Other·February 6, 2017

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. Representing the California Department of Public Health Services: Health Facilities Evaluator Nurse's: 34336, 34331, and 37335. The facility census was 44, with one bed hold. There were 12 sampled residents. Three Entity Reported Incidents (CA00483494,CA00505800 and CA00511524) and one Complaint (CA00512840) were investigated during the survey process. Two deficiencies were issued for Complaint #: CA00512840. Refer to F208 and California Code of Regulations, Title 22, 72523 (c) (2) (B). One deficiency was cited for Entity Reported Incident CA00483494. Refer to F323. Notice Of Intent To Issue A Citation was issued to the facility on 12/30/16 One deficiency was cited for Entity Reported Incident CA00511524. Refer to F241. Entity Reported Incident CA00505800 was substantiated, with no deficiency.

F208 PROHIBITING CERTAIN ADMISSION

F208 12/14/2016 SS=E 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: 2S1G11 Facility ID: CA01000001007 If continuation sheet 1 of 26 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: _______________ 555826 (X3) DATE SURVEY COMPLETED 12/20/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REDWOODS, A COMMUNITY OF SENIORS 40 Camino Alto Mill Valley, CA 94941 (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 POLICIES CFR(s): 483.15(a)(1)-(7) (a) Admissions policy. (1) The facility must establish and implement an admissions policy. (2) The facility must(i) Not request or require residents or potential residents to waive their rights as set forth in this subpart and in applicable state, federal or local licensing or certification laws, including but not limited to their rights to Medicare or Medicaid; and (ii) Not request or require oral or written assurance that residents or potential residents are not eligible for, or will not apply for, Medicare or Medicaid benefits. (iii) Not request or require residents or potential residents to waive potential facility liability for losses of personal property. (3) The facility must not request or require a third party guarantee of payment to the facility as a condition of admission or expedited admission, or continued stay in the facility. However, the facility may request and require a resident representative who has legal access to a resident’s income or resources available to pay for facility care to sign a contract, without incurring personal financial liability, to provide facility payment from the resident’s income or resources. (4) In the case of a person eligible for Medicaid, a nursing facility must not charge, solicit, accept, or receive, in addition to any amount otherwise required to be paid under the State plan, any gift, money, donation, or other FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2S1G11 Facility ID: CA01000001007 If continuation sheet 2 of 26 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: _______________ 555826 (X3) DATE SURVEY COMPLETED 12/20/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REDWOODS, A COMMUNITY OF SENIORS 40 Camino Alto Mill Valley, CA 94941 (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 consideration as a precondition of admission, expedited admission or continued stay in the facility. However,(i) A nursing facility may charge a resident who is eligible for Medicaid for items and services the resident has requested and received, and that are not specified in the State plan as included in the term ‘‘nursing facility services’’ so long as the facility gives proper notice of the availability and cost of these services to residents and does not condition the resident’s admission or continued stay on the request for and receipt of such additional services; and (ii) A nursing facility may solicit, accept, or receive a charitable, religious, or philanthropic contribution from an organization or from a person unrelated to a Medicaid eligible resident or potential resident, but only to the extent that the contribution is not a condition of admission, expedited admission, or continued stay in the facility for a Medicaid eligible resident. (5) States or political subdivisions may apply stricter admissions standards under State or local laws than are specified in this section, to prohibit discrimination against individuals entitled to Medicaid. (6) A nursing facility must disclose and provide to a resident or potential resident prior to time of admission, notice of special characteristics or service limitations of the facility. (7) A nursing facility that is a composite distinct part as defined in § 483.5 must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under paragraph (c)(9) of this section. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2S1G11 Facility ID: CA01000001007 If continuation sheet 3 of 26 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: _______________ 555826 (X3) DATE SURVEY COMPLETED 12/20/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REDWOODS, A COMMUNITY OF SENIORS 40 Camino Alto Mill Valley, CA 94941 (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 ensure their admission procedures did not include waivers that released the facility from liability for losses of personal property, when three of 12 sampled residents (Residents 5, 9, and 10) or his/her responsible party signed a "Release from Liability for Patients Valuables" upon admission to the facility. This failure may result in resident's waiving their rights to a theft and loss prevention program or replacement of lost items by the facility. Findings: Review of the facility's document titled, "Release From Liability for Patients Valuable" (undated), indicated the facility "Cannot Accept Responsibility for valuables maintained at your bedside." The resident or his/her responsible party was to sign a section that stated, "...the [Facility] shall not be liable for loss...to personal property unless such property is deposited within safe...I accept full responsibility for all personal property including, but not limited to, monies, jewelry, hearing aids, eye glasses, dentures..." During an interview on 12/12/16 at 10:45 a.m., Administrative Staff AL stated Resident 5 had two pairs of eyeglasses. Approximately one month ago, around 11/7/16, one pair of Resident 5's eyeglasses were lost. Administrative Staff AL stated staff conducted a couple searches, however, Resident 5's second pair of eyeglasses remained lost. The eyeglasses had not been replaced by the facility. Administrative Staff AL stated the waiver of release from liability, "sets the tone" FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2S1G11 Facility ID: CA01000001007 If continuation sheet 4 of 26 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: _______________ 555826 (X3) DATE SURVEY COMPLETED 12/20/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REDWOODS, A COMMUNITY OF SENIORS 40 Camino Alto Mill Valley, CA 94941 (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 on admission, for resident's and families "to be aware of valuables" in the facility. Review of Resident 9's record revealed Resident 9 signed a "Release From Liability For Patients Valuables", dated 11/24/16. Review of Resident 10's record revealed Resident 10's responsible party signed a "Release From Liability for Patients Valuable" dated 11/29/16. The facility's policy and procedure titled, "Theft and Loss Policy," indicated under section A-5, "If a resident signs a 'Waiver of Inventory,' the facility shall not assume liability for any lost items."

