Inspection visit

OtherJuly 29, 2019

Q: What happened during the July 29, 2019 survey of Redwood Grove Post Acute?

This was a other survey of Redwood Grove Post Acute on July 29, 2019. The surveyor cited no deficiencies.

Q: Were any deficiencies cited at Redwood Grove Post Acute on July 29, 2019?

No deficiencies were cited during this survey.

Q: What type of survey was this?

This was a other survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

Redwood Grove Post AcuteCMS #070000068

Clean visit · 0 citations

Inspector’s narrative

What the inspector wrote

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 recertification survey conducted on 7/17/19. The facility was licensed for 144 beds. The census at the time of the survey was 111. The sample size was 23. A Class "B" citation was issued (see F755 and

F759). For Facility Reported Incident CA00643743 regarding Quality of Care/Treatment, a federal deficiency was identified (see F689). Representing the California Department of Public Health: 38174 Health Facilities Evaluator Nurse; 10918, Health Facilities Evaluator Nurse; 39949 Health Facilities Evaluator Nurse; 38087, Health Facilities Evaluator Nurse; 35790, Health Facilities Evaluator Nurse; 39588, Health Facilities Evaluator Nurse.

F552 SS=D Right to be Informed/Make Treatment Decisions CFR(s): 483.10(c)(1)(4)(5)

F552 08/05/2019 §483.10(c) Planning and Implementing Care. The resident has the right to be informed of, and participate in, his or her treatment, including: §483.10(c)(1) The right to be fully informed in language that he or she can understand of his or her total health status, including but not limited to, his or her medical condition. §483.10(c)(4) The right to be informed, in advance, of the care to be furnished and the type of care giver or professional that will 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: 9W9N11 Facility ID: CA070000068 If continuation sheet 1 of 45 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 07/17/2019 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 furnish care. §483.10(c)(5) The right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to follow it's policy for one of one sampled resident (Resident 88) when Resident 88's legal representative was not notified Resident 88 refused to use the splint. This failure had violated the right of the resident and his legal representative to choose treatment alternative or choose other options that resident prefer. Findings: Review of Resident 88's clinical record indicated, Resident 88 had diagnoses including anoxic brain damage (an injury to the brain due to lack of oxygen). Review of Resident 88's Order Summary dated 5/3/19 indicated, he had an order for restorative nursing assistant program (RNA program, exercise program intended to maintain or improve physical function) for orthotic (an artificial support or brace for the limbs) donning (put on) on left upper extremities (LUE) for six hours three times a week. During an interview with restorative nursing assistant E (RNA E) on 7/16/19 at 11:15 a.m., he stated Resident 88 had been refusing to wear the splint on his LUE. Review of Resident 88's "Physician FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 2 of 45 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 07/17/2019 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 Communication Facsimile" dated 7/8/19, indicated the provider was informed of Resident 88's refusal to wear the splint. The provider wrote an order "please notify responsible person, significant other ..". There was no evidence in Resident 88's clinical record the significant others was informed. During a concurrent interview and record review with registered nurse C (RN C) on 7/17/19 at 8:52 a.m., he confirmed the legal representative was not notified of Resident 88's refusal to wear the splint. Review of the facility's undated policy, "Change of Condition Notification", indicated notification of ....legal representative or family member should be properly documented in the resident's medical record.

F554 SS=D Resident Self-Admin Meds-Clinically Approp CFR(s): 483.10(c)(7)

F554 08/05/2019 §483.10(c)(7) The right to self-administer medications if the interdisciplinary team, as defined by §483.21(b)(2)(ii), has determined that this practice is clinically appropriate. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 3 of 45 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 07/17/2019 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 This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to implement the policy on self-administration of medication for two of two sampled residents (Residents 87 and 86) when medications were kept at Residents 87 and 86 room unattended. These failures had the potential for unsafe and improper administration of medications. Findings : 1. Review of Resident 87's clinical record indicated, she was admitted to the facility with a diagnoses including encephalopathy (a disease that affects the function or structure of the brain). Review of Resident 87's Minimum Data Set (MDS, an assessment tool) dated 5/13/19 indicated, she was cognitively intact. During an observation on 7/14/19 at 10:31 a.m. in Resident 87's room, two bottles of Tums (an anti-acid medication) were found on top of the bedside cabinet and one bottle at the tray table. During an interview with Resident 87, she stated, "I take two Tums twice a day and I had those since I came here." During a concurrent interview and record review with registered nurse B (RN B) on 7/14/19 at 10:49 a.m., she confirmed the above observation. RN B stated Resident 87's "Self Administration of Medication Assessment" dated 7/8/19, indicated Resident 87 did not chose to self-administer but the interdisciplinary team (IDT, team members from different departments involved in a resident's care) recommended she was a candidate for selfFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 4 of 45 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 07/17/2019 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 administration. RN B stated the IDT should have reassessed Resident 87's selfadministration of medication. RN B also stated, Resident 87 did not have an order for Tums. 2. Review of Resident 86's clinical record indicated, she was admitted to the facility with a diagnoses including Alzheimer's Disease (a type of brain disorder that causes problems with memory, thinking and behavior). During an observation on 7/14/19 at 10:43 a.m. in Resident 86's room, a bottle of B-complex (a type of vitamin supplements) with Resident 86's name was on top of the bedside table. Resident 86 stated, "I don't take it." During a concurrent interview and record review with RN B on 7/14/19 at 10:49 a.m., she confirmed, the above observation. RN B stated the medicine should not be with Resident 86. RN B also stated, Resident 86 did not have order for B-complex. Review of Resident 86's "Self Administration of Medication Assessment" dated 6/21/19 indicated, Resident 86 was not a candidate for self administration of medication. Review of the facility's 11/17 policy, "SelfAdministration by Resident ", indicated residents who desire to self-administer medications were permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe and the medications were appropriate and safe for selfadministration. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 5 of 45 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 07/17/2019 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)

