Other·November 13, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during the investigation of a complaint. Complaint number: CA00657091 Representing the Department: HFEN 31403 The investigation was limited to the specific complaint and does not represent a full inspection of the facility. A deficiency was issued for complaint number CA00657091

F626 SS=D Permitting Residents to Return to Facility CFR(s): 483.15(e)(1)(2)

F626 01/30/2020 §483.15(e)(1) Permitting residents to return to facility. A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following. (i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semiprivate room if the resident(A) Requires the services provided by the facility; and (B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services. (ii) If the facility that determines that a resident who was transferred with an expectation of 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: NUYY11 Facility ID: CA020000119 If continuation sheet 1 of 5 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 11/26/2019 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 returning to the facility, cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges. §483.15(e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility refused to re-admit one of three sampled residents (Resident 1) following a brief hospital emergency department (ED) visit to evaluate knee pain. The hospital determined that Resident 1 was medically stable and ready to return to the facility. The facility refused Resident 1's bed hold request and readmission. This failure resulted in Resident 1's emotional distress when she heard that she would not be allowed to return to her residence at the facility. Findings: A record review of the "Face Sheet" indicated Resident 1 was admitted to the facility and had diagnoses that included Amyotrophic Lateral Sclerosis or ALS. "ALS is a progressive disease that attacks nerve cells that control voluntary movement. The disease makes the nerve cells stop working and die. The nerves lose the ability to trigger specific muscles which FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NUYY11 Facility ID: CA020000119 If continuation sheet 2 of 5 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 11/26/2019 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 causes muscles to become weak and leads to paralysis (loss of the ability to move)." [www.cdc.gov/als] The record review of the nurse's progress notes titled, "Departmental Notes" dated 9/27/19 at 5:50 p.m. indicated Resident 1 was to be transported to the hospital for evaluation of her knee pain. The record review of the physician orders for Resident 1 dated 9/27/19 directed staff to, "Send Resident out to acute (hospital) for further evaluation and management." The record review of the hospital's ED report dated 9/28/19 indicated Resident 1 was brought to the ED for a suspected knee injury. The injury was described as "...no pain, no visible injury..." X-rays of the left knee and thigh bone showed no findings. The "Anticipated Discharge" date was 9/28/19 and disposition was "Medically Stable" to return to the skilled nursing facility. A record review of the hospital's case manager (CM) notes dated 9/27/19 at 2207 (10:07 p.m.) indicated, "Per Dr. (name), pt (patient) is not welcome back at (facility name) ... Update 2237 (11:37 p.m.): CM spoke to family at bedside re: (regarding) situation and (facility name) refusal of pt's return. Pt tearful when hearing news of their refusal ...Update 2345 (11:45 p.m.) ...Unable to place pt back at (facility name) tonight regardless of medical clearance ..." In an interview and concurrent record review, on 10/1/19 at 11:45 a.m., the facility's administrator (ADM) stated Resident 1 was currently in the hospital and could not be readmitted because she required 1:1 care. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NUYY11 Facility ID: CA020000119 If continuation sheet 3 of 5 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 11/26/2019 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 A record review of the "Admission Criteria" (undated) reflected, "The objectives of our admission criteria policy are to ...admit residents who can be cared for adequately by the facility. Examples of conditions that can be treated adequately in this facility include: ...Neuromuscular disorders. Examples of nursing/medical needs that can be met adequately include: ...limited mobility." A record review of the Care Plan Conference Summary dated 8/28/19 reflected there was no documentation that Resident 1 required 1:1 nursing care. Further review of the "discharge plan/return to community referral" section indicated for "LTC" (long term care). In an interview on 10/1/19 at 12:30 p.m., the Licensed Vocational Nurse 1 (LVN 1) stated Resident 1 did not need 1:1 care, and was able to let staff know if she needed anything. The record review of the "Patient Care Plan: Communication Problem" dated 8/23/19 indicated, "1:1 care when available, until acclimated (adjusted) to staff and routine x (times) 3 weeks." There was no plan for continuing 1:1 care after three weeks (9/13/19). A record review of the "Telephone Physician Orders" dated 9/27/19 indicated, "No readmission. Facility cannot provide the care that she needs." There was no documentation indicating what the care needs were that the facility could no longer provide. In an interview on 10/1/19 at 1:40 p.m., the Medical Director (MD 1) stated he wrote the order because staff (unable to recall name) said she required 1:1 nursing supervision, which they could not provide. MD 1 clarified that he did not speak to Resident 1 about this issue, did not think she needed 1:1 care, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NUYY11 Facility ID: CA020000119 If continuation sheet 4 of 5 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 11/26/2019 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 the facility could continue to provide care after her hospitalization. During an observation and interview on 10/1/19 at 1:25 p.m., the Director of Nursing (DON) showed that Resident 1's room was empty and available. A record review of the "Bed Hold Request Form" dated 9/27/19 indicated Resident 1's RP signed the request for bed hold following her return from the hospital. The record review of the "Bed-Holds and Returns" (undated) policy indicated, "Prior to transfer and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. Residents may return to and resume residence in the facility after hospitalization or therapeutic leave as outlined in this policy." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NUYY11 Facility ID: CA020000119 If continuation sheet 5 of 5