Other·October 30, 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 an entity reported incident and a complaint conducted on 10/26/18. For Entity Reported Incident CA00607785 regarding Quality of Care/Treatment, the Department did not substantiate a violation of federal or state regulations. For Complaint CA00607756 regarding Quality of Care/Treatment, a federal deficiency was identified (see F660). A class "B" citation was also issued. Inspection was limited to the specific entity reported incident and complaint investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 39238, Health Facilities Evaluator Nurse.

F660 SS=D Discharge Planning Process CFR(s): 483.21(c)(1)(i)-(ix)

F660 10/30/2018 §483.21(c)(1) Discharge Planning Process The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to postdischarge care, and the reduction of factors 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: DTMR11 Facility ID: CA070000068 If continuation sheet 1 of 4 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 10/26/2018 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 leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth at 483.15(b) as applicable and(i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident. (ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. (iii) Involve the interdisciplinary team, as defined by §483.21(b)(2)(ii), in the ongoing process of developing the discharge plan. (iv) Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs. (v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan. (vi) Address the resident's goals of care and treatment preferences. (vii) Document that a resident has been asked about their interest in receiving information regarding returning to the community. (A) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose. (B) Facilities must update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities. (C) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why. (viii) For residents who are transferred to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DTMR11 Facility ID: CA070000068 If continuation sheet 2 of 4 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 10/26/2018 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 another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a postacute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality measures, and data on resource use to the extent the data is available. The facility must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident's goals of care and treatment preferences. (ix) Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to involve one of three residents (Resident 1) in discharge planning. This failure resulted in Resident 1 being unaware of her discharge plans. Findings: Review of Resident 1's clinical record indicated she was admitted at the facility on 9/24/18 with diagnoses including anxiety disorder (mental disorder characterized by feelings of worry). Review of Resident 1's minimum data set (MDS, a resident assessment tool) dated 10/6/18, indicated she is cognitively intact. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DTMR11 Facility ID: CA070000068 If continuation sheet 3 of 4 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 10/26/2018 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 Review of interdisciplinary team (IDT, a group of healthcare providers from different fields who work together toward the same goal to provide the best outcome for the resident) care conference dated 9/25/18, indicated Resident 1 did not attend the care conference. During an interview and record review, with minimum data set coordinator (MDSC) on 10/24/18 at 10:41 a.m., he reviewed Resident 1's clinical record and confirmed there was only one IDT conference done. He further stated the IDT care conference on 9/25/18 did not discuss detailed discharge planning for Resident 1. Review of Resident 1's Notice of Action About Your Treatment Request (a letter from an insurance provider) dated 10/17/18 addressed to Resident 1 and the facility, indicated "We only authorize 2 weeks at a time." "If the information is not received within 14 calendar days from the original TAR (TAR, a treatment authorization request) submission date of 10/10/18 the TAR will be subject to administrative denial on 10/31/18. We anticipate that a decision will be made on 10/31/18. You will receive another letter informing you of the decision at that time." "You may appeal this decision. The enclosed 'Your Rights' information notice tells you how." During a telephone interview with Resident 1 on 10/25/18 at 3:57 p.m., Resident 1 stated she did not attend the IDT care conference on 9/25/18. She further stated she did not receive a copy of the Notice of Action About Your Treatment Request letter. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: DTMR11 Facility ID: CA070000068 If continuation sheet 4 of 4