Other·January 12, 2018

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 a standard abbreviated survey regarding investigation of a complaint conducted on 1/3/18, 1/5/18, and 1/8/18. For Complaint CA00567327 regarding Resident Rights, a federal deficiency was identified (see F550) and a state deficiency was identified for a violation unrelated to the complaint (see Title 22, Section 72541). A Class "B" citation was also issued. Inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility.

F550 SS=D Resident Rights/Exercise of Rights CFR(s): 483.10(a)(1)(2)(b)(1)(2)

F550 01/12/2018 §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A 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: IDP711 Facility ID: CA070000068 If continuation sheet 1 of 3 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: _______________ 055017 (X3) DATE SURVEY COMPLETED 01/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD GROVE POST ACUTE 2990 Soquel Ave Santa Cruz, CA 95062 (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 facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to respect residents' rights when the facility told 4 of 5 sampled residents not to leave their rooms, not to receive visitors, and told residents not to walk outside the building. Findings: During an interview with the director of nursing (DON) on 1/3/18 at 1:45 p.m., she confirmed the facility staff were confining residents in their rooms, limiting visitors and residents were discouraged to walk out on pass or walk out of the building. During an interview with the facility receptionist on 1/5/28 at 1:30 p.m., she stated the facility restricted visitors because of a current outbreak FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IDP711 Facility ID: CA070000068 If continuation sheet 2 of 3 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: _______________ 055017 (X3) DATE SURVEY COMPLETED 01/08/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE REDWOOD GROVE POST ACUTE 2990 Soquel Ave Santa Cruz, CA 95062 (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 or illness. During an observation on 1/5/18 at 1:32 p.m., Resident 1 was sitting on his bed in his room. During an interview with Resident 1 on 1/5/18 at 1:35 p.m., he stated the facility staff told him not to leave his room, not to have any visitors, and not to walk outside of the building. During an observation on 1/5/18 at 1:40 p.m., Resident 2 was laying down in bed in his room. During an interview with Resident 2 on 1/5/18 at 1:41 p.m., he stated the facility also told him not to leave his room, not to have any visitors, and not to walk outside of the building. During an observation on 1/5/18 at 1:43 p.m., Resident 4 was laying down in bed in her room. During an interview with Resident 4 on 1/5/18 at 1:44 p.m., she stated the facility suggested for her to not to leave the room, not to have visitors, and she was told not to walk out of the building but she walked out anyway. During an observation on 1/5/18 at 1:49 p.m., Resident 6 was laying down on his bed in his room. During an interview with Resident 6 on 1/5/18 at 1:50 p.m., he stated that he was told he could not leave his room two nights before and was also told he could not go outside. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: IDP711 Facility ID: CA070000068 If continuation sheet 3 of 3