F241 SS=D DIGNITY AND RESPECT OF INDIVIDUALITY F241 CFR(s): 483.10(a)(1) 01/19/2017 (a)(1) A facility must treat and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident’s individuality. The facility must protect and promote the rights of the resident. This REQUIREMENT is not met as evidenced by: Based on interviews and record review, the facility failed to ensure one of 12 sampled residents (Resident 1) was treated with dignity and respect when Resident 1's request for assistance to the bathroom was not honored. This failure resulted in Resident 1 not being assisted in a timely manner and and potentially compromised Resident 1's physical and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2S1G11 Facility ID: CA01000001007 If continuation sheet 5 of 26 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: _______________ 555826 (X3) DATE SURVEY COMPLETED 12/20/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REDWOODS, A COMMUNITY OF SENIORS 40 Camino Alto Mill Valley, CA 94941 (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 psychosocial well-being. Findings: During an interview on 12/16/16 at 2:50 p.m., Resident 1 recalled an incident that occurred the prior month and stated she needed her incontinent pad changed and was told by Unlicensed Staff O they had no available incontinent pads. She stated a little later Unlicensed Staff O came in and brought an incontinent pad and changed her. Resident 1 stated the incident made her feel "bad" and had her "upset". Resident 1 stated she felt like Unlicensed Staff O was telling her "I'm the boss." Resident 1 stated it made her feel "uncomfortable". During an interview on 12/16/16 at 3:05 p.m., Unlicensed Staff O stated [on 11/18/16] she was assigned to Hallway 1 (residents) and the Cafe. Unlicensed Staff O stated she had to distribute to Hallway 1 the dinner tickets to residents so they could pick out what they wanted when Resident 1 called for assistance. She stated she told Resident 1 she had two more tickets to deliver and she would be "right back". Unlicensed Staff O stated she came back to the resident and got her up to the bathroom. She stated peri-care was done and she assisted the resident back to bed. Unlicensed Staff O stated the next day she was called in by administrative staff and was told of the issue (did not change her incontinent pad or help her to the bathroom). Unlicensed Staff O stated she did help Resident 1 and it was only a "few minutes" that Resident 1 had to wait. She denied speaking with Resident 1 in a rude manner or tone. During an interview on 12/16/16 at 3:25 p.m., Administrative Staff B stated she spoke with Resident 1 regarding the incident. She stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2S1G11 Facility ID: CA01000001007 If continuation sheet 6 of 26 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: _______________ 555826 (X3) DATE SURVEY COMPLETED 12/20/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REDWOODS, A COMMUNITY OF SENIORS 40 Camino Alto Mill Valley, CA 94941 (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 she told the resident Unlicensed Staff O would not be caring for her any longer. Review of an untitled document, completed by Licensed Staff D, dated 11/18/16, submitted to the Department on 11/21/16, documented Resident 1 told Licensed Staff D about the incident. Resident 1 stated, "I asked her [Unlicensed Staff O] to help me to the toilet when she was holding little pieces of paper in her hand and she said, No, I need to do these first (referring to the meal tickets in her hand used to mark the resident meal choice for dinner)." Resident 1 stated, "When she speaks with me it seems rough." Licensed Staff D documented when Unlicensed Staff O was asked about the incident with Resident 1, Unlicensed Staff O stated, "But she is always complaining." Review of a document titled, Suspected Abuse Investigation Form, dated 12/15/16 indicated during the incident on 11/18/16, Unlicensed Staff O did not deny having informed Resident 1 to wait while she passed the remaining meal tickets to other residents.

