol (a non narcotic pain reliever) 325 milligram (mg) in a small medicine cup. The resident refused the pain medication saying she would like to have them later. LN S stated he would throw them out. LN S put the two Tylenol tablets in a small trash can near the door. When asked if that was what he normally did with the medication, LN S stated he normally disposed of them in the disposal box in the medication room. During an observation and interview on 4/12/17 at 8:45 a.m., a locked cabinet was in the medication room, with a box for disposal of medications. The DON stated staff should not have put unused medication in the trash, as someone might pick it out of the trash. The DON stated it should have been put in the disposal box or locked up in the medication cart. The DON stated there was a medication disposal company that picked up unused medication or it was returned to the pharmacy. Review of the facility policy for Disposal Of Medications And Medication-Related Supplies, dated 3/4/14, indicated unused, unwanted and non-returnable medications should be removed from their storage area and secured until they were destroyed. The policy indicated the facility could use a medical waste hauler for pick-up of unwanted medication for disposal. 2. An observation on 4/12/17 at 8:50 a.m., of the medication refrigerator, revealed a bottle labeled Senior-Jarro Dophilus (a probiotic supplement used to replenish beneficial bacteria in the body) with a best if used by date of 2/16. The DON stated it was not removed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 26 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 because the year 2016 looked like 2018. Six Intravenous (IV) ceftriaxone (an antibiotic medication administered through the vein) 1 gm in 50 milliliters Dextrose (D5W - glucose (sugar) solution), in a brown plastic bag were located in the medication refrigerator. The fluid in the bags was tan color and the "use by" date was 2/8/17 on each bag. The DON stated the medication in the IV bags was for a resident (Sampled Resident 8) who had pneumonia. She stated the resident went to the hospital instead of receiving the medication in the facility. The DON stated usually the medication did not look that color, and the refrigerator should be checked daily for temperatures and the contents checked monthly for outdates. Review of the facility policy for Storage of Medications revised 11/11/15 indicated outdated, contaminated or deteriorated medication and those in containers that are cracked, soiled or without secure closures were immediately removed from the inventory and disposed of according to facility procedures for disposal. 3. During an observation and interview on 4/12/17 at 8:15 a.m., the controlled medication storage area for discontinued medication, contained a bottle of Lorazepam 2 mg (milligrams) / ml (milliliters) [Medication used to treat anxiety - a Schedule IV controlled drug classification]. The bottle had markings on the side to 22 ml. The bottle label indicated it was a 30 ml bottle and the level of fluid medication in the bottle was above the level of 22 ml, filled to the neck of the bottle. There was a dropper type of applicator in the screw top lid. A log indicated there was 29.25 ml left in the bottle. There was no label on the bottle to indicate which resident it was for. During an interview at this time, the DON stated the contents of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 27 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 bottle was not measured to account for the exact amount left in the bottle. The DON confirmed the bottle did not have measurement markings to indicate the amount that was actually in the bottle. The DON stated the medication was brought in by a hospice agency and stated the resident label may have been on the box for the medication which was discarded. Review of the controlled medication log indicated a resident's name, a prescription number for the medication, quantity, date received and directions for use of the medication. There was no identification on the container to indicate name of the resident or prescription number. The Medication Storage In The Facility Storage of Medication policy, dated 11/11/2015, indicated all medications dispensed by the pharmacy, should be stored in the container with the pharmacy label. Review of the Medication Storage In The Facility - Controlled Medication Storage policy, revised 3/4/14, indicated the facility created a controlled substance accountability record for schedule II, III, IV, and V medications and at each shift, a physical inventory of all controlled substances was conducted and any discrepancy was reported to the administrator. The medication regimen of the residents who had the discrepancies are reviewed to assure the resident received all the medication ordered and the goal of therapy was met. Accountability records for the discontinued controlled substances were maintained with the unused supply until it is destroyed or disposed of. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 28 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

