Inspection·October 9, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the observation, interview, and record review, the facility failed to adequately monitor and supervise one of three sampled residents (Resident 1) to prevent him from entering other female residents' rooms. This failure resulted to Resident 1 entering Residen 2 and Resident 3's room and could compromised the residents' rights to a safe environment in the facility. Findings: Review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including Cerebral Infarction due to Unspecified Occlusion or Stenosis of Unspecified Cerebral Artery (blockage or narrowing in a cerebral artery. This leads to a stroke); abnormalities of gait and mobility. Review of Resident 1's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 8/8/24, indicated Resident 1 had a Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 5 indicating severe cognition (mental process of thinking, learning, and understanding) impairment. The MDS indicated that Resident 1 needed supervision for mobility and transfers. Resident 1 uses a wheelchair, and once seated in the wheelchair, Resident was able to wheel at least 150 feet in a corridor independently. Review of Resident 1's Situation, Background, Assessment, Recommendation (SBAR, a communication tool used by healthcare workers when there is a change of condition among the residents) form, dated 8/27/23, indicated Resident 1 was found inappropriately touching himself in front of another female resident (Resident 3). Review of Resident 1's Interdisciplinary (IDT, a group of health care professionals with different areas of expertise who work together toward the goals of the patients) Risk Management Meeting Notes, dated 8/28/23 indicated Resident 1 was found by a certified nursing assistant (CNA) in female residents' room inappropriately touching himself. The CNA escorted Resident 1 from the room and Resident 1 was placed on every 1-hour monitoring following the incident, and a stop sign was placed outside female residents' room to deter Resident 1 from returning. The IDT Risk Management Meeting Notes further indicated Resident 1 had behavior of constantly cleaning hallways and doors. Review of Resident 1's SBAR, dated 9/3/24, indicated Resident 1 was inappropriately touching Resident 2 and was witnessed by CNA A (Certified nursing Assistant A). CNA A saw Resident 1 in Resident (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 055017 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055017 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/09/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Redwood Grove Post Acute 2990 Soquel Avenue Santa Cruz, CA 95062 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)