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(d)(1)(2)(n)(1)-(3)

F323 02/12/2017 (d) Accidents. The facility must ensure that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2S1G11 Facility ID: CA01000001007 If continuation sheet 7 of 26 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: _______________ 555826 (X3) DATE SURVEY COMPLETED 12/20/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REDWOODS, A COMMUNITY OF SENIORS 40 Camino Alto Mill Valley, CA 94941 (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 (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed’s dimensions are appropriate for the resident’s size and weight. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure one of 12 sampled residents (Resident 6), who had a history of falls, received adequate supervision and assistance to prevent accidents. Resident 6 propelled her wheelchair away from the nurses station, unnoticed by staff, and fell in the doorway of her room. Resident 6 sustained an extension of the right hip fracture that was surgically repaired approximately two months prior. A second hip surgery was required at the acute care hospital. Findings: Review of Resident 6's face sheet (admission FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2S1G11 Facility ID: CA01000001007 If continuation sheet 8 of 26 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: _______________ 555826 (X3) DATE SURVEY COMPLETED 12/20/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REDWOODS, A COMMUNITY OF SENIORS 40 Camino Alto Mill Valley, CA 94941 (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 record), undated, documented Resident 6 was admitted to the facility on 2/22/16. The face sheet noted Resident 6 had multiple active diagnoses including a fracture of the ulna (the thinner and longer of the two bones in the forearm, on the side opposite to the thumb), a fracture of right neck of the femur (long thigh bone meeting at the hip), dementia (a disorder of the mental processes marked by memory disorders, personality changes, and impaired reasoning), anxiety, depression, hypertension (high blood pressure), and atrial fibrillation (an abnormal, irregular heart rhythm). Resident 6's Minimum Data Set (MDS - an assessment tool), dated 2/29/16, indicated a Brief Interview for Mental Status (BIMS) score of "3" (scores of 0 to 7 denoted severe cognitive impairment.) Functional Status, indicated Resident 6 was not yet ambulating (walking) and required extensive assistance, with two staff members, for transfers (bed to wheelchair, wheelchair to toilet.) A subsequent MDS assessment, dated 3/21/16, documented Resident 6's BIMS score remained at "3." Resident 6's transfer ability, indicated she had improved to the point of requiring limited assistance (staff provided guided maneuvering of limbs or other non-weight bearing assistance) for transfers with one staff member present. The MDS cognitive assessment, dated 10/18/16, indicated Resident 6's BIMS score remained at "3." Review of the facility's "Fall Risk Assessment," for Resident 6, dated 2/22/16, indicated Resident 6 had a total score of 15. A score of 10 or more indicated high risk for falls. The assessment further indicated: Resident 6 had intermittent confusion, history of 1-2 falls in the prior three months, balance problems while standing and walking, and did not consistently use assistive devices (walker, wheelchair, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2S1G11 Facility ID: CA01000001007 If continuation sheet 9 of 26 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: _______________ 555826 (X3) DATE SURVEY COMPLETED 12/20/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REDWOODS, A COMMUNITY OF SENIORS 40 Camino Alto Mill Valley, CA 94941 (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 cane). The fall assessment documented Resident 6 had taken or currently took the following medications within the previous seven days: antihypertensives (lowers blood pressure), anesthetics (pain relievers), benzodiazepines (sedatives generally used for anxiety and/or sleep problems), and antidepressants (drugs used to treat depression). A subsequent Fall Risk Assessment, dated 4/4/16, at 8:14 p.m., had a score of 13. Review of the facility's "Charge Nurse Rounds Report," with the residents' fall risk scores, indicated, on 5/2/16, Resident 6 had an increased score of 17. On 7/18/16, the fall risk score rose to 21. The Care Plan for the prevention of falls, dated 2/22/16, indicated Resident 6 had risk factors that required monitoring and intervention to reduce potential for falls. Risk factors included, "Altered mental status as evidenced by confusion." The goal of the Care Plan was Resident 6 would have no injuries due to falls "with supervision and verbal reminders for better control of risk factors..." The facility's approach (interventions) to reduce the potential for falls was to, "attempt to anticipate needs toileting, hydration...before Resident attempts to fulfill on own; bring [Resident 6] to the nurse's station when out of bed for observation; require 1-2 persons to assist with all transfers; and encourage Resident to sit in areas well supervised by staff." Updated approaches, dated 3/29/16, after a fall to the floor next to her bed on 3/28/16, included, "visual checks of resident every two hours; position [Resident 6] near the nurse's station for increase (sic) visibility." After another fall on 6/28/16, interventions were to place Resident 6 at the nurse's station or in the activity room for increased visibility and monitor resident's whereabouts. After another fall on 