Other·June 11, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Depaertment of Public Health during the investigation of an entity reported incident number CA00628755. Representing the Department : 36593, HFEN. The inspection was limited to the specific entity reported incident investigated and does not represent the findings of a full inspection of the facility. Two deficiencies were issued for entity reported incident number CA00628755.

F603 SS=G Free from Involuntary Seclusion CFR(s): 483.12(a)(1)

F603 05/31/2019 §483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide an environment free of corporal punishment and protection from abuse 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: W7D811 Facility ID: CA020000119 If continuation sheet 1 of 6 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: _______________ 555499 (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD HEALTHCARE CENTER LLC 3145 High Street Oakland, CA 94619 (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 when Licensed Vocational Nurse (LVN) 1 locked Resident 1 out of the facility for going outside to smoke a cigarette early in the morning (approximately 5 a.m.). LVN 1 refused to open the front door for Resident 1 to enter the facility. Despite pleas from Resident 1, Resident 1 was left outside for one and half hour in a gown. These failures caused emotional distress for Resident 1 when he cried, expressed having ongoing fear of LVN 1 and had the potential for psychological harm. Findings: During an interview on 3/19/19 at 11:00 a.m., Resident 1 stated, he went out of the front door to smoke cigarette on 3/14/19 around 5a.m. and LVN 1 saw him go out and slammed the door after him. Resident 1 stated he knocked the door and asked LVN 1 to open the door and LVN 1 refused to open the door. Resident 1 further stated he stayed outside for about one and half hour when he saw the Dietary Manager (DM) walk by. Resident 1 asked DM to open the door who did not. Resident 1 waited for Certified Nursing Assistant (CNA) 1 to walk by to open the door for him. Resident 1 stated once he was inside, LVN 1 told him that next time he goes outside to smoke at night LVN 1 will make Resident 1 sleep outside. Resident 1 stated it was cold, he wore only gown, and no pants. Resident 1 stated that LVN 1 had locked him outside the facility on two other occasions for going outside to smoke. Resident 1 stated LVN 1 ran the facility like a jail. Resident 1 stated he felt violated, disrespected, and was moved to tears because of this incident. Record review of the Minimum Data Set (MDS - Resident Assessment tool used to guide FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W7D811 Facility ID: CA020000119 If continuation sheet 2 of 6 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: _______________ 555499 (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD HEALTHCARE CENTER LLC 3145 High Street Oakland, CA 94619 (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 care), dated 2/7/19, indicated Resident 1 had clear speech was able to express his ideas and wants, and understood what others stated to him. Resident 1 was mobile with a wheelchair. Resident 1 had capacity to make decisions by himself. Record review of the physician order, dated 1/24/19, indicated Resident 1 may go out on pass for four hours. During an interview on 3/19/19 at 11:12 a.m., Dietary Manager (DM), stated he walked by the hallway, heard Resident 1 knocked on the front door. DM stated LVN 1 told him not to open the door for Resident 1 to enter the facility. DM stated LVN 1 told DM that Resident 1 did not listen to instructions not to go outside. And that he did not open the door. Record review of the nurse's notes indicated on 3/12/19 around 4:00 a.m., LVN 1 locked Resident 1 outside when he went outside to smoke cigarette. LVN 1 indicated in the record that she was not going to open the door for Resident 1 to enter the facility. Record review of facility's investigation report, indicated on 3/14/19, LVN 1 locked Resident 1 out and refused to open the door for Resident 1 to enter the facility. During an interview on 3/19/19 at 12:05 p.m., LVN 1 stated she locked Resident 1 out of the facility because Resident 1 did not listen to her instruction not to go outside late at night and during the early morning hours to smoke. LVN 1 stated she saw Resident 1 banging the front door and she refused to open the door. LVN 1 stated DM wanted to open the door for Resident 1 but LVN 1 told DM not to open the door for Resident 1 but to let Resident 1 stay outside. LVN 1 confirmed that on 3/12/19 and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W7D811 Facility ID: CA020000119 If continuation sheet 3 of 6 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: _______________ 555499 (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD HEALTHCARE CENTER LLC 3145 High Street Oakland, CA 94619 (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 3/14/19 she had locked Resident 1 out of the facility for going outside to smoke. Record review of Resident 1's behavior care plan, dated 11/14/18 and 12/8/18 included the following interventions: "provide nonconfrontational environment, do not scold or reprimand and do not force resident to comply against their wishes." During an interview on 3/21/19 at 9:56 a.m., CNA 2 stated during the early morning hour of 3/14/19, she heard Resident 1 banging on the front door. CNA 2 stated she opened the door and assisted Resident 1 to his room. CNA 2 stated Resident 1 was upset and cursed at staff. The facility's policy and procedure titled, Abuse-Prevention Program, revised August 2006, read, "Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. Our facility is committed to protecting our residents from abuse by anyone including, but not necessarily limited to facility staff, other residents, consultants, volunteers, staff from other agencies providing services to our residents, family members, legal guardians, surrogates, sponsors, friends, visitors or any individual."

F607 SS=D Develop/Implement Abuse/Neglect Policies CFR(s): 483.12(b)(1)-(3)

F607 05/31/2019 §483.12(b) The facility must develop and implement written policies and procedures that: §483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W7D811 Facility ID: CA020000119 If continuation sheet 4 of 6 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: _______________ 555499 (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD HEALTHCARE CENTER LLC 3145 High Street Oakland, CA 94619 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.12(b)(2) Establish policies and procedures to investigate any such allegations, and §483.12(b)(3) Include training as required at paragraph §483.95, This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to follow its Abuse policy and procedure when Licensed Vocational Nurse (LVN1) was not provided mandated abuse prevention training upon hire or annually. This failure to train LVN 1 contributed to LVN 1 locking Resident 1 out of the facility. Findings: During an interview on 3/19/19 at 12:05 p.m., Licensed Vocational Nurse (LVN) 1, stated she did not remember if she was provided abuse prevention training upon hire or since. LVN 1 went on to say that she locked Resident 1 out of the facility because Resident 1 did not listen to her instruction not to go outside late at night or during early hours of the morning to smoke cigarettes. LVN 1 stated she locked Resident 1 out on the morning of 3/14/19 and would not let him in even though she could see him banging the front door. LVN 1 stated DM wanted to open the door for Resident 1 but LVN 1 told DM not to open the door for Resident 1. LVN 1 confirmed that on two other occasions she had locked Resident 1 out of the facility for going outside to smoke cigarettes. Record review of the employee file, indicated LVN1 was hired 11/1/17. During an interview and review of LVN 1's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W7D811 Facility ID: CA020000119 If continuation sheet 5 of 6 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: _______________ 555499 (X3) DATE SURVEY COMPLETED 05/09/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD HEALTHCARE CENTER LLC 3145 High Street Oakland, CA 94619 (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 employee file on 3/19/19 at 12:49 p.m., the Director of Staff Development (DSD), could not provide LVN1's mandatory Abuse prevention training records and stated LVN1 had no records of abuse prevention training form the time of hire or since. The facility's policy and procedure titled, Abuse- Prevention Program, revised August 2006, read: "Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. Our abuse prevention program provides policies and procedures that govern, as a minimum: (b) Mandated staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse, stress management, dealing with violent behavior or catastrophes, etc." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: W7D811 Facility ID: CA020000119 If continuation sheet 6 of 6