F441 INFECTION CONTROL, PREVENT SPREAD, F441 LINENS CFR(s): 483.80(a)(1)(2)(4)(e)(f) SS=E ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 05/17/2017 (a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: (1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards (facility assessment implementation is Phase 2); (2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 29 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 (iv) When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi) The hand hygiene procedures to be followed by staff involved in direct resident contact. (4) A system for recording incidents identified under the facility’s IPCP and the corrective actions taken by the facility. (e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. (f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, staff interview and policy review, the facility failed to ensure a system was in place for preventing infections when: 1. Three staff members did not wash hands or use hand sanitizer after removal of gloves which could result in cross contamination (bacteria or other microorganisms are FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 30 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 unintentionally transferred from one substance or object to another, with harmful effect). 2. Two Beds had bed rails covered with a foam material which was porous (a non-smooth surface with holes) which could not be cleaned by the disinfectant to prevent the spread of infection. 3. One out of two staff members used an antiseptic (inhibits growth of bacteria or other infectious organisms) wipe to clean a glucometer (a device used to test the amount of glucose [sugar] in the blood) instead of the disinfectant (destroys bacteria or other infectious organisms) wipe recommended by the manufacturer, which could lead to cross contamination if the disinfectant used was not effective against bacteria or virus which could remain on the meter. 4. One tub was not maintained or cleaned per manufacturer's instructions which could lead to cross contamination if cleaning was not effective. 5. One bathroom wall stained with a brown substance and one toilet bowl had brown substance on the rim, which could lead to cross contamination if touched by residents or staff. 6. One bedpan was left sitting on a toilet in a bathroom used by multiple residents which could lead to cross contamination if the bedpan was touched or used by multiple residents. Findings: 1. During an observation on 4/11/17 at 6:10 a.m., LN E put on gloves and wiped the glucometer with an antiseptic wipe. LN E then put on new gloves without using hand hygiene between glove change and checked FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 31 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 Unsampled Resident 23's blood sugar with the glucometer. LN E cleaned the glucometer again and removed the gloves but did not wash her hands or use hand sanitizer before inputting information in the computer on the medication cart. During an observation on 4/11/17 at 7:30 a.m., LN L took off his gloves after drawing up insulin (medication used for blood sugar control) for Sampled Resident 6, and did not wash or cleanse hands before using the computer. LN L administered the insulin injection to Sampled Resident 6's abdomen with gloves on, took off the gloves and handled the curtain and the sharps box in the room before washing his hands. During an observation on 4/11/17 at 9:10 a.m., LN V administered medication to Unsampled Resident 24. LNV removed her gloves in the room and handled the door knob before she went down the hallway to wash her hands in the sink at the nursing station. During an interview on 4/14/17 at 10:10 a.m., the DSD who was the infection control coordinator stated facility staff should wash hands after the removal of their gloves and before touching surfaces because bacteria could be on staff's hands after glove removal. The DSD stated, holes could be in the gloves and bacteria could be trapped under their gloves, causing cross contamination when staff touched surfaces after glove removal. The DSD stated they followed CDC (Centers for Disease Control) guidelines for infection control. Review of the Long Term Care Infection Control Manuel, dated 2003, indicated under USING GLOVES, to wash hands after removal of gloves, as gloves do not replace hand washing. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 32 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 3/17 CDC guidelines for healthcare providers indicated after glove removal, hand hygiene should be performed. 