F656 Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) SS=D ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 08/05/2019 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 6 of 45 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 07/17/2019 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 (A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to develop a comprehensive care plan for one of 23 (Resident 90) when the interdisciplinary team (IDT, a team of different professional disciplines that work together to provide the greatest benefit for the resident) did not assess Resident 90 to accommodate his food preferences. This failure had the potential for a decline in quality of life. Findings: Review of Resident 90's clinical record, his minimum data set (MDS, an assessment tool) dated 6/26/19, indicated Resident 90 is able to make his needs known and was cognitively intact. During an interview with Resident 90 on 7/14/19 at 11:24 a.m., he stated he wanted regular textured food and does not want pureed food. During an observation on 7/15/19 at 7:50 a.m., certified nursing assistant I (CNA I) fed Resident 90 pureed textured food for breakfast. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 7 of 45 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 07/17/2019 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 Resident 90 requested for pancakes and regular textured food; CNA I stated the kitchen sent him pureed food. Review of Resident's 90's quarterly nutrition assessment dated 4/4/19, indicated a recommendation from the registered dietician (RD) for the IDT to discuss Resident 90's preference for regular textured food to improve quality of life. During an interview and concurrent record review with the director of nursing (DON) on 716/19 at 5:13 p.m., he reviewed the nutrition assessment of the RD on 4/4/19 and confirmed record review above. The DON stated the IDT should have discussed Resident 90's food preference. The DON further reviewed Resident 90's clinical record and was unable to find an IDT discussion regarding Resident 90's food texture preference. During an interview with the social services director (SSD) on 7/17/19 at 8:21 a.m., she stated she could not find any IDT meeting that discussed Resident 90's preference for a food texture upgrade. Review of the facility's policy, "Comprehensive Care Plan" revised on 4/16, indicated the facility's care planning/IDT develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain.

F658 SS=D Services Provided Meet Professional Standards FORM CMS-2567(02-99) Previous Versions Obsolete

F658 Event ID: 9W9N11 08/05/2019 Facility ID: CA070000068 If continuation sheet 8 of 45 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 07/17/2019 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 CFR(s): 483.21(b)(3)(i) §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to follow physician orders for one of one sampled resident (Resident 52), when registered nurse (RN) did not give apple juice and glucagon (hormone) as ordered during hypoglycemic episodes (blood sugar below reference ranges). These failures had the potential to result to life-threatening complications. Finding: During review of clinical record, Resident 52 was admitted on 2/24/19 with diagnoses including diabetes mellitus (DM, high blood sugar) with non-coma (deep state of prolonged unconsciousness) ketoacidosis (excess blood acids), DM Type 1 (insulin dependent) with hyperglycemia (blood sugar above target levels), and DM Type 2 (adult onset diabetes) with diabetic autonomic neuropathy (type of nerve damage that can occur with diabetes). During observation on 7/14/19 at 9:00 a.m., Resident 52 was lying in bed and his eyes closed in a deep sleep. On 07/15/19 at 4:30 p.m., Resident 52 was sitting in bed and conversant. He stated yesterday morning he had hypoglycemic episode. Resident 52 also stated the nurse gave his insulin too early and did not ensure he ate his breakfast. The paramedic staff injected sugar in him. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 9 of 45 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 07/17/2019 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 During an interview with CNA U on 7/16/19 at 9:02 a.m., CNA U stated Resident 52 was shaking while walking in the nurses' station. Resident 52 had tremors and body sweat. During interview with RN T on 7/15/19 at 4:45 p.m., RN T stated she checked Resident 52's finger sticks blood glucose (FSBG, a method to measure blood sugar) on 7/14/19 at 7:15 a.m. When the result showed 42 milligrams per deciliter (mg/dl, unit of sugar in the blood), RN T did not give apple juice to Resident 52 which he preferred because immediately available on hand was orange juice. RN T also stated that when Resident 52's FSBG continued to drop from 42 mg/dl to 23 mg/dl, RN T did not administer glucagon because she did not know it was available in the emergency kit and so she called paramedics who gave dextrose (simple sugar). Review of Resident 52's physician's order dated 5/17/19 indicated the following orders: "If hypoglycemic, please give apple juice instead of orange juice; Give Glucagon 1 mg IM/SC x 1 if BS is low and unresponsive, check FSBS 15 min if remain unresponsive with low BS MR X 1, notify MD and call 911 as needed for DM; Hypoglycemia protocol: >70 Call MD, Give 4 oz PO repeat FSBS in 15 min and notify MD as needed; Give oral instant glucose 31 gm PO if needed BS < 70, check BS in 10 min if continue to be low MR x 1 & call MD, as needed. The facility's policy and procedure, "Nursing Care of the Resident with Diabetes Mellitus" revised date 4/07, indicated, " Assist the resident with his or her specific medication regimen, as ordered and as needed..." According to https://emedicine.medscape.com/article/ FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 10 of 45 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 07/17/2019 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 2087913-overview#a1, indicated the American Diabetes Association defines the normal glucose reference ranges as: Fasting plasma glucose - 70-99 mg/dL, Postprandial plasma glucose at 2 hours - Less than 140 mg/dL , Random plasma glucose - Less than 140 mg/dL . The value for hypoglycemia is a blood glucose level of less than 70 mg/dL.