7/12/16, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2S1G11 Facility ID: CA01000001007 If continuation sheet 10 of 26 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: _______________ 555826 (X3) DATE SURVEY COMPLETED 12/20/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REDWOODS, A COMMUNITY OF SENIORS 40 Camino Alto Mill Valley, CA 94941 (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 interventions dated 7/28/16, were to monitor Resident 6's activity with frequent checks for safety, bring to common areas to avoid being left alone, and "provide 1:1 sitter as appropriate." Review of the Interdisciplinary Notes, dated 2/23/16 at 5:31 p.m., indicated Resident 6 "...needs constant supervision...is very impulsive and is a high risk for fall." Resident 6's Care Plan, dated 2/22/16 and 3/29/16 did not indicate a plan to provide "constant supervision." During an interview on 4/21/16 at 11:30 a.m., Licensed Staff D stated Resident 6 was confused when admitted to the facility in February 2016. Resident 6's family provided a daytime sitter to accompany the resident. At night, the facility provided a sitter from a homecare agency. Interdisciplinary Notes dated 2/23/16, at 5:31 p.m., indicated Resident 6 was provided a "one on one sitter" for being "very impulsive" and a high risk for falls. Resident 6's Care Plan did not document the addition of a sitter. Review of attendance records from a private homecare company, indicated Resident 6 had a sitter for 12-hour shifts, generally from 6 p.m. to 6 a.m. or 8 p.m. to 8 a.m., starting on 2/22/16. There was no attendance record of a sitter after 3/21/16. During a concurrent interview, on 4/21/16, at 2 p.m., Licensed Staff D stated, approximately one week before 3/28/16, there was no longer a sitter, "Because she had cleared," (confusion had diminished.) There was no documentation of a nursing assessment that indicated Resident 6's decrease in confusion or evaluation of need for a sitter. A licensed nurse's note dated 3/21/16, at 10:33 p.m., indicated Resident 6 was alert "with confusion." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2S1G11 Facility ID: CA01000001007 If continuation sheet 11 of 26 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: _______________ 555826 (X3) DATE SURVEY COMPLETED 12/20/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REDWOODS, A COMMUNITY OF SENIORS 40 Camino Alto Mill Valley, CA 94941 (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 Licensed nurses notes, dated 3/27/16 at 7:37 a.m., indicated Resident 6 was confused and tried to get out of bed and dislodged her urinary catheter (a thin sterile tube inserted into the bladder to drain urine.) A nurses note, dated 3/27/16, at 10:39 p.m., indicated Resident 6 had increased agitation and kept wanting to get out of bed. Confusion was noted and Resident 6 was placed in her wheelchair during the shift. A clip alarm (an alarm unit placed on a resident's wheelchair and clipped to the resident's clothing which activates an alarm if the resident attempts to get up from the wheelchair unassisted) was "in place." Licensed nurses notes, dated 3/28/16 at 7:31 a.m., indicated Resident 6 had an unwitnessed fall at 6:30 a.m. Resident 6 was found sitting on the floor next to her bed, "confused and highly impulsive" and had mild pain to her right hip. The licensed nurse noted there was no apparent injury or bruising and the resident was able to move her extremities (arms/legs) without difficulty. Licensed nurses notes, dated 4/4/16, contained the following documentation: On 4/4/16 at 4 a.m., Resident 6, "...continues to be confused...Fall precautions maintained. Bed low. Alarms in place." The nursing note at 2:43 p.m. documented , "...resident had been agitated during the day." On 4/4/16 at 10:25 p.m., Licensed Staff H documented Resident 6 had an unwitnessed fall at 7:45 p.m. No injury or bruising was identified, however, Resident 6 "complained of moderate to severe right hip pain, unrelieved by Tylenol (pain reliever)...alternating with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2S1G11 Facility ID: CA01000001007 If continuation sheet 12 of 26 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: _______________ 555826 (X3) DATE SURVEY COMPLETED 12/20/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REDWOODS, A COMMUNITY OF SENIORS 40 Camino Alto Mill Valley, CA 94941 (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 Tramadol" (a narcotic pain medication used to treat moderate to severe pain.) Additionally, the nurse's note indicated Resident 6 remained agitated and continued to ask to be toileted. Resident 6's doctor and family were informed of the fall, and Resident 6 was monitored every 30 minutes during the shift. Review of the acute care hospital's discharge summary, dated 4/12/16, indicated Resident 6 was at [the facility] when she tried to get up on her own and had a ground level fall. Resident 6 sustained a right periprosthetic (around the components and/or implants of her hip surgery in February 2016) hip fracture. Resident 6 was admitted to the hospital on 4/7/16. On 4/8/16, Resident 6 underwent another right hip surgery to repair the new fracture. During the interview on 4/21/16 at 11:30 a.m., Licensed Staff D stated Resident 6 had an unwitnessed fall the evening of 4/4/16. Resident 6's physician ordered an X-ray of her right hip which appeared "normal." Licensed Staff D stated Resident 6 continued to have right hip pain after the fall, unrelieved by pain medication. A follow-up office visit to Resident 6's surgeon, on 4/7/16, (to examine the resident after the original hip surgery in February) revealed an extension of the