2. During an observation on 4/11/17 at 3:50 p.m., of Resident 3's bed rails, there was black foam around the upper bed rails, taped at the ends with red tape. The foam had divots where pieces had come out. During an interview at this time, LN L stated Sampled Resident 3 had very fragile skin and the foam was a protection measure. During an observation on 4/11/17 at 3 p.m. Sampled Resident 7 also had foam padding on her right upper bed rail. During an interview on 4/13/17 at 11:05 a.m., Maintenance Manager H stated regarding the cleaning of the foam on Sampled Resident 3's bed rails, he thought it was cleanable and it was there because the resident was in danger of skin tears. Maintenance Manager H stated the foam was changed out once a month, and confirmed it had holes and gouges in it and stated it was a porous surface. Maintenance Manager H stated that they used the Peroxide Multi surface cleaner and disinfectant to clean it. The Maintenance Manager stated a porous surface was where water can sit inside the material and non porous was where the surface did not retain any water. Review of the Peroxide Multi surface Cleaner and disinfectant label indicated it was for use as a viricidal and bactericidal disinfectant on a non porous surface. During an interview on 4/14/17 at 11 a.m., the DSD stated for items to be appropriately cleaned, directions should be followed on the cleaning product, and items needed to be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 33 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 appropriate for use and cleanable. 3. During an observation on 4/11/17 at 6:10 a.m., LN E cleaned the glucometer with a wipe from a blue container of Midline Epi-Clenz (brand name) sanitizer wipes before checking Unsampled Resident 23's blood sugar. After using the glucometer, LN E wiped it with a wipe from the red labeled container of Dispatch (brand name) bleach. When asked which wipe should be used LN E stated staff could use either one. During an observation and interview with LN E on 4/11/17 at 7:30 a.m., while looking at the medication cart with the wipes that she used, there was a blue label container of Midline EpiClenz instant hand sanitizer wipes with 65% alcohol and container of red labeled Dispatch bleach wipes which indicated it was effective against bacteria, fungus and viruses in one minute. LN E stated the Midline Epi-clenz was for sanitizing hands and the Dispatch red labeled wipes should have been used to clean the glucometer. L N E stated she was nervous and initially used the wrong wipe to clean the glucometer and stated she usually used the red container wipes. Review of the glucometer (EvenCare G3 meter) manufacturer's updated 2016 guidelines, provided by the facility, indicated Dispatch hospital cleaner disinfectant with bleach was approved cleaner and disinfecting agent for the meter. Review of Cleaning and Disinfection of Resident Care Items and Equipment facility policy, last revised in 2014 , indicated reusable resident care equipment should be decontaminated and or sterilized between resident's according to manufacturer's instructions. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 34 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 4. During an observation on 4/14/17 at 11:45 a.m., there was a Hot Tub Room across from the women's bathroom and housekeeping closet which contained a white Jacuzzi (brand name) tub with jets and a large flexible sprayer shower head as well as a large plastic yellow duck on the side attached to the tub. During an interview on 4/14/17 at 11:50 a.m., Maintenance Manager H stated he was there since October of 2012 and stated the Jacuzzi tub was fairly new then in 2012. Maintenance Manager H stated the tub was rarely used. Maintenance Manager H stated the tub was cleaned with Dispatch disinfectant after it was used and stated there was no log of maintenance or cleaning of the tub. Maintenance Manager H stated he did not know how many times the tub was used since he had been there. Review of the cleaning information, undated, provided by the Maintenance Manager, for Side Entry Whirlpool Tub (part No 1118387) indicated under Cleaning your Tub, in addition to disinfection of the tub after use, staff needed to do a heavy duty' "Shock treatment"' approximately once every 80-150 baths. The Maintenance Manager stated he was not aware of what that shock treatment meant. Review of Section 4- Safety Inspection/Troubleshooting of the side entry whirlpool Tub (part No 1118387) on line manual indicated after 80-150 baths to do a heavy duty cleaning involving a extensive cleaning and disinfection of the tub. The Maintenance Manager stated he watched a video on cleaning the tub with the Dispatch cleaner and stated he was responsible for maintenance of the Tub. The on line manual indicated every 6 months or as necessary, have a qualified technician perform a thorough inspection and servicing. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 35 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 5. During an observation on 4/10/17 at 4:30 p.m., the bathroom wall shared by the residents in Room 20 had multiple of yellowish/brown streaks right of the toilet tank. During an observation on 4/11/17 at 4:30 p.m., the toilet bowl shared by the residents in Room 2 had brown substance on the right side of the toilet bowl rim and inside the toilet bowl. During concurrent observation and interview on 4/12/17 at 3:40 p.m., the bathroom wall shared by the residents in Room 20 still had multiple of yellowish/brown streaks right of the toilet tank. Maintenance Manager H stated the yellowish/brown streaks were probably toilet tank condensation. The toilet bowl shared by the residents in Room 2 still had brown substance on the right side of the toilet bowl rim. When Maintenance Manager H was asked what the brown substance was on the toilet