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 08/05/2019 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide an oversight to prevent fall for two of six sampled residents (Residents 34 and 101), when Resident 34 and Resident 101 had a fall incident and sustained an injury. Findings: 1. Review of Resident 34's clinical record, Resident 34 was admitted on 2/12/18 with diagnoses including Alzheimer's disease (memory loss), glaucoma (group of eye conditions that can cause blindness) and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 11 of 45 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 07/17/2019 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 benign neoplasm of prostate (age-associated prostate gland enlargement that can cause urination difficulty). Review of Resident 34's MDS dated 7/03/19, indicated Resident 34 was severely impaired cognitively and required supervision during transfer and ambulation. Review of Resident 34's fall risk assessment dated 4/30/19 indicated Resident 34 was high risk for fall. During observation on 7/14/19 at 10:16 a.m., Resident 34 was alert and sat in a wheelchair and propelled himself in the hallway. During review of Resident 34's progress note dated 6/14/19, indicated Resident 34 had an unwitnessed fall in the hallway and sustained a skin tear on his right arm. During interview with LVN Q on 7/18/19 at 4:14 p.m., LVN Q stated she lost sight of him at the time. During interview with CNA R on 7/18/19 at 4:47 p.m., CNA R stated the assigned CNA to the resident was busy working with another resident. Review of Resident 34's fall care plan dated 2/20/17, indicated "Monitor safety for unassisted transfer. Educate and provide verbal cues for safety awareness and assist resident when needed." 2. Review of Resident 101's clinical record, Resident 101 was admitted on 9/28/18 with diagnoses including dementia (memory loss), glaucoma, and osteoporosis (causes bones to become weak and brittle). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 12 of 45 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 07/17/2019 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 Resident 101 's comprehensive MDS dated 4/16/19, indicated Resident 101 was severely cognitively impaired and required supervision during transfers. Review of Resident 101 's fall risk assessment dated 6/16/19, indicated Resident 101 was fall high risk (score of 10). Resident 101 had history of exit seeking/ wandering room to room or within the building or out of the facility. During observation on 7/14/19 at 9:52 a.m., Resident 101 was not in her bed. Resident 101 was alert, speaking Spanish, and was wearing plain black closed shoes. Resident 101 was walking independently with no assistive device in the hallway at Station 2. Review of Resident 101's progress note dated 6/26/19, indicated at 6:00 p.m., Resident 101 was found on floor and sustained a head laceration (1 cm). Resident 101 was transferred via ambulance to acute hospital for CT scan and evaluation. During an interview with CNA N on 7/16/19 at 1:15 p.m., CNA stated there was no regular periods to monitor the whereabouts of Resident 101. During an interview with RNA O on 7/16/19 at 9:15 p.m., she stated CNA P could not find Resident 101 at the time. It was too late to assist Resident 101 when RNA O saw her tripp on the floor in the RNA area. RNA O also stated that sometimes the resident would remove her shoes. During an interview with CNA P on 7/17/19 at 10:45 a.m., CNA P stated he could not find Resident 101 after she ate her dinner. RNA O called CNA P to go to RNA area where she saw Resident 101's bleeding head. CNA P also FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 13 of 45 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 07/17/2019 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 stated there was no constant period of time to actually watch resident's whereabouts and that whoever facility staff present where the resident was, had to supervise the resident to prevent his fall. During an interview with LVN F at 11:00 a.m., she stated "Staff at least should know her whereabouts." Review of Resident 101's fall care plan related to dementia with wandering behavior dated 10/01/18 indicated "Educate and provide verbal cues for safety awareness and assist resident when needed. Monitor resident's whereabouts regularly or at frequent intervals. Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, resident prefers..."

F740 SS=D Behavioral Health Services CFR(s): 483.40

F740 08/05/2019 §483.40 Behavioral health services. Each resident must receive and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident's whole emotional and mental well-being, which FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 14 of 45 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 07/17/2019 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 includes, but is not limited to, the prevention and treatment of mental and substance use disorders. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 88) with behavioral problem would be adequately monitored and would received the necessary care and services. This failure had the potential for residents not attaining their highest well-being. Findings: Review of Resident 88's clinical record indicated, he was admitted to the facility with a diagnoses including anoxic brain damage (an injury to the brain due to lack of oxygen). Review of Resident 88's Minimum Data Set (MDS, an assessment tool) dated 6/26/19, indicated he had memory problem and severely impaired cognitively. Review of Resident 88's Order Summary Report dated 3/22/19, indicated Resident 88 was nothing by mouth (NPO, [nil per os] a medical instruction meaning to withhold food and fluids) and required enteral feeding (nutrition taken through the mouth or through a tube that goes directly to the stomach) through his gastrostomy tube (G-tube, a tube inserted through the wall of the abdomen directly into the stomach). Review of Resident 88's care plan dated 4/23/19 indicated chewing on personal items and/or self. The interventions were to notify the provider, physical and occupational therapist, and redirect Resident 88 when noted chewing on personal item and self. On 6/17/19 Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 15 of 45 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 07/17/2019 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 88 had a behavioral problem; picks on his dressing and put on his mouth,and episodes of yelling. The interventions did not include specific approach to address the behavior of picking on his dressing and putting on his mouth. Review of Resident 88's therapy progress documentation dated 4/23/19, indicated the speech therapist reviewed his functional status related to his oral intake and gratification, and determined Resident 88 was not safe to resume oral intake. During an observation with certified nursing assistant D (CNA D) on 7/15/19 at 9:30 a.m., Resident 88 was continuously chewing a white object. CNA D stated, "he was eating his dressing from his thigh". CNA D pointed on Resident 88's right thigh wound and it did not have a dressing in place. CNA D stated, "he had this behavior before". During an interview with registered nurse C (RN C) on 7/15/19 at 9:38 a.m., he confirmed Resident 88's behavior of chewing his gowns, linens, and wound dressing was not new, "anything he could grab, he would eat". RN C stated he knew Resident 88 had a monitoring behavior every two hours in place. During an interview and concurrent record review with RN A on 7/15/19 at 3:52 p.m., he confirmed Resident 88 did not have the every two hours behavior monitoring. RN A stated Resident 88 care plan should indicate specific interventions to address the above behaviors. Review of the facility's policy, "Comprehensive Care Plan" revised on 4/16, indicated the facility's care planning/IDT develops and maintains a comprehensive care plan for each resident that identifies the highest level of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 16 of 45 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 07/17/2019 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 functioning the resident may be expected to attain . Care plans were revised as changes in the resident's condition dictate.