repaired right hip fracture. During an interview on 4/21/16 at 3:10 p.m., Unlicensed Staff K stated she was assigned to care for Resident 6 on the P.M. shift (3-11 p.m.) on 4/4/16. Unlicensed Staff K described Resident 6 as being "agitated" since admission and was "a fall risk." Unlicensed Staff K stated, on 4/4/16 between 5 and 6 p.m., she took Resident 6 to the dining room for dinner and Resident 6 was "shouting" telling people to take her home and saying, "Who's coming for me?'" Unlicensed Staff K stated, between 6 and 7 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2S1G11 Facility ID: CA01000001007 If continuation sheet 13 of 26 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: _______________ 555826 (X3) DATE SURVEY COMPLETED 12/20/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REDWOODS, A COMMUNITY OF SENIORS 40 Camino Alto Mill Valley, CA 94941 (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 6 wanted to go to the bathroom three times, although she had a urinary catheter. Unlicensed Staff K stated, "I took her to the bathroom though." Unlicensed Staff K stated, on 4/4/16 at 7:15 p.m., she placed Resident 6, in her wheelchair, at the nurse's station, informed Licensed Staff D and continued caring for other residents. At 7:45 p.m., Unlicensed Staff K stated housekeeping staff found Resident 6 on the floor at the threshold of her room. Unlicensed Staff K stated no one saw her (Resident 6) leave the nurse's station. Unlicensed Staff K stated Resident 6 was found on her back and the clip alarm was "on" (sounding off). Unlicensed Staff K stated five staff members responded to Resident 6's fall. When asked if Resident 6 had pain, Unlicensed Staff K stated, "No, she told the nurse she was ok." For the remainder of the P.M. shift, Unlicensed Staff K stated she sat with Resident 6 and "she (Resident 6) was still yelling out and saying, 'There's a man here,' like she was hallucinating." When asked to describe some of the safety measures the facility implemented for resident's at risk for falls, Unlicensed Staff K stated, "room changes, floor mat, call cord (call bell) within reach, bed alarm, clip [alarm]." During a telephone interview on 4/25/16 at 2:38 p.m., Family Member Q stated Resident 6 had a history of mild to moderate dementia but after hip surgery in February, "With anesthesia and morphine, she became increasingly confused." Family Member Q stated, on 4/4/16 Resident 6 "probably felt like she needed to use the bathroom, took herself there and tried to stand on her own." During a telephone interview on 4/26/16 at 2:17 p.m., when asked who monitored residents when they were placed at the nurse's station, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2S1G11 Facility ID: CA01000001007 If continuation sheet 14 of 26 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: _______________ 555826 (X3) DATE SURVEY COMPLETED 12/20/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REDWOODS, A COMMUNITY OF SENIORS 40 Camino Alto Mill Valley, CA 94941 (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 Licensed Staff D stated the licensed nurse (on duty) "would be there, especially when preparing for med pass (administering medications) but not at all times." Licensed Staff D stated the CNA (Certified Nursing Assistant) "would alert the licensed nurse that a resident is being placed there" while the CNA tends to his/her other residents. During an interview on 5/2/16 at 12:20 p.m., when asked who monitored Resident 6's whereabouts on the evening of 4/4/16, Licensed Staff D stated, "Staff involved in her care...would have to coordinate, to keep an eye on her." During a telephone interview on 5/2/16 at 2:20 p.m., Licensed Staff G stated, she responded to Resident 6's fall on 4/4/16 and, "She was on the floor by the time I got there." When asked how residents were monitored at the nurse's station, Licensed Staff G stated, "We're all watching them," and a CNA would tell the nurse if he/she placed a resident at the nurse's station. Licensed Staff G stated Resident 6 did not have a sitter when she fell on 4/4/16. During a telephone interview on 5/2/16 at 3:53 p.m., Licensed Staff H stated she was assigned to care for Resident 6 on 4/4/16. Licensed Staff H described Resident 6 as being "Very, very agitated, she didn't want to be there," [at the facility]. When asked to describe "agitated," Licensed Staff H stated Resident 6 was very forgetful and repeated over and over "can you help me, I want to go home." Licensed Staff H stated Resident 6 could not recall having just spoken to a family member on the telephone. Licensed Staff H stated Resident 6 was at the nurse's station after dinner and, "I continued my med pass." Licensed Staff H stated the CNA "usually tells me she's (Resident 6) there (at the nurse's station) or I see her there." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2S1G11 Facility ID: CA01000001007 If continuation sheet 15 of 26 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: _______________ 555826 (X3) DATE SURVEY COMPLETED 12/20/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REDWOODS, A COMMUNITY OF SENIORS 40 Camino Alto Mill Valley, CA 94941 (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 When asked who supervised Resident 6 at the nurse's station, Licensed Staff H stated, "I go back and forth and I park (place) my cart (medication cart) at the nurse's station and the CNA's walk by her." When asked how long Resident 6 was at the nurse's station, Licensed Staff H stated she did not know and added, "I didn't see her leave the nurse's station...next thing she's on the floor in her room." When asked how she supervised or monitored an agitated and confused resident as Resident 6 was described, Licensed Staff H stated "I assign one CNA to stay with her if there's no sitter available" and kept the bed "very low" and a padded floor mat next to the bed. Licensed Staff H confirmed Resident 6 did not have a 1:1 sitter on the evening of 4/4/16. During an interview on 10/11/16 at 2:04 p.m., Administrative Staff B stated Resident 6 was on the facility's Falling Star Program. Concurrent review of the facility's Falling Star policy indicated the Falling Star Program was used to remind staff to monitor "high risk" residents for fall prevention and that these resident's have interventions in their care plans to reduce and/or prevent repeat falls. During an interview on 12/13/16 at 12:50 p.m., when asked if Resident 6 had a current 1:1 sitter, Licensed Staff D stated she had a family companion during the day, however, "No sitter, not on a regular basis." When asked how staff "monitored" Resident 6 to prevent falls, Licensed Staff D stated licensed staff and CNA's (certified nurse assistants) made visual checks, placed resident near common areas "if restless," and used a sensor monitor (an alarm that sounds if a resident attempts to get up from bed or wheelchair). During an observation, on 12/15/16 at 11:55 a.m., in the dining room, Resident 6 sat in a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2S1G11 Facility ID: CA01000001007 If continuation sheet 16 of 26 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: _______________ 555826 (X3) DATE SURVEY COMPLETED 12/20/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REDWOODS, A COMMUNITY OF SENIORS 40 Camino Alto Mill Valley, CA 94941 (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 wheelchair alone at the table. During a telephone interview on 12/19/16 at 9:55 a.m., Licensed Staff D stated Resident 6 had two additional falls on 6/28/16 and 7/12/16. Review of the facility's policy and procedure titled, Resident Accident and Incident, dated 6/7/13, indicated the purpose of the policy was to ensure each resident...received adequate supervision and assistance to prevent accidents and/or injury..." When a resident was identified as "at risk for falls or accidents," the policy indicated the facility would implement procedures to prevent accidents and injury related to accidents. Review of the facility's policy and procedure titled, Fall Prevention Program, dated 8/31/15, indicated a resident with a high risk for falls or potential for repeated falls would be "monitored daily for falls and/or lack of falls to determine effectiveness of...interventions..." 


F371 SS=F FOOD PROCURE, STORE/PREPARE/SERVE F371 - SANITARY CFR(s): 483.60(i)(1)-(3) 01/20/2017 (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 applicable State and local laws or regulations. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2S1G11 Facility ID: CA01000001007 If continuation sheet 17 of 26 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: _______________ 555826 (X3) DATE SURVEY COMPLETED 12/20/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REDWOODS, A COMMUNITY OF SENIORS 40 Camino Alto Mill Valley, CA 94941 (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 (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. (i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. (i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to store, prepare, and distribute food under sanitary conditions as evidenced by: 1) Refrigerator contained molded sweet potatoes and wilted celery. 2) Two of four staff interviewed failed to demonstrate the correct procedure for testing quaternary sanitizer (antimicrobial and disinfectant solution). 3) Washed dishes were stacked tightly and not contained in drying racks before stacking and storing. These failures increased the risk for resident's exposure to food-borne illness. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2S1G11 Facility ID: CA01000001007 If continuation sheet 18 of 26 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: _______________ 555826 (X3) DATE SURVEY COMPLETED 12/20/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REDWOODS, A COMMUNITY OF SENIORS 40 Camino Alto Mill Valley, CA 94941 (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 1) During an observation on 12/12/16, at 10:40 a.m., a refrigerator designated as Number Two refrigerator, contained a box stamped with a received date of 12/09/16, the contents included ten sweet potatoes. Two of ten sweet potatoes had a fuzzy gray substance that covered approximately one and one-half inch by one inch of 1 sweet potato and approximately one inch of the second potato. A second box in refrigerator Number Two contained a box stamped with a received date of 11/29/16, that contained four bunches of celery and three loose, individual wilted stalks of celery. During concurrent observation and interview, Executive Chef stated the gray fuzzy substance on the sweet potatoes was mold. Executive Chef lifted the three stalks from the box, one was split down the middle. The Executive Chef stated the celery sticks and the molded potatoes were bad and he discarded them. The policy and procedure for storage of produce was requested on 12/12/16, at 10:43 a.m., Director of Dining Services presented a facility policy titled "Production, Purchasing, Storage", Subject: Receiving, policy #B004, dated 5/95, revised date of 1/16. Policy for storage of produce was not specified on the policy provided by the facility. 