bowl rim, he stated, "Poop." Maintenance Manager H stated the resident bathrooms and bedrooms were deep cleaned every day, but no logs/schedules were kept. During an interview on 4/13/17 at 10:00 a.m., Maintenance Manager H was asked how the housekeepers knew what and how to clean the resident's rooms / bathrooms and the various areas of the facility. He stated everything was based on the deep cleaning policy. During an interview on 4/13/17 at 10:15 a.m. translated by Maintenance Manager H, Housekeeper Z stated she knew what and how to clean because she had been a housekeeper at the facility for years. Housekeeper Z stated her room assignment was Room 19-31, which she started after the residents' breakfast. Review of the facility policy titled, "Room Deep FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 36 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 Cleaning - Policy and Procedure," undated, indicated: 1. Deep clean rooms are disinfected and cleaned according to our Room Deep Cleaning procedure and guidelines as listed in the Room Deep Cleaning Checklist, which was not made available and 2. Environmental staff were to attend specific in-services and training on how to deep clean resident's rooms, which were not made available. Review of the facility policy titled, "Housekeeping Services," dated 2003, indicated thorough scrubbing will be used for all environmental surfaces that are being cleaned in resident care areas. 6. During concurrent observation and interview on 4/12/17 at 5:40 p.m., the bathroom shared by the residents in Room 5/6 had an unlabeled bedpan sitting on top of the toilet tank. Maintenance Manager H stated a resident's bedpan should be stored inside the resident's nightstand. During an interview on 4/17/17 at 10:40 a.m., CNA AA stated a resident's bedpan was supposed to be placed in a plastic bag and then stored inside the resident's nightstand. CNA AA stated if a bedpan was left on top of a resident's toilet, it should be thrown away and stated, "That is a no no." The CNA stated a resident's bedpan did not need to be labeled because the bedpan should be place in a plastic bag and stored in the resident's nightstand. A policy on storing and labeling residents' personal care items was requested, but none was made available. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 37 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 


F460 SS=E BEDROOMS ASSURE FULL VISUAL PRIVACY CFR(s): 483.90(e)(1)(iv)-(v)

F460 05/17/2017 (e)(1)(iv) Be designed or equipped to assure full visual privacy for each resident; (e)(1)(v) In facilities initially certified after March 31, 1992, except in private rooms, each bed must have ceiling suspended curtains, which extend around the bed to provide total visual privacy in combination with adjacent walls and curtains This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to maintain complete privacy for 26 of 62 resident beds by not providing adequate curtains. This failure resulted in or potentially caused lack of privacy, dignity and/or psychosocial harm for residents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 38 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 Findings: During concurrent observation and interview on 4/12/17 at 3:40 p.m., Rooms 4B, 19B, and 26B were missing the front panel privacy curtain, so the residents were not provided full privacy. Maintenance Manager H stated it looked like the wrong privacy curtains were hung back up after being washed. Maintenance Manager H agreed residents in Room 4B, 19B, and 26B were not provided full privacy. During an observation of resident rooms on 4/13/2017 at 8 a.m., the following was identified; Room 1A: Missing one curtain panel to provide complete coverage around bed. Rooms 1B, 2B, 3B, 4B, 5B, 8B, 9B, 10B, 11B, 12B, 15A, 15B, 19A, 19B, 22A, 22B, 23A, 23B, 23D, 27B, 29B: Missing curtain panels to cover the entire foot of the resident beds. Room 7B:No curtains available for entire length of the bed. One side curtain panel was available between Beds A and B leaving Resident B with limited visual privacy. Room 23C: Was missing approximately three feet of the curtain panel to provide complete privacy. Room 24 A: Missing approximately three feet of the curtain panel at the foot of bed. 26 A and B: Were missing multiple panels to provide complete privacy around both beds. During an interview with Unsampled Resident 22 on 4/13/2017 at 8:45 a.m., when asked if she had any concerns about privacy, Resident 22 stated, "Every day." Resident 22 stated staff did not pull the curtains for privacy and it "Makes me feel bad ... I've asked them (to pull curtains) and they say OK and then nothing changes." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 39 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 Observation of Resident 22's room on 4/13/2017 at 8:45 a.m., showed no curtains available to provide privacy along the entire right side of Bed B (Resident 22's bed). Review of the facility policy titled, "Quality of Life - Dignity," revised 8/11, indicated staff shall promote, maintain and protect residence privacy, including bodily privacy during assistance with personal care and during treatment.