F755 SS=E Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 08/05/2019 §483.45 Pharmacy Services The facility must provide routine and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 17 of 45 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 07/17/2019 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 emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure the policy regarding use of emergency medication kit was implemented when used emergency medication kits were not returned to pharmacy and items removed from the emergency medication kit were not documented. These deficient practices have the potential to compromise the health and safety of the residents due to lack of emergency medication kit accountability which may lead to improper FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 18 of 45 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 07/17/2019 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 drug use. During a medication storage audit with the director of nursing (DON) on 7/15/19 at 8:49 a.m., the following were observed: 1. Pharmacy emergency kit was found inside a medication cabinet with following labels: a. IV (intravenous) supply emergency kit with a green plastic zip tie. b. IV medication emergency kit with a green plastic zip tie. c. Oral emergency kit with a green plastic zip tie. d. Injectable emergency kit with a green plastic zip tie. e. CIII - CV (Controlled Substances 3 to 5) emergency kit with a green plastic zip tie. f. CII (Controlled Substances 2) Narcotic emergency kit with a green plastic zip tie. Each pharmacy emergency kits were labeled with specific medications, quantity, expiration dates and pharmacy label. During a follow-up interview with the DON, he confirmed the green plastic zip tie means emergency kits are sealed and not been used. 2. A clear box labeled "Tray 2" was found inside a medication cabinet with the following medications inside: a. 2 vials of Meropenem (antibacterial agent used to treat infections) 500 mg (milligram, a unit of measurement) b. 2 vials of Ceftriaxone (antibacterial agent used to treat infections) 1 gm (gram, a unit of measurement) c. 4 vials of Imipenem Cilastatin (antibacterial agent used to treat infections) 500 mg d. 3 vials Clindamycin 500 mg / 4 ml FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 19 of 45 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 07/17/2019 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 (antibacterial agent used to treat infections) (milliliters, a unit of measurement) e. 4 Cefasolin 1 gm (antibacterial agent used to treat infections) Review of the label on top of the clear box labeled "Tray 2" revealed list of following medications: a. Piperacillin / Tazobactam (antibacterial agent used to treat infections) 3.375 mg vial (#2) b. Meropenem 500 mg / vial (#4) c. Ceftriaxone 1 gm vial (#4) d. Impinem / Cilastatin 500 mg vial (#4) e. Cefazolin 1 gm vial (#6) f. Clindamycin 600 mg/4ml (#3) g. Piperacillin / Tazobactam 2.25 gm vial (#6) During a follow-up interview with the DON, he confirmed the label corresponded with the contents and quantity of the clear box labeled "Tray 2." 3. A clear box labeled "Tray 1" was found inside a medication cabinet with the following medications inside: a. 4 vials of Ampicillin Sulbactam (antibacterial agent used to treat infections) 1.5 gm b. 3 vials of Cefepime (antibacterial agent used to treat infections) 1 gm c. 4 vials of Ampicillin (antibacterial agent used to treat infections) 1 gm d. 3 vials of Nafcillin (antibacterial agent used to treat infections) 2 gm Review of the label on top of clear box labeled "Tray 1" revealed list of following medications: a. Ampicillin / Sulbactam 1.5 gm/ml (#6) b. Cefepime 1gm vial (#4) c. Vancomycin (antibacterial agent used to treat infections) 500 mg vial (#2) d. Ceftazidime (antibacterial agent used to treat infections) 1 gm vial (#4) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 20 of 45 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 07/17/2019 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 e. Ampicillin (antibacterial agent used to treat infections) 1 gm vial (#6) f. Vancomycin 750 vial (#2) g. Nafcillin 2 gm vial (#3) h. Vancomycin 1 gm vial (#2) During a follow-up interview with the DON, he confirmed the label corresponded with the contents and quantity of the clear box labeled "Tray 1". 4. Another clear box labeled "Tray 2" was found inside a medication cabinet with the following medications inside: a. 2 vials of Piperacillin /Tazobactam 3.375 mg b. 3 vials of Ceftriaxone 1 gm c. 4 vials Impinem / Cilastatin 500 mg d. 6 vials Cefazolin 1 gm e. 3 vials Clindamycin 600 mg/ 4 ml f. 6 vials of Piperacillin /Tazobactam 2.25 mg Review of the label on top of the clear box labeled "Tray 2" revealed list of following medications: h. Piperacillin / Tazobactam 3.375 mg vial (#2) i. Meropenem 500 mg / vial (#4) j. Ceftriaxone 1 gm vial (#4) k. Impinem / Cilastatin 500 mg vial (#4) l. Cefazolin 1 gm vial (#6) m. Clindamycin 600 mg/4ml (#3) n. Piperacillin / Tazobactam 2.25 gm vial (#6) During a follow-up interview with the DON, he confirmed the label corresponded with the contents and quantity of the clear box labeled "Tray 2". During a follow-up interview with the DON on 7/15/19 at 9:08 a.m., he stated medication found inside the three clear boxes were facility owned and purchased. The DON stated facility bought the above medications because FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 21 of 45 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 07/17/2019 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 pharmacy was always late in delivering medications. The DON confirmed there were no logs used to account medications that was taken from three clear boxes. The DON confirmed the three boxes did not have green zip ties and a specific pharmacy label. During an interview with the consultant pharmacist (CP) on 7/15/19 at 3:48 p.m., she stated the three clear boxes found inside the medication cabinets were part of an IV medication emergency kit from the pharmacy. The CP stated the facility should have a log related to what was taken out of emergency kit. The CP stated she was at facility two months ago and denied seeing three clear boxes with medications inside medication cabinet. During an interview with the CP on 7/15/19 at 5:07 p.m., she confirmed those clear boxes were not intended to be taken out of the pharmacy emergency kit and should have been returned to the pharmacy after opening. During an interview with the DON on 7/15/19 at 5:12 p.m., the DON stated he was new at the facility and did not know medications that were found inside clear boxes were part of emergency kits. The DON confirmed he previously, when asked by the surveyor, responded incorrectly. During an interview with administrator (ADM) on 7/17/19 at 12:38 p.m., she stated medications that were found inside the clear boxes were pharmacy owned. The ADM stated the DON was new and provided the surveyor a "wrong" answer. The ADM stated she was not aware staff took clear boxes out of the pharmacy IV emergency kit and left it in the facility. The ADM confirmed staff should have placed the clear boxes back inside the pharmacy IV emergency kit upon returning the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 22 of 45 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 07/17/2019 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 kit to pharmacy. A review of the facility's policy, "Emergency Pharmacy Service and Emergency Kits (California Specifics)" dated 9/10, indicated: " #8. Upon removal of any medication or supply item from the emergency kit, the nurse documents the medication or item used on an emergency kit lo. One copy of this information should be immediately faxed to the pharmacy with the original prescriber order or refill request form and placed within the resealed emergency kit until it is scheduled for exchange. The hard copy will be retained in the nursing care center. Items to be documented on the log include: a. Resident's name b. Medication name, strength and quantity c. Date and time of medication removal d. Prescriber's name e. Date and time pharmacy notified f. Signature of nurse removing and administering the dose. #12. When the replacement kit arrives, the receiving nurse gives the used kit to the pharmacy personnel for return to the pharmacy."