2) During an observation and concurrent interview on 12/12/14 at 11:00 a.m., Unlicensed Staff I dipped a rag into a red bucket of solution and wiped the counters for two minutes, then removed her gloves and washed her hands for approximately 30 seconds. When asked how she knew the solution in the red bucket was effective for cleaning the counters, Unlicensed Staff I located a package of test strips and stated she would test the sanitizer. She then placed the test strip in the solution in the red bucket and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2S1G11 Facility ID: CA01000001007 If continuation sheet 19 of 26 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: _______________ 555826 (X3) DATE SURVEY COMPLETED 12/20/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REDWOODS, A COMMUNITY OF SENIORS 40 Camino Alto Mill Valley, CA 94941 (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 removed the test strip after approximately five seconds. The color of the test strip indicated a concentration level of 100 ppm (parts per million). When asked what level of sanitizer was needed for cleaning effectively, Unlicensed Staff I stated 200 ppm. When asked how long she held the test strip in the solution to test the level, Unlicensed Staff I stated one second, and that she was not sure. The Executive Chef reminded Unlicensed Staff I that the correct testing time was 10 seconds and was printed on the package of test strips. Unlicensed Staff I repeated the procedure for using the test strip in the cleaning solution. The solution tested 300 ppm. When asked the date of the last inservice regarding the sanitizer, Unlicensed Staff I stated every three weeks. During an observation and concurrent interview on 12/15/16 at 8:26 a.m., Unlicensed Staff R dipped a rag into a red bucket of solution and wiped the food cart for two minutes. When asked how the solution in the red bucket was determined to be effective at cleaning, Unlicensed Staff R stated she used a test strip to check the level of sanitizer. She then placed the test strip into the solution in the red bucket and removed the test strip after approximately two seconds. The color of the test strip indicated the sanitizer concentration level was 100 ppm. When asked what level of sanitizer was needed for cleaning effectively, Unlicensed Staff R stated 200 ppm. When asked how long she held the test strip in the solution to test the level, Unlicensed Staff R stated she did not know. When asked where she would find the information for testing the sanitizer level, she stated on the sanitizer package. Unlicensed Staff R retested the sanitizer level and held the test strip in the solution for 10 seconds, the color of the test strip indicated 300 ppm. When asked the last date of the last in-service regarding sanitizer, Unlicensed Staff R stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2S1G11 Facility ID: CA01000001007 If continuation sheet 20 of 26 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: _______________ 555826 (X3) DATE SURVEY COMPLETED 12/20/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REDWOODS, A COMMUNITY OF SENIORS 40 Camino Alto Mill Valley, CA 94941 (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 she did not remember. The facility policy and procedure titled, "Sanitation and Infection Control, Sanitizing Food Contact Surfaces", Policy #F013, dated 5/95, revised date 1/15, Procedures, Important, indicated Follow manufacturer's directions for using detergents and sanitizers. Review of the quaternary sanitizer manufacturer's label directions, indicated dip the test strip into the sanitizing solution for 10 seconds. 3) During an observation on 12/14/16 at 3 p.m., a cart next to the washing machine contained two stacks of approximately eight plates. Unlicensed Staff J stated they were clean dishes that were drying. When the stack of eight plates was lifted from the cart, a dark wet area approximately four inches by four inches was revealed. When asked what the dark area was on the cart, Unlicensed Staff J stated it was water. Unlicensed Staff J lifted the top four plates from the stack of eight and concurred that the surface of the plate was covered with water droplets. When asked if there were any other steps he would take after washing the dishes, he pointed to several plates that rested against three inch prongs between several square compartments within a gray plastic crate. Unlicensed Staff J then stated the gray plastic crates were used to dry glasses. He then wheeled the cart to the kitchen preparation area and stated he would place the dishes on the shelves for the dinner tray line. During an interview on 12/15/16 at 4:00 p.m., the Director of Dining Services stated the facility did not have enough gray racks and too little counter space to dry all the dishes between meals. When asked to describe the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2S1G11 Facility ID: CA01000001007 If continuation sheet 21 of 26 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: _______________ 555826 (X3) DATE SURVEY COMPLETED 12/20/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REDWOODS, A COMMUNITY OF SENIORS 40 Camino Alto Mill Valley, CA 94941 (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 gray racks, the Dining Services Supervisor stated the gray racks were approximately four feet by four feet and had smaller four-inch by four inch compartments with four, 3" (inch) prongs for each compartment. She also stated the dishwasher was trained to use more gray racks to prevent moisture between plates when stacked. The Director of Dining Services further stated moisture on plates allowed bacteria to "make its home too soon" [grow] when droplets of water remained on the surface of the plates too long when stacked.