F465 SS=F SAFE/FUNCTIONAL/SANITARY/COMFORTA F465 BLE ENVIRON CFR(s): 483.90(i)(5) 05/17/2017 (i) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. (5) Establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account non-smoking residents. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 40 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 by: Based on observation, interview, and record review, the facility failed to ensure a safe, comfortable, and sanitary environment when: 1. There was no hot water in one resident bathroom. 2. 15 out of 17 resident toilets had sharp rust colored bolts anchoring the base of the toilet; Caulking was missing around the base of the toilet; one toilet tank lid was chipped. 3. 16 out of 17 resident bathrooms and/or bedrooms had: a. door frames with chipped paint, b. rubber wall base board either missing, cracked, or loose, and c. walls were scratched, missing paint and/or plaster, and holes. 4. The linoleum located in residents' rooms and bathrooms was chipped, cracked, and/or stained in multiple areas. 5. Blinds were broken in two resident rooms. These failures had the potential to cause environmental hazards due to sharp surfaces, prevent the floor and baseboards to be cleaned and sanitized appropriately, and negatively impact residents comfort and homelike environment. Findings: 1. On 4/10/17 at 10:45 a.m., the hot water in the bathroom shared by the residents in Rooms 26/27 remained cold to touch after continuous running for 5 minutes. The water temperature was 66º Fahrenheit. During concurrent observation and interview on 4/12/17 at 3:40 p.m., the running water used by the residents in Rooms 26/27 was still cold to touch. Maintenance Manager H stated he was aware of the water being cold and stated there FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 41 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 was not much he could do about it and stated it would warm up after awhile. 2. During observations on 4/11/17 at 4:30 p.m., 4/12/17 3:40 to 5:25 p.m., and 4/13/17 at 9:00 a.m.: 2a. Toilets located in the bathrooms shared by the residents in Rooms 3/4, 5/6, 7/8, 9/10, 14/15, 18, 19, 20, 21, 22, 23, 25, and 28/29 had protruding rust colored bolts anchoring the base of the toilet. The toilet bolt caps were missing. b. The base of the toilets had peeled and/or missing caulking (used to fill or close seams or crevices of a toilet base, window, etc.) and / or caulking was rust in color located in the bathrooms shared by the residents in Rooms 2, 7/8, 11/12, 14/15, 19, 22, and 24. c. The residents' toilet tank lid located in the bathroom shared by the residents in Room 19 had an approximate two inch chip located above the toilet lever. 3.a. Residents bathroom door frames located in the bathrooms shared by the residents in Rooms 2, 3/4, 5/6, 7/8, 9/10, 11/12, 16/17, 19, 20, 21, 22, 23, 24, 26/27, and 28/29 had multiple areas with chipped paint. b. Rubber wall base board was either missing, cracked, loose, and/ or pulling away from the wall located in the bathrooms shared by the residents in Rooms 7/8, 21, and 24. c. There was an approximate 6 x 6 inch hole in the wall around the toilet shut off valve located in bathroom shared by the residents in Room 21. d. There was exposed plaster located in Rooms 3B, 5A, 8A, 10A, 19A, 22A, and 24A. e. The bathroom walls were scratched, peeling and/or missing paint, and/or missing plaster in the bathrooms shared by the residents in Rooms 2, 3/4, 20, 21, 23, and 24. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 42 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 4. The linoleum tiles were chipped and/or cracked and the base board was missing in Rooms 11B, 19A, and 25C/D. Multiple bathrooms shared by the residents in Rooms 5/6, 7/8, 11/12, 19, 22, 25, and 28/29 had linoleum tiles which were peeling up, chipped, cracked, and/or had stains that were rusty or grayish purple in color. During concurrent observation and interview on 4/12/17 at 3:40 p.m. to 5:20 p.m., Maintenance Manager H stated the bathroom walls, linoleum tiles, rubber base boards, door frames, etc. should be fixed and caps should cover toilet bolts. Maintenance Manager H stated he was in charge of maintenance, housekeeping, and laundry and had priorities. Maintenance Manager H stated he was notified when something needed to be repaired and/or replaced via way of: 1. the Maintenance Log located at the nurse's station, 2. During the daily stand-up meeting, which all managers attended, and/or 3. after "Angel Rounds." Maintenance Manager H stated "Angel Rounds" referred to the facility managers were assigned resident rooms whereby they checked on the residents and their rooms every day. 5. The window blinds in Rooms 26 and 28 were broken. Review of the policy/procedure titled, "Maintenance Service," revised 12/09, indicated Maintenance Department is responsible for maintaining the building is in good repair and is safe and operable. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 43 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 


F517 SS=F WRITTEN PLANS TO MEET EMERGENCIES/DISASTERS CFR(s): 483.75(m)(1)