F757 SS=D Drug Regimen is Free from Unnecessary Drugs CFR(s): 483.45(d)(1)-(6)

F757 08/05/2019 §483.45(d) Unnecessary Drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used§483.45(d)(1) In excessive dose (including duplicate drug therapy); or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 23 of 45 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 07/17/2019 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 §483.45(d)(2) For excessive duration; or §483.45(d)(3) Without adequate monitoring; or §483.45(d)(4) Without adequate indications for its use; or §483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or §483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide adequate monitoring for efficacy of Nuedexta (used to treat uncontrollable laughter or crying) for one of one sampled resident (Resident 38). These medication had the potential to cause medication adverse effects. Finding: Review of clinical record, Resident 38 was admitted on 12/31/2003, with diagnoses including multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves), pseudobulbar affect (uncontrollable laughter or crying) and paraplegia (paralysis of lower extremities). Review of Resident 38's medication and treatment administration record dated 7/19, there was no behavioral monitoring of Resident 38's laughing or crying episode. During an interview with LVN F on 7/17/19 at 12:13 p.m., she confirmed, no documentation the episode of laughing or crying was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 24 of 45 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 07/17/2019 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 monitored. According to http://www.avanir.com/nuedexta (website for Nuedexta), Nuedexta was approved for the treatment of PseudoBulbar Affect (PBA). PBA is a medical condition that causes involuntary, sudden, and frequent episodes of crying and/or laughing in people living with certain neurologic conditions or brain injury. PBA episodes were typically exaggerated or don't match how the person feels. Most common side effects were diarrhea, dizziness, cough, vomiting, weakness, swelling of feet and ankles, urinary tract infection, flu like symptoms, abnormal liver tests, and gas.

F758 SS=D Free from Unnec Psychotropic Meds/PRN Use F758 CFR(s): 483.45(c)(3)(e)(1)-(5) 08/05/2019 §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--§483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 25 of 45 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 07/17/2019 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 specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure one of one sampled resident (Resident 81) was assessed when, Valium (anti-anxiety and sedative) PRN (as needed) order for Resident 81 has no physician justification for the continued PRN use order after 14 days. This failure had the potential to exposed the resident in the use of unnecessary drugs. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 26 of 45 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 07/17/2019 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 Findings: During review of Resident 81's physician order dated 5/9/19 indicated "Valium 2 milligram (mg, unit of mass). Give 1 tablet by mouth every 12 hours as needed for anxiety manifested by inability to relax." During interview with LVN F on 7/17/19 at 2:00 p.m., LVN F confirmed there was no physician justification for continued use of PRN Valium and stated there should have been one. The facility's policy and procedure, "Use of Antipsychotics/Psychotropics", undated, indicated "PRN Psychotropic's (excluding antipsychotics): 14 day limitation on all PRN orders. Order may be extended beyond 14 days if the attending physician or prescribing practitioner: 1 Believes it is appropriate to extend the order. 2. Documents clinical rationale for the extension and 3. Provides a specific duration of use..."

F759 SS=D Free of Medication Error Rts 5 Prcnt or More CFR(s): 483.45(f)(1)