F465 SS=F SAFE/FUNCTIONAL/SANITARY/COMFORTA F465 BLE ENVIRON CFR(s): 483.90(i)(5) 01/20/2017 (i) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. (5) Establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account non-smoking residents. This REQUIREMENT is not met as evidenced by: Based on observations and interviews, the facility failed to ensure a safe and comfortable environment for residents when laundry and trash containers, and assistive devices lined Hallway 1 and 2. This failure had the potential to result in falls and injuries to residents, staff and visitors caused by blocked halls and inaccessible hand rails in Hallway 1 and 2. During an observation on 12/12/16 at 9:45 a.m., in Hallway 1 up against one wall there FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2S1G11 Facility ID: CA01000001007 If continuation sheet 22 of 26 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: _______________ 555826 (X3) DATE SURVEY COMPLETED 12/20/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REDWOODS, A COMMUNITY OF SENIORS 40 Camino Alto Mill Valley, CA 94941 (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 was one resident transfer lift (assistive device that allows patients to be transferred between a bed and a chair or other similar resting places), one exercise type machine, four wheelchairs, one trash container and, one laundry container. In Hallway 2 against one wall there was one resident transfer lift, two wheelchairs, one trash container, and one laundry container. In both hallways, sections of the handrails along the walls were blocked by the equipment. During an observation on 12/12/16 at 2:10 p.m., against the wall adjacent to Rooms 24 and 26 (Hallway 2), one transfer lift, two wheelchairs, one trash container, and one laundry container blocking sections of the hallway handrails. During a concurrent observation one resident used the handrail to self-propel in a wheelchair. During an observation on 12/13/16 at 11 a.m., adjacent to Rooms 22 and 24 [Hallway 2], were two wheelchairs, one resident transfer lift, one trash container, and one laundry container against a wall, blocking sections of the hallway handrails. During an observation on 12/14/16 at 2:30 p.m., adjacent to Rooms 26 and 28 [Hallway 2], were two wheelchairs, one trash container, and one laundry container against one wall, blocking sections of the hallway and handrails. During a concurrent observation, one wheelchair-bound resident self-propelled down the middle of Hallway 2, adjacent to Rooms 22 and 24. A second resident use a walker and had difficulty moving closer to the wall to avoid running into the wheelchair bound resident due to the equipment in the hallway. During an interview on 12/16/16 at 10:30 a.m., Unlicensed Staff N stated there was no place to put the lifts, wheelchairs so they, "stay in the hallway". FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2S1G11 Facility ID: CA01000001007 If continuation sheet 23 of 26 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: _______________ 555826 (X3) DATE SURVEY COMPLETED 12/20/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REDWOODS, A COMMUNITY OF SENIORS 40 Camino Alto Mill Valley, CA 94941 (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 on 12/16/16 at 3:25 p.m., Unlicensed Staff P stated there was no storage so the equipment stayed in the hallway. She stated if a wheelchair belonged to a resident they would usually fit in the resident's room; but if there were extra wheelchairs and walkers there was not enough space or storage anywhere to put the items. During an interview on 12/16/16 at 3:35 p.m., Unlicensed Staff K stated equipment went in the hallway because there was no storage for "things" like that. Unlicensed Staff K stated there was no "extra" room to put these items.

F500 SS=E OUTSIDE PROFESSIONAL RESOURCESARRANGE/AGRMNT CFR(s): 483.70(g)(1)(2)(i)(ii)

F500 01/19/2015 (g) Use of outside resources. (1) If the facility does not employ a qualified professional person to furnish a specific service to be provided by the facility, the facility must have that service furnished to residents by a person or agency outside the facility under an arrangement described in section 1861(w) of the Act or an agreement described in paragraph (g)(2) of this section. (2) Arrangements as described in section 1861(w) of the Act or agreements pertaining to services furnished by outside resources must specify in writing that the facility assumes responsibility for(i) Obtaining services that meet professional standards and principles that apply to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2S1G11 Facility ID: CA01000001007 If continuation sheet 24 of 26 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: _______________ 555826 (X3) DATE SURVEY COMPLETED 12/20/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REDWOODS, A COMMUNITY OF SENIORS 40 Camino Alto Mill Valley, CA 94941 (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 professionals providing services in such a facility; and (ii) The timeliness of the services. This REQUIREMENT is not met as evidenced by: Based on interview and employee record review, the facility's contract with outside hiring agencies did not specify the services provided by the agency and that the agency services included professional reference checks for three of four licensed nurse records reviewed. This failure did not ensure all licensed nurses that worked at the facility met the standard qualifications required for direct patient care. Findings: During a concurrent interview and record review on 12/15/16 at 10:00 a.m., three licensed nurses' employee records contained no written verification that indicated the Human Resources Manager had checked professional references prior to hire. When asked who performed the reference checks and what date they were performed, the HR director stated the facility did not perform the reference checks and two outside agencies were given the responsibility of performing the reference checks. During a concurrent interview and record review on 12/15/16 at 12:02 p.m., the two agency contracts, dated 6/18/14 and 8/19/15, revealed the outside agency contract agreements did not specify in writing, the responsibility for obtaining reference checks or any other services for hiring facility employees. The Human Resources Manager concurred that the two outside agency contracts did not specify in writing, the responsibility of performing reference checks. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2S1G11 Facility ID: CA01000001007 If continuation sheet 25 of 26 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: _______________ 555826 (X3) DATE SURVEY COMPLETED 12/20/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE THE REDWOODS, A COMMUNITY OF SENIORS 40 Camino Alto Mill Valley, CA 94941 (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 facility document titled "Manager's Step-by Step Hiring Checklist", dated 2015. Step 6 indicated Check references. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 2S1G11 Facility ID: CA01000001007 If continuation sheet 26 of 26