F517 05/17/2017 The facility must have detailed written plans and procedures to meet all potential emergencies and disasters, such as fire, severe weather, and missing residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to: 1. Update the Disaster and Emergency Manual to reflect facility specific needs and practices. This failure could impede staff's effective response to assure the safety of residents and visitors during a disaster. 2. Ensure adequate perishable food supplies consistent with the emergency menu as evidenced by inadequate supply of bread for three of nine meals needed during an emergency or disaster. Failure to ensure adequate perishable food supplies to be utilized in the event of a widespread disaster may compromise the nutritional and medical status of residents. Findings: 1. On 4/12/17 at 3:20 p.m., a review of the facility's Disaster Emergency Manual indicated a non-specific emergency plan that was not personalized for the individual needs of facility and location. The Disaster Emergency Manual contained a generic corporate plan from the facility's corporate organization. The paperwork in the manual was not updated to reflect facility specific information. The manual contained multiple forms with headings that were left FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 44 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 blank and missing the name of the facility. During a concurrent interview, the Administrator was asked if the forms in the Disaster Emergency Manual were being used by the facility she replied they were not. The emergency manual contained no evidence of review with assistance of local emergency authorities. The Administrator stated there was no participation by the facility in county disaster planning or county disaster drills. The Disaster Emergency Resident Relocation Plan agreement with an assisted living facility for potential emergency relocation was not updated, complete or available for review according to the Administrator. 2. During concurrent observation, interview, and review of the "Emergency Inventory Guide" and "Emergency Menus," dated 6/11, on 4/14/17 at 3 p.m. and 3:30 p.m., Dietary Supervisor U stated there was no separate bread supply to fulfill the emergency supply recipes: 1. Day 1's lunch menu, which included a tuna sandwich on two slices of bread, 2. Day 2's dinner menu, which included a slice of bread, and 3. Day 3's lunch menu, which included a chicken sandwich on two slices of bread. Dietary Supervisor U stated the two freezers used to store the perishable food products needed for the residents daily meals, which included loaves of sliced bread, were too small to store the additional bread needed for the emergency inventory. Dietary Supervisor U stated she received food products on Tuesday and Friday. Dietary Supervisor U stated there were 39 loaves of bread in the freezers today (4/14/17), but they were being used for the daily scheduled meals. Dietary Supervisor stated if an emergency occurred today (4/14/17), there would be enough bread, but if FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 45 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 an emergency occurred in the next three days, there would not be enough bread to fulfill the recipes for 3 of the 9 emergency meals specified. Dietary Supervisor U stated there was no substitution plan for Day 1's lunch menu, which included a tuna sandwich on two slices of bread, 2. Day 2's dinner menu, which included a slice of bread, and 3. Day 3's lunch menu, which included a chicken sandwich on two slices of bread. Review of the Emergency Inventory Guide, indicated based on a minimum of 168 residents and staff per day, there should be 1. 336 slices of bread for Day 1, 2. 168 slices of bread for Day 2, and 336 slices of bread for Day 3, which totaled 840 slices of bread.

F518 SS=E TRAIN ALL STAFF-EMERGENCY PROCEDURES/DRILLS CFR(s): 483.75(m)(2) FORM CMS-2567(02-99) Previous Versions Obsolete

F518 Event ID: QZNA11 05/17/2017 Facility ID: CA010000082 If continuation sheet 46 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 The facility must train all employees in emergency procedures when they begin to work in the facility; periodically review the procedures with existing staff; and carry out unannounced staff drills using those procedures. This REQUIREMENT is not met as evidenced by: Based on interview, observations and record review the facility failed to review and utilize the Emergency Disaster Manual during staff orientation and inservices. This failure could impede staff's effective response to assure safety of residents and visitors during a disaster. Findings: On 4/12/2017 at 5:00 p.m., the DSD stated during an interview, the Emergency Disaster Training occurred with new employee orientation and at one inservice a year. The DSD stated she relied on what she knows, and did not use the (facility) Disaster binder. On 4/13/2017 at 8:00 a.m., Staffer O was asked to describe the facility procedure for evacuation. He replied, "I do not know." When asked where he would go to find the information, Staffer O looked on posted signs in the lobby and hallway without locating requested information. Staffer O was asked to locate the Disaster /Emergency Binder and he stated he was unaware of its location and requested to ask someone and return with the information later. During a concurrent interview and record review on 4/13/2017 at 3:15 p.m., the DSD was unable to provide documentation of the orientation facility tour and Emergency / Disaster review for LN S, CNA I, CNA B and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 47 of 48 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: _______________ 055853 (X3) DATE SURVEY COMPLETED 04/17/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD COVE HEALTHCARE CENTER 1162 S Dora St Ukiah, CA 95482 (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 the DSS. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: QZNA11 Facility ID: CA010000082 If continuation sheet 48 of 48