Other·March 16, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a REVISIT of the Recertification survey completed 12/12/16 to 12/20/16. Representing the California Department of Public Health was Health Facilities Evaluator Nurse 31423. The census on the date of entry, 2/14/17, was 45. 


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

F323 (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. 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: 2S1G12 Facility ID: CA01000001007 If continuation sheet 1 of 9 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: _______________ 555826 (X3) DATE SURVEY COMPLETED 02/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REDWOODS, A COMMUNITY OF SENIORS 40 Camino Alto Mill Valley, CA 94941 (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 (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 ensure accurate fall risk assessment or full implementation of the fall prevention program for five of five sampled residents admitted due to falls with injury as evidenced by: 1. Resident 6 was not ensured the supervision as specified in her care plan; 2. Resident 1's environment was not free of accident hazards, and her care plan was not revised as appropriate; 3. Resident 13's fall risk was not assessed timely; 4. The facility's "Falling Stars" program was inconsistently implemented for Residents 13 and 15. This failure placed residents at increased risk of injury or death due to additional falls. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2S1G12 Facility ID: CA01000001007 If continuation sheet 2 of 9 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: _______________ 555826 (X3) DATE SURVEY COMPLETED 02/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REDWOODS, A COMMUNITY OF SENIORS 40 Camino Alto Mill Valley, CA 94941 (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 facility document titled "Fall Prevention Program" indicated "Falling Stars is a program used for residents identified at high risk for falls and/or with a history of falls (past or current). It reminds staff to monitor these patients for fall prevention. It alerts staff to patients at risk for falls and who have approaches or interventions in their care plans to reduce and/or prevent repeat falls." Procedures included "3. Update and/or implement Falling Stars interventions if the patient...has a history of falls (past or current)...4. Identify patients that have Falling Stars interventions with the symbol_stars_that means that the patient is at risk for falls; Suggested Placement of the symbol: a. Resident's door....d. Smart Charts - Care Plan Section/Flag Charts." Documentation guidelines indicated, "In patient's smart chart [electronic medical record], light blue fall risk alert would show if pt scored >10-17 score at risk for fall. A red colored fall flag would indicate resident had a recent fall and/or scored >17 identifying pt as high risk." 1. Review of the clinical record for Resident 6 revealed she was admitted to the facility on 2/22/16 following a fall with hip fracture requiring surgical replacement of the hip joint. A subsequent fall on 4/4/16, while residing in the facility, required a second hip surgery. Review of Resident 6's care plan dated 8/23/16 revealed "[Resident 6] at risk of accidental falls related to [history of] falls with [fracture]." Approaches (interventions) dated 2/7/17 included, "provide 1:1 monitoring with sitter or to be brought to office for staff interaction" and "resident to be with staff at all times and with actual transfer of care to next staff." Resident 6's care plan also revealed she was "able to propel self and attempt to transfer FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2S1G12 Facility ID: CA01000001007 If continuation sheet 3 of 9 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: _______________ 555826 (X3) DATE SURVEY COMPLETED 02/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REDWOODS, A COMMUNITY OF SENIORS 40 Camino Alto Mill Valley, CA 94941 (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 independently without assistance to toilet; with poor retention of instructions." Approach dated 8/23/16 included, "ensure resident is within view of staff to monitor activity and for safety." During observation on 2/14/17 at 1 p.m., Resident 6 sat in her wheelchair next to her bed. A visitor, who identified herself as a relative (Family T), sat on Resident 6's bed. During concurrent interview, Family T stated she visited Resident 6 every morning for three or four hours. When asked if she was expected to visit daily or to supervise Resident 6, Family T stated, "No, but we're very close family. I visit every morning." During observation on 2/15/17 at 9:50 a.m., Family T was in Resident 6's room talking on the phone. Resident 6 sat in her wheelchair at a table in the dining room. The activity director and an unidentified male employee were also in the dining room. The activity director left the room, followed approximately one minute later by the male employee, leaving Resident 6 without supervision. The activity director returned approximately two minutes later. No hand off of Resident 6's care was observed. During observation on 2/15/17 at 12:52 p.m., Resident 6 sat in her wheelchair at a table in the dining room after the noon meal. Family T sat beside her at the table. Two serving staff cleared dishes onto a cart in the dining room, and a nursing assistant worked in the adjacent pantry area. Family T left the dining room and walked to the restroom located in the nurses station. No hand off of Resident 6's care was observed. Dietary staff left the dining room and the nursing assistant continued to work in the pantry area. The nursing assistant then went to the far end of the dining room and removed table linens with her back to Resident 6. Resident 6 moved her wheelchair back and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2S1G12 Facility ID: CA01000001007 If continuation sheet 4 of 9 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: _______________ 555826 (X3) DATE SURVEY COMPLETED 02/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REDWOODS, A COMMUNITY OF SENIORS 40 Camino Alto Mill Valley, CA 94941 (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 forth with her feet while she sat unsupervised at the table. Family T returned three minutes later. 