F759 08/05/2019 §483.45(f) Medication Errors. The facility must ensure that its§483.45(f)(1) Medication error rates are not 5 percent or greater; This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility had 15.38 percent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 27 of 45 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 07/17/2019 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 medication error rate when four medication errors out of 26 opportunities were observed during medication pass for two out of six residents (38 and 24). These failures had the potential to compromise the resident's medical health. Findings: 1. During a medication pass observation with licensed vocational nurse F (LVN F) on 7/15/19 at 8:12 a.m., LVN F expelled bubble from Glatopa (used to treat multiple sclerosis (MS, a disease in which the immune system eats away at the protective covering of nerves) )20 milligrams/milliliters (mg/ml, a unit of measurement) prefilled syringe, administered two puffs of AirDuo RespiClick 55/14 Aerosol Powder Breath Activated 55-14 MCG/ACT (Fluticasone-Salmeterol, prevent symptoms of asthma and chronic obstructive pulmonary disease) and failed to rinse Resident 38's mouth after. During an interview with LVN F on 7/15/19 at 8:26 a.m., LVN F confirmed she expelled an air bubble from Glatopa 20mg/ml prefilled syringe, administered two puffs of FluticasoneSalmeterol and forgot to rinse Resident 38's mouth. During a review of record for Resident 38, the Order Summary Report dated 7/15/19 indicated an order for AirDuo RespiClick one puff inhale orally two times a day related to other asthma. A review of Glatopa's manufacturer specification indicated to do not try to push the air bubble from the syringe before giving injection to prevent losing any medication. A review of AirDuo Respiclick's manufacturer specification indicated "AIRDUO RESPICLICK FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 28 of 45 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 07/17/2019 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 can cause serious side effects, including: fungal infection in your mouth and throat (thrush). Rinse your mouth with water without swallowing after using AIRDUO RESPICLICK to help reduce your chance of getting thrush". During an interview with the director of nursing (DON) on 7/16/19 at 4:04 p.m., the DON stated LVN F should have followed the manufacturer guidelines related to administration of Glatopa, should have administered one puff of AirDuo RespiClick based on physician order and confirmed LVN F should have rinsed Resident 38's mouth after inhaling AirDuo RespiClick to prevent fungal infections. A review of the facility's policy, "Medication Administration General Guidelines" dated 9/18, indicated medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. 2. During a medication pass observation with licensed vocational nurse H (LVN H) on 7/16/19 at 8:22 a.m, LVN H failed to rinse a cup of medication to make sure the full dose was taken by Resident 24. During an interview with LVN H on 7/16/19 at 8:35 a.m., LVN H confirmed she should have rinsed the cup of "Sinemet" to make sure Resident 24 received the full dose. During an interview with the DON on 7/16/19 at 4:17 p.m., the DON confirmed LVN H should have rinsed the cup of medication to make sure Resident 24 received the full dose. A review of the facility's policy, "Medication Administration General Guidelines" dated 9/18, indicated "the soufflé cup is rinsed with water to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 29 of 45 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 07/17/2019 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 get all of the medication contained within the cup to facilitate ordered dose."

F761 SS=D Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 08/05/2019 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure medications were stored/labeled when: 1 .Refrigerator was out of temperature FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 30 of 45 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 07/17/2019 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 requirements. 2. One insulin pen with no pharmacy label 3. Two bottles of eye drop medications improperly stored and a bottle of insulin with no open date. 4. Two eye drop medications expired and three insulins improperly stored. These failures could potentially compromise the health and safety of the resident. Findings: 1. During a medication room audit and interview with the director of nursing (DON) on 7/15/19 at 8:49 a.m., the DON confirmed the refrigerator had an internal temperature of 30 degrees Fahrenheit while several medications requiring refrigeration were inside. A review of the facility's policy, "Storage of Medication" dated 9/18, indicated Medication requiring "refrigeration" or "temperatures between 2C (Celsius, a unit of measurement) (36F (Farenheit, a unit of measurement) and 8C (46F)" are kept in a refrigerator with a thermometer to allow temperature monitoring. 2. During a medication cart audit with the DON on 7/15/19 at 9:37 a.m., a Basaglar Kwik Pen (an insulin to treat diabetes) was found inside a cart with no pharmacy label. During a follow-up interview with the DON, he confirmed a Basaglar Kwik Pen did not have proper pharmacy label. A review of the facility's policy, "Medications and Medications Labels" dated 5/16, indicated medications are labeled in accordance with currently accepted professional principles including appropriate auxiliary and cautionary instructions to promote safe medication use FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 31 of 45 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 07/17/2019 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 following state and federal laws. 3. During a medication cart audit with licensed vocational nurse F (LVN F) on 7/15/19 at 9:45 a.m., a Basaglar Kwikpen was found in the cart with no open date and two bottles of Latanoprost (an eye drop medication for glaucoma) was stored in the cart unopened. During a follow-up interview with LVN F, she confirmed the Basaglar Kwikpen had no open date and two bottles of Latanoprost were unopened. She also stated the Basaglar Kwikpen needed to have a date open label and Latanoprost needed to be refrigerated when it's unopened. A review of manufacturer specification for Latanoprost indicated to store unopened bottles under refrigeration at 2C (36F) to 8C (46F). (https://www.accessdata.fda.gov/drugsatfda_do cs/label/2012/020597s044lbl.pdf) A review of the facility's policy, "General Guidelines" dated 9/18, indicated certain products or package types such multi-dose vials and ophthalmic drops have specified shortened end-of-use dating, once opened, to ensure medication purity and potency. A review of the facility's policy, "Storage of Medication" dated 9/18, indicated Medication requiring "refrigeration" or "temperatures between 2C (36F) and 8C (46F)" are kept in a refrigerator with a thermometer to allow temperature monitoring. 4. During a medication cart audit with licensed vocation nurse K (LVN K) on 7/15/19 at 9:57 a.m., the following was observed. a. Latanoprost was opened 5/28/19 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 32 of 45 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 07/17/2019 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 b. Latanopost was opened 5/30/19 c. Novolog (an insulin to treat diabetes) unopened d. Lispro (an insulin to treat diabetes) unopened e. Levemir (an insulin to treat diabetes) unopened. During a follow-up interview with LVN K, she confirmed that Latanoprost was opened passed allowable date based on manufacturer specifications and unopened bottles of insulin should be refrigerated. A review of manufacturer specification for Latanoprost indicated once a bottle is opened for use, it may be stored at room temperature for 6 weeks. (https://www.accessdata.fda.gov/drugsatfda_do cs/label/2012/020597s044lbl.pdf) A review of the facility'a policy, "General Guidelines" dated 9/18, indicated certain products or package types such multi-dose vials and ophthalmic drops have specified shortened end-of-use dating, once opened, to ensure medication purity and potency. A review of the facility's policy, "Storage of Medication" dated 9/18, indicated Medication requiring "refrigeration" or "temperatures between 2C (36F) and 8C (46F)" are kept in a refrigerator with a thermometer to allow temperature monitoring.

