Health inspection·June 25, 2024

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide written notice prior to multiple room changes for one of four sampled residents (Resident 1). This failure had the potential to compromise Resident 1's rights. Also, there was no documentation that the facility monitored Resident 1 after one room change. This failure had the potential to compromise the facility's ability to identify complications related to the room change and implement interventions accordingly. Findings: Review of Resident 1's clinical record indicated he was admitted on [DATE]. Further review of the clinical record indicated the facility implemented room changes for Resident 1 on 11/15/23, 11/17/23, and 1/2/24. During a telephone interview and concurrent record review with social services staff C (SS C) on 6/25/24, at 1:13 p.m., SS C reviewed Resident 1's clinical record remotely (from a location outside of the facility) and confirmed Resident 1 had room changes on the dates mentioned above. SS C explained when the facility implements room changes, they should complete a Room Transfer form (document that explains the reason for the room change and that must be signed by the resident), complete a consent form, and do behavior/psychosocial monitoring for 72 hours. SS C confirmed for Resident 1's room changes on 11/15/23, 11/17/23, and 1/2/24, there was no documentation that indicated the facility completed a Room Transfer form or a consent form prior to the room changes. SS C also confirmed for Resident 1's room change on 1/2/24, there was no documentation that indicated the facility did behavior/psychosocial monitoring for 72 hours. Since SS C was reviewing Resident 1's clinical record remotely, licensed nurse D (LN D) was also asked to review the record. During an interview and concurrent record review with LN D on 6/25/24, at 1:43 p.m., LN D reviewed Resident 1's medical record and confirmed for the room changes on 11/15/23, 11/17/23, and 1/2/24, there was no documentation that indicted the facility completed a Room Transfer form or a consent form prior to the room changes. LN D also confirmed for Resident 1's room change on 1/2/24, there was no documentation that indicated the facility did behavior/psychosocial monitoring for 72 hours. The facility's policy titled Room Change/Roommate Assignment, revised 3/2021, indicates the resident is given advanced written notice prior to a room change. 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 4 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 06/25/2024 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)