2. During observation on 2/14/17 at 11:50 a.m., Resident 1 sat on the edge of her bed reading a magazine. Resident 1's four-wheeled walker was three or four steps away, near the foot of her bed. Several pages of folded newspaper, approximately 11 inches by 11 inches, lay on the floor in the path between Resident 1 and her walker. Resident 1 stood up with the magazine in her left hand, bent forward slightly to touch the bed with her right hand to steady herself, and took several steps to her walker, narrowly avoiding the newspaper on the floor. During observation on 2/15/17, at 1:15 p.m., Resident 1 ambulated with her walker through the dining room, down the hall, into her room, and into her bathroom. At 1:21 p.m., Resident 1 came out of her bathroom with her walker, went to a shelf in her room to retrieve a book, then moved to the edge of her bed and sat down. Multiple observations on 2/14/17 and 2/15/17 revealed a small star next to Resident 1's name outside the door to her room, indicating she was on the Falling Stars program. Review of Resident 1's care plan reflected she was at risk for falls due to a history of fall with fracture. Interventions included "Keep room well lit and clutter free" and "monitor all [out of bed] activities." Resident 1's electronic medical record indicated a fall risk score of 15 (medium risk) on 11/12/17. Her next quarterly fall risk assessment, dated 2/13/17, was 5 (no risk). During an interview on 2/15/17 at 12 p.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2S1G12 Facility ID: CA01000001007 If continuation sheet 5 of 9 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: _______________ 555826 (X3) DATE SURVEY COMPLETED 02/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REDWOODS, A COMMUNITY OF SENIORS 40 Camino Alto Mill Valley, CA 94941 (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 Administrative Staff B stated fall risk meetings were held every Tuesday, and provided a binder containing a weekly list of residents with their fall risk scores. Review of the binder revealed Resident 1 consistently scored 15, including 2/14/17. When queried about the different scores for Resident 1, 5 in her clinical record and 15 in the fall risk binder, Administrative Staff B stated, "That's quite a drop." Administrative Staff B stated the lower score was done by a staff nurse on the evening of 2/13/17 and should be reviewed by the interdisciplinary team. Administrative Staff B confirmed the care plan was not revised to reflect Resident 1's reduced fall risk. Review of the facility's "Fall Prevention Program" indicated "The Interdisciplinary Team makes the decision to keep a patient in Falling Stars or remove a patient from Falling Stars based on the patient's individual needs based on a combination of criteria...." 3. Review of Resident 13's clinical record indicated she was 99 years old and admitted 1/12/17 after a fall resulting in a neck fracture. During an interview and concurrent review of Resident 13's electronic medical record on 2/15/17 at 10:50 a.m, Administrative Staff S confirmed Resident 13 had a single fall risk assessment, "opened" on 1/16/17 and electronically signed and "locked" on 2/14/17. Review of a printed copy of Resident 13's Fall Risk Assessment revealed a "form date" of 1/16/17. Administrative Staff S confirmed she could not tell when the assessment was actually done. During an interview on 2/15/17 at 12 p.m., Licensed Staff D stated the "form date" indicated when the electronic form was initially opened, and the "locked" date indicated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2S1G12 Facility ID: CA01000001007 If continuation sheet 6 of 9 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: _______________ 555826 (X3) DATE SURVEY COMPLETED 02/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REDWOODS, A COMMUNITY OF SENIORS 40 Camino Alto Mill Valley, CA 94941 (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 final step of signing and closing the form. Licensed Staff D confirmed the date of Resident 13's fall risk assessment could be any time between when the form was opened 1/16/17 and locked on 2/14/17. During an interview on 2/15/17 at 2:15 p.m., when queried about the facility policy regarding completion of an initial fall risk assessment, Administrative Staff B stated, "I think 24 hours after admission." Licensed Staff D stated, "I'm not sure. Review of the facility's Fall Prevention Program indicated "Identify patients that are newly admitted or readmitted with a high-risk falls [sic] or have a potential for repeat falls. Assess patient quarterly, annually and with significant change to identify patients' change in risk status." The policy did not address how soon after admission a fall risk assessment must be completed. 4. Review of Resident 15's clinical record revealed she was admitted to the facility on 1/26/17 after a fall resulting in pelvic fracture. Resident 15's fall risk assessment scored 10 (low risk), despite her admission for a fall with injury 19 days previously. The chart did not include a red flag indicating a recent fall per facility policy. Multiple observations on 2/14/17 and 2/15/17 revealed no star by Resident 15's door per facility policy. Review of Resident 13's clinical record revealed she was admitted to the facility on 1/12/17 after a fall resulting in a neck fracture. Resident 13's fall risk assessment scored 10 (low risk), despite her admission for a fall with injury 34 days previously. The chart included a red flag indicating a recent fall, but multiple observations on 2/14/17 and 2/15/17 revealed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2S1G12 Facility ID: CA01000001007 If continuation sheet 7 of 9 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: _______________ 555826 (X3) DATE SURVEY COMPLETED 02/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REDWOODS, A COMMUNITY OF SENIORS 40 Camino Alto Mill Valley, CA 94941 (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 no star by Resident 13's door per policy. During an interview on 2/15/17 at 12:54 p.m., Administrative Staff B was asked to explain the Falling Stars program. Administrative Staff B stated residents with a high risk of falls had a colored flag (red or blue) in their electronic medical record and a star placed next to their names by the door to their rooms. Administrative Staff B stated residents were considered high risk if their score was greater than 14 on the fall risk assessment, or if they had a recent fall. When asked what was considered a "recent fall," Administrative Staff B stated, "In the last quarter," and confirmed a quarter was the previous three months. When asked how Resident 15 was identified as low risk after a fall with a broken neck, or how Resident 13 was identified as low risk after a fall with a pelvic fracture yet had a red flag in her chart but no star outside her room, Administrative Staff B had no response. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2S1G12 Facility ID: CA01000001007 If continuation sheet 8 of 9 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: _______________ 555826 (X3) DATE SURVEY COMPLETED 02/15/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REDWOODS, A COMMUNITY OF SENIORS 40 Camino Alto Mill Valley, CA 94941 (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 
 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2S1G12 Facility ID: CA01000001007 If continuation sheet 9 of 9