F810 SS=D Assistive Devices - Eating Equipment/Utensils CFR(s): 483.60(g)

F810 08/05/2019 §483.60(g) Assistive devices The facility must provide special eating equipment and utensils for residents who need FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 33 of 45 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 07/17/2019 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 them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to provide two of three residents (Residents 90 and 26) with adaptive assistive device during meals when Residents 90 and 26 were not given nosey cut cups (a cup with a nose cut out that allows with proper head positioning, avoid neck extension and spillage). This failure could potentially compromise residents' head and neck positioning while drinking and limit the degree of independence of the resident. Findings: Review of Resident 90's clinical record indicated he has diagnoses including quadriplegia (paralysis that results in the partial or total loss of use of all their limbs and torso). During an observation on 7/15/19 at 7:50 a.m., Resident 90 was being fed breakfast by certified nursing assistant I (CNA I). A nosey cut cup was not observed on Resident 90's meal tray and was not used while giving beverages to Resident 90. Review of the facility list of residents needing adaptive equipment indicated Resident 90 required a nosey cut cup. During an interview with the minimum data set coordinator (MDSC) on 7/17/19 at 9:06 a.m., the MDSC confirmed Resident 90 needed a nosey cut cup during meals. Review of Resident 26's clinical record indicated he has diagnoses including FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 34 of 45 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 07/17/2019 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 dysphagia (difficulty swallowing) and paraplegia (paralysis of the legs and lower body). Review of Resident 26's care plan indicated Resident 26 was at risk for nutritional problem and adaptive equipment of a nosey cut cup was indicated. During several meal observations on 7/14/19 at 12:17 p.m., 7/15/19 at 8:22 a.m., 7/16/19 at 8:02 a.m. and 12:16 p.m., no nosey cut cup was observed provided for Resident 26. During an interview with CNA J on 7/16/19 at 11:39 a.m., he stated Resident 26 does not use any adaptive assistive device including a nosey cut cup. During an interview and concurrent record review with the MDSC on 7/17/19 at 8:59 a.m., he confirmed Resident 26 needed a nosey cut cup and it was recommended by the registered dietitian.

F812 SS=E Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 08/05/2019 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 35 of 45 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 07/17/2019 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 applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure food safety and sanitation requirements were met as evidenced by: 1. Gas stove was covered with dark substance 2. Back of gas stove was found with dirt and other debris 3. Milk temperature was not within acceptable range 4. Three compartment sink has no observable air gap 5. Rust was found on the ceiling of the walk in refridgetor 6. A pan of ground beef was cooked 8 hours early prior to serving These failures had the potential to result in cross contamination and can cause food borne illnesses in a medically vulnerable population of residents who consumed food from kitchen. Findings: 1. During a kitchen observation with the kitchen supervisor (KS) on 7/15/19 at 7:44 a.m., the bottom part of the gas stove was covered with sticky dark brown residue. The KS confirmed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 36 of 45 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 07/17/2019 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 the gas stove was covered with sticky dark brown residue and it was hard for kitchen staff to clean it. A review of the facility's policy, "Sanitation" dated 2015, indicated kitchen staff is responsible for all the cleaning with the exception of ceiling vents, light fixtures and the hood over stoves, which be cleaned by the maintenance staff. According to the 2017 Federal FDA Food Code, food-contact surfaces and utensils were to be clean to sight and touch and nonfoodcontact surfaces of equipment were to be free of accumulation of dust, dirt, food residue and other debris. 2. During a kitchen observation with the kitchen supervisor (KS) on 7/15/19 at 7:44 a.m., behind gas stove was dark particles and food residue. KS confirmed behind kitchen gas stove needs to be clean. A review of the facility's policy, "Sanitation" date 2015, indicated kitchen staff is responsible for all the cleaning with the exception of ceiling vents, light fixtures and the hood over stoves, which be cleaned by the maintenance staff. According to the 2017 Federal FDA Food Code, food-contact surfaces and utensils were to be clean to sight and touch and nonfoodcontact surfaces of equipment were to be free of accumulation of dust, dirt, food residue and other debris. 3. During a tray line observation pm 7/16/19 at 11:43 a.m., cups of liquid food items were already inside the tray cart before tray line starts. During a follow up interview with kitchen cook S FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 37 of 45 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 07/17/2019 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 (KC S) she indicated, cups of liquid food items were placed inside tray cart around 11:30 a.m. During an observation and interview with kitchen cook S (KC S) 7/16/19 at 11:59 a.m., KC S measured the temperature of the "milk" two consecutive times. KC S confirmed the temperature of the milk was at 53F (Farenheit, a unit of measurement) and stated "Milk should be below 40." During a test tray observation and interview with the KS on 7/16/19 at 12:43 p.m., she stated the milk was at 50F when it reached the furthest station from the kitchen. The KS confirmed it was warm. During an interview with the registered dietician (RD) on 7/16/19 at 3:09 p.m., the RD stated milk was a high hazard food and should be served per facility policy. A review of the facility's policy, "Meal Service" dated 2015, indicated cold food items will be place on the trays as close to serving time and possible to assure the temperature is below 41F. To accomplish this, all cold foods will be pre-poured and kept in the refrigerator or freezer and pulled out in small quantities at a time. A review of the facility's policy, "Meal Service" dated 2015, indicated milk/cold beverage were recommended to be at less than or equal to 45F at delivery to resident. 4. During an observation and interview with the KS on 7/16/19 at 10:00 a.m., the three compartment sink had no observable air gap and confirmed by the KS. During an interview with the administrator (ADM) on 7/16/19 at 10:03 a.m., the ADM FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 38 of 45 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 07/17/2019 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 confirmed three compartment sink has no observable air gap. According to the Federal Food Code (2017), there was to be an air gap between the water supply inlet and the flood level rim of the plumbing fixture, equipment, or nonfood equipment that was at least twice the diameter of the water supply inlet and may not be less that one inch. 5. During an initial kitchen tour with the DM on 7/14/19 at 9:08 a.m., rust was observed on the ceiling of the walk-in refrigerator. During an interview with the Maintenance Supervisor on 7/16/19 at 9:48 a.m., he confirmed the observation above and stated it needed to be replaced. 6. During a kitchen observation 7/14/19 at 9:42 a.m., a pan of cooked ground beef was found inside the oven. During a concurrent interview with the KS, she stated the ground beef inside the oven was for dinner, she further stated she cooked the ground beef after breakfast and was not supposed to. Dinner meal preparation should be done after lunch and not after breakfast. The nutritional value of food which are heated for long periods of time compromises both the palatability and nutritional value of food (Nutrition.gov).

