Other·January 29, 2018

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a standard abbreviated survey regarding investigation of a facility reported incident on 1/11/18. For Entity Reported Incident CA00567132 regarding Accidents, a federal deficiency was identified (see F689). A Class "B" Citation was also issued. Inspection was limited to the specific entity reported incident investigated and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 10673, Health Facilities Evaluator Nurse.

F689 SS=D Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 02/02/2018 §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 interview and record review, the 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: 5DQO11 Facility ID: CA070000097 If continuation sheet 1 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056212 (X3) DATE SURVEY COMPLETED 01/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REDWOODS POST-ACUTE 1267 Meridian Ave San Jose, CA 95125 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility failed to provide supervision for one of 3 sampled residents (1). Resident 1 required supervision due to impaired safety awareness and an unstable psychological condition. This failure resulted in Resident 1 lighting his mattress on fire and endangering the lives of the residents in the facility. Findings: Review of Resident 1's clinical record indicated diagnoses of schizoaffective disorder (mental disorder characterized by abnormal thought process), adjustment disorder with mixed disturbances of emotions and conduct (a mental disorder with excessive reaction to a stressful life event which causes negative behavioral changes and impacts emotional stability), and major depressive disorder (a mental health problem characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). Further review of Resident 1's clinical record indicated a physician order dated 9/15/17 for oxygen at two liters per minute via nasal cannula as needed for shortness of breath. Review of Resident 1's care plan initiated on 9/15/17 indicated heightened safety risk due to impaired safety awareness and unstable psychological condition. Among the interventions included staff supervision during smoking times and staff to retain lighters. During an interview with licensed vocational nurse A (LVN A) on 1/11/18 at 10:40 a.m., she stated Resident 1 requested to smoke. LVN A stated she gave certified nursing assistant B (CNA B) Resident 1's cigarette and lighter. She stated the charge nurse has Resident 1's lighter locked in the medication cart. LVN A stated activity staff who supervised Resident 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5DQO11 Facility ID: CA070000097 If continuation sheet 2 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056212 (X3) DATE SURVEY COMPLETED 01/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REDWOODS POST-ACUTE 1267 Meridian Ave San Jose, CA 95125 (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 in the smoking area should have returned the lighter to the charge nurse after Resident 1 smoked. LVN A stated another resident kept her busy and that she forgot to retrieve the lighter. LVN A stated when the fire alarm sounded, she went to Resident 1's room. She stated the fire was already extinguished. LVN A stated she unplugged the oxygen concentrator and took it out of the room. She stated staff should have immediately removed Resident 1's oxygen concentrator out of his room when the fire was discovered. During an interview with CNA B on 1/11/18 at 11:12 a.m., she stated LVN A gave her Resident 1's cigarette and lighter. CNA B stated she wheeled Resident 1 to the smoking area and gave the cigarette and lighter to the activities assistant (AA). CNA B stated she went back to her work station and resumed care to her other assigned residents. During an interview with Resident 1 on 1/11/18 at 1:00 p.m., he stated he could not recall the fire incident that occurred in his room recently. During an interview with the activities director (AD) on 1/11/18 at 1:45 p.m., she stated the AA "made a mistake on 1/2/18 of not getting back Resident 1's lighter after the smoking session". During an interview with the AA on 1/11/18 at 2:15 p.m., he stated Resident 1 had the lighter with him when he wheeled him into the front lobby. The AA stated he thought it was safe for Resident 1 to keep the lighter. The AA stated he was mistaken to allow Resident 1 to keep the lighter. The AA stated he should have returned Resident 1's lighter to the charge nurse after the smoking session. During an interview with CNA C on 1/11/18 at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5DQO11 Facility ID: CA070000097 If continuation sheet 3 of 4 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056212 (X3) DATE SURVEY COMPLETED 01/16/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REDWOODS POST-ACUTE 1267 Meridian Ave San Jose, CA 95125 (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 2:45 p.m., she stated one of the staff in the front lobby asked her to bring Resident 1 back to his room. CNA C stated she was unaware Resident 1 came from the smoking area. CNA C stated she was uninformed that the AA did not get the lighter from Resident 1 after smoking. Review of the Fire Investigation Report dated 1/2/18 indicated at approximately 9:30 a.m., staff noticed fire coming from Resident 1's room. The fire alarm sounded and staff proceeded to the room where they saw Resident 1 next to his bed with the mattress on fire. Resident 1 was removed. The staff put out the fire with a fire extinguisher. The conclusion of the Fire Investigation Report indicated: 1. CNA C when asked to bring Resident 1 him back to his room from the lobby was not informed that Resident 1 was returning from smoking. 2. CNA C wheeled Resident 1 to his room without checking to see if he had any smoking items. 3. Resident 1 had a behavioral episode and lit the mattress on fire out of frustration and feeling of being ignored. Review of the undated policy and procedure titled "Safe Smoking Policy" indicated "Residents that are not deemed safe will have their cigarettes and lighters secured and kept locked." Review of the facility policy and procedure titled "Supervision of Resident Care" dated 10/13/06 indicated "the licensed nurse shall supervise all care and assure that the resident is protected..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 5DQO11 Facility ID: CA070000097 If continuation sheet 4 of 4