Health inspection·April 14, 2023

F 0555 Honor the resident's right to choose his or her attending physician. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure resident's primary care physician's current working phone number was listed on their face sheets (a document in each resident's clinical record that indicated a summary of the resident's important information) for three out of three residents (Resident 1, 2, and 3). This failure had the potential for residents, and residents' responsible parties (RP - responsible party) to be unable to contact the residents' primary care physician when needed. Residents Affected - Few Findings: Record review of Resident 1's face sheet indicated admission on [DATE] with the attending primary physician's name and his contact phone number. Record review of Resident 2's face sheet indicated admission on [DATE] with the attending primary physician's name and his contact phone. Record review of Resident 3's face sheet indicated admission on [DATE] with the attending primary physician's name and his contact phone number. During a phone interview with Resident 1's RP on 3/24/2023 at 8:25 a.m., the RP stated the facility provided her a non-working contact phone number for Resident 1's primary care physician when she requested to talk to Resident 1's physician. She stated she was unable to contact this physician with the phone number provided. During record review and concurrent interview with the director of nursing (DON) on 3/24/2023 at 3:15 p.m., the DON acknowledged the face sheets for Residents 1, 2, and 3 indicated the primary care physician's name and phone number. The health facilities evaluator nurse (HFEN) in the presence of the DON, called the primary care physician's phone number indicated on the face sheets four times. Each time HFEN called, received a busy tone, and was disconnected shortly thereafter. The DON acknowledged the physician's contact phone number indicated on the face sheets was not a working number. The DON confirmed this phone number was given to residents and their families upon request. The DON stated staff should have updated residents' face sheets with their physician's current working phone number. Review of facility's policy and procedure (P&P), Record of Admission, revised December 2006, it indicated, At the time of the resident's admission, a resident identification and summary record is completed. Our identification and summary record includes, but not limited to: The name and telephone number of the resident's attending and alternate physician. (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: 056212 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 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 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)