F880 SS=D Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f) FORM CMS-2567(02-99) Previous Versions Obsolete

F880 Event ID: 9W9N11 08/05/2019 Facility ID: CA070000068 If continuation sheet 39 of 45 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 07/17/2019 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 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 40 of 45 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 07/17/2019 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 (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: 3. During a medication pass observation with LVN F on 7/15/19 at 8:12 a.m., LVN F administered Glatopa (used to treat multiple sclerosis (MS, a disease in which the immune system eats away at the protective covering of nerves)) 20 milligrams/milliliters (mg/ml, a unit of measurement) prefilled syringe via injection subcutaneously (fat layer between the skin and muscle) without wearing gloves. During an interview with LVN F on 7/15/19 at 8:26 a.m., LVN F confirmed she did not wear glove during administration of Glatopa via injection subcutaneously. A review of the facility's policy, "Medication FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 41 of 45 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 07/17/2019 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 Administration Subcutaneous" dated 9/10, indicated put on gloves prior to subcutaneous injection. 4. During a medication pass observation with registered nurse G (RN G) on 7/15/19 at 11:31 a.m., RN G did not clean rubber cup of insulin vial prior to injecting needle. During an interview with RN G on 7/15/19 at 11:34 a.m., she confirmed she forgot to clean the rubber cup of insulin vial prior to injecting needle. A review of the facility's policy, "Medication Administration Subcutaneous" dated 9/10, indicated swab rubber cap with antimicrobial agent. 5. During a medication pass observation with LVN H on 7/16/19 at 8:22 a.m., LVN H removed gloves and put one on without performing hand hygiene three times while administering medication via gastrostomy tube (G-tube, a tube inserted through the wall of the abdomen directly into the stomach). During an interview with LVN H on 7/16/19 at 8:35 a.m., LVN H confirmed she did not wash her hands every time she changed gloves and don a new ones. According to Centers for Disease Control and Prevention (CDC) clinical indications for hand hygiene includes immediately after glove removal. (https://www.cdc.gov/handhygiene/providers/in dex.html) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 42 of 45 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 07/17/2019 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 Based on observation, interview, and record review, the facility failed to ensure infection prevention practices were followed for five of five sampled residents (Residents 93, 88, 38, 54, and 24) when: 1. Resident 93, his indwelling catheter (a thin, sterile tube inserted into the bladder to drain urine bag) did not have a privacy bag and was placed on the floor 2. Resident 88, he was observed chewing on his treatment dressing 3. Resident 38, a licensed nurse did not use gloves while giving medication via injection 4. Resident 54, a licensed nurse did not clean a rubber cup of insulin vial prior to injecting needle, and 5. Resident 24, a licensed nurse did not perform hand hygiene in between glove changes Findings: 1. During an observation on 7/14/19 at 12:51 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 43 of 45 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 07/17/2019 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 p.m, Resident 93 was in bed and his indwelling catheter bag was uncovered and placed on the floor. During an interview with certified nursing assistant L (CNA L) on 7/14/19 at 12:54 p.m., she confirmed the above observation and stated she did not realize the bag was on the floor since she came on duty on 7/14/19. During an interview with licensed vocational nurse M (LVN M) who was also the infection preventionist on 7/17/19 at 10:06 a.m., she stated the indwelling catheter bag should be covered in a blue bag at all times. A review of the facility's undated policy, "Foley/ Indwelling Catheter Care", indicated it was the facility's policy to provide services relating to use of foley/indwelling catheter to prevent resident from developing related infection. 2. During an observation together with CNA D on 7/15/19 at 9:30 a.m., Resident 88 was observed continuously chewing a white object. CNA D stated "he was eating his dressing from his thigh". CNA D pointed to Resident 88's right thigh wound and it did not have a dressing in place. CNA D stated, "he had this behavior before". During an interview with registered nurse C (RN C) on 7/15/19 at 9:38 a.m., he confirmed Resident 88's behavior of chewing his gowns, linens, and wound dressing was not new, "anything he could grab, he would eat". FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 44 of 45 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 07/17/2019 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)

F912 Bedrooms Measure at Least 80 Sq Ft/Resident F912 CFR(s): 483.90(e)(1)(ii) SS=B ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 08/05/2019 §483.90(e)(1)(ii) Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms; This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to ensure multiple resident rooms had at least 80 square feet per resident. Having less than 80 square feet per resident could potentially compromise the care and services the residents received. Findings: The following resident rooms' square footage measured as follows: Room number Number of beds Square footage 101 103 105 107 109 111 114 116 118 119 2 2 2 2 2 2 2 2 2 2 74.9 74.9 74.9 74.9 74.9 71.05 74.9 74.9 71.5 74.9 During the survey, observations and interviews with residents and staff, indicated there were no concerns regarding the square footage of the rooms. Nursing care and services were not impacted by the shortage of space. Recommend continuance of the room waiver. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 9W9N11 Facility ID: CA070000068 If continuation sheet 45 of 45

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Citations

No citations recorded on this visit

The surveyor cited no deficiencies during this survey.

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Common questions about this visit

What happened during the July 29, 2019 survey of Redwood Grove Post Acute?

This was a other survey of Redwood Grove Post Acute on July 29, 2019. The surveyor cited no deficiencies.

Were any deficiencies cited at Redwood Grove Post Acute on July 29, 2019?

No deficiencies were cited during this survey.

What type of survey was this?

This was a other survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Other·July 29, 2019