Health inspection·February 14, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility's revised 7/2017 policy Assistance with Meals indicated residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity; for example, a. Not standing over residents while assisting them with meals. 2. During an observation, on 2/10/23 at 11:53 a.m., Resident 31, who was in his room with the physical therapy assistant (PTA) performing exercises, was viewable from the hallway with his blue incontinence pads on and bare legs exposed to public view. During a concurrent interview with the PTA, she validated the observation and stated she could have pulled the cubicle curtain to provide privacy for Resident 31 during therapy treatment. The PTA stated, Sorry it won't happen again. During a concurrent interview with the PTA, on 2/14/23 at 8:38 a.m., the PTA stated she was now more mindful of pulling the curtains to provide privacy to residents. Review of the facility's revised December 2016 policy and procedure Resident Rights indicated employees shall treat all residents with kindness, respect and dignity. Review of the facility's revised February 2020 policy and procedure Quality of Life-Dignity indicated staff shall promote, maintain and protect resident privacy, which included bodily privacy during assistance with personal care and treatment procedures. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 2 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 145) discharged from Medicare Part A services received a Notice of Medicare Non-Coverage (NOMNC, a form given to Medicare recipients notifying that Part A coverage is being terminated and providing information on how to file an appeal of that decision) letter in a timely manner. Residents Affected - Few This failure had the potential to prevent the resident from filing a timely appeal of the decision to discharge from Medicare Part A services. Findings: Review of Resident 145's clinical records indicated, Resident 145 was admitted to the facility on [DATE] with a diagnosis of fracture of the neck part of the left femur (broken hip bone). The facility initiated a discharge of Medicare Part A services on 12/21/2022. Review of Resident 145's NOMNC letter, dated 12/21/2022, indicated, The effective date coverage of your current Medicare coverage will end: 12/21/2022. Further review of the NOMNC letter's second page indicated, I have been notified that coverage of my services will end on the effective date indicated on this notice and that I may appeal this decision by contacting my QIO . NOMNC issued to RR (responsible representative) via phone 12/21. During a concurrent interview and record review of Resident 145's NOMNC letter with the case manager (CM), on 2/13/2023 at 10:28 a.m., the CM confirmed the notification of the last covered day (LCD - last day of Medicare coverage) in the NOMNC letter was done on 12/21/2022 by a phone call with the representative. The CM stated the notification should have been done 48 hours before the LCD. During an interview with the social service director (SSD), on 2/14/2023 at 12:49 p.m., the SSD confirmed Resident 145 was a planned discharge. The SSD stated the notification of the LCD in the NOMNC letter should have been done 48 hours prior to 12/21/2022. Review of the CMS (Centers for Medicare & Medicaid Services) NOMNC instructions, titled Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123, indicated, The NOMNC must be delivered at least two calendar days before Medicare covered services end or the second to last day of service if care is not being provided daily. Note: The two day advance requirement is not a 48 hour requirement If the provider is personally unable to deliver a NOMNC to a person acting on behalf of an enrollee, then the provider should telephone the representative to advise him or her when the enrollee's services are no longer covered. The date of the conversation is the date of the receipt of the notice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 3 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation and interview, the facility failed to maintain a organized and sanitary environment for one non-sampled resident (Resident 116) when the room was disorganized, her tray table used for meals had chipped areas, and one wooden cabinet drawer was broken. These failures created a disorganized and unsanitary environment that could pose safety risks for Resident 116 . Findings: During an observation, on 2/7/23 at 12:24 p.m., Resident 116 sat in a wheelchair in her room among multiple personal belongings scattered throughout the room and under her bed, such as dirty or used clothes, linens, sheets, blankets. During a concurrent interview, Resident 116 stated she needed help to organize her room and that she could not do it by herself. During an observation with the director of nursing (DON), on 2/13/23 at 9:24 a.m., a wooden cabinet next to Resident 116's personal belongings were still scattered throughout her room and under her bed, such as dirty or used clothes, linens, sheets, blankets. A wooden cabinet next to Resident 116's bed contained unlabeled/undated food items that included a half bottle of coffee, some juices, apple sauce, opened salad dressing, seeds, chips, noodles. Some of the food items were on the floor. The tray table was dirty, with chipped edges and paint, and was full of food (juices, chips, apple sauce, etc.). The lower drawer of a wooden cabinet was broken. The DON verified the observation and confirmed the need to organize and clean the room. During an observation on 2/14/23 at 8:07 a.m., Resident 116 was in her room with a tray table full of personal items and a breakfast tray on her wheelchair. Licensed vocational nurse I (LVN I) verified the observation. During an interview with ADON B 2/14/23, at 8:18 a.m., ADON B verified unlabeled/undated food on the floor of Resident 116's room. The ADON B stated, food should be dated. Resident 116 stated, yesterday's afternoon's assigned CNA was not able to help her clean up and organize her room. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 4 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Review of Resident 6's progress notes, dated 11/27/22, indicated she was sent out to the acute hospital due to nausea, vomiting and decreased oxygen saturation (measurement of oxygen in the blood). During a record review and concurrent interview with the social services director (SSD), on on 2/10/23 at 9:50 a.m., the SSD confirmed Resident 6 was not included in any lists faxed to the Ombudsman office for notification purposes. The SSD stated, . should have faxed the transfer notice . Review of the facility's revised October 2022 policy and procedure Transfer or Discharge Notice indicated the facility shall provide a resident and/or resident's representative with a thirty day written notice of an impending transfer or discharge. A copy of the notice will be sent to the Office of the State Long-Term Ombudsman. Based on interview and record review, the facility failed to follow their policy and procedure to notify the Office of the State Long-Term Care Ombudsman (organization that advocates for the residents) when four of four sampled residents (Residents 6, 135, and 146) were transferred to the acute care hospital or discharged from the facility without notifying the Ombudsman. This failure had the potential to compromise the residents' admission, transfer, and discharge rights. Findings: Review of Resident 135's clinical record indicated she was transferred to an acute care hospital on [DATE] following a fall. Review of Resident 146's clinical record indicated he was discharged from the facility on 12/18/22 AMA (leaving the facility against medical advice). During an interview with the social services director (SSD) on 2/9/23 at 8:15 a. m., he reviewed the list of transfers and discharges for November 2022 and December 2022. He confirmed that Resident 135 had been transferred to the acute care hospital on [DATE], and Resident 146 had been discharged AMA on 12/18/22. The SSD was unable to provide evidence that the long-term care Ombudsman was notified for both Resident 135's transfer to an acute care hospital and Resident 146's discharge from the facility. During a record review and concurrent interview with SSD on 2/9/23 at 8:15 a.m., he provided the list of residents who were discharged or transferred from the facility during the months of October, November, and December of 2022. The SSD stated he compiles the resident transfers and discharges during the month and faxes the list of residents to the Ombudsman at the end of each month. The SSD stated he did not have the fax verification report for the months of October, November, and December that indicated the Ombudsman received the notifications. The SSD stated sometimes the fax machine does not always work and he did not received the fax verification report, which confirmed the Ombudsman was notified. The SSD confirmed the Ombudsman was not notified of transfers or discharges for 27 residents in October 2022, 18 residents in November 2022, and 22 residents in December. The SSD confirmed the Ombudsman should be notified of the transfers and discharges of residents in the facility. Review of the facility's revised October 2022 policy and procedure, Transfer or Discharge Notice, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 5 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 Level of Harm - Minimal harm or potential for actual harm indicated the facility shall provide a resident and/or resident's representative with a thirty-day written notice of an impending transfer or discharge. A copy of the notice will be sent to the Office of the State Long-Term Ombudsman. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 6 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete and transmit the Minimum Data Set (MDS, a comprehensive assessment tool) discharge assessment in a timely manner for one of 29 sampled residents (Residents 126). Residents Affected - Few This failure resulted in the resident's discharge assessment not being transmitted and received by the Center for Medicare and Medicaid System within the time requirement. Findings: During the record review and concurrent interview with the minimum data set nurse (MDSN), on 2/14/23 at 2:32 p.m., the MDSN reviewed Resident 126's closed record that indicated he was admitted on [DATE] and was discharged home on [DATE]. The MDSN confirmed Resident 126's discharge MDS was not completed. The MDSN stated she would complete and transmit Resident 126's discharge MDS to the Center for Medicare and Medicaid System. Review of the Resident Assessment Instrument Process (RAI-guidance and information gathering for resident's strengths, needs, care plan, and tracking of changes in residents' condition), dated October 2017, indicated, .Tracking Records and Assessments are federally mandated, and therefore, must be performed for all residents of Medicare and/or Medicaid certified nursing homes .Discharge Assessment .MDS Completion Date .No later Than discharge date + [plus] 14 calendar days) .Transmission Date No Later than .MDS Completion Date + 14 calendar days . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 7 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to accurately code in the MDS (Minimum Data Set- an assessment tool) for three of 29 sampled residents (Resident 103, 108 and 90) when the completed and transmitted MDS did not include: Residents Affected - Few 1. Resident 103's three fall incidents, one of which resulted in minor injury. 2. Resident 108's functional limitation on one side of an upper extremity. 3. Resident 90's special treatments and procedures. These ommissions in coding resulted in an inaccurate MDS. Findings: 1. Review of Resident 103's clinical record with the minimum data set coordinator (MDSC) and the assistant director of nursing B (ADON B), on 2/8/23 at 4:45 p.m., indicated fall incidents with no injury occurred on 8/19/22 and 8/25/22; and, a fall incident with minor injury occurred on 11/5/22. Both MDS C and ADON B verified Resident 103's fall incidents were unaccounted for in Resident 103's MDS, dated [DATE]. During a concurrent interview with the MDSC, she stated, . will make modification right now. 2. During an observation and concurrent interview with Resident 108, on 2/7/23 at 11:47 a.m., he stated his left shoulder had movement imitations while he demonstrated how he could hardly raise his left arm. During an interview and record review with the assistant director of nursing B (ADON B) and director of nursing (DON), on 2/8/23 at 5:43 p.m., both staff reviewed Resident 108's MDS, dated [DATE], which indicated he had no impairment or functional limitations in range of motion (ROM) of his upper or lower extremities. During an interview and record review on 2/8/23 at 4:45 p.m with MDS C, she confirmed Resident 108 had left shoulder ROM limitations per clinical assessments and that there was an error in the coding of the MDS which needed to be revised to indicate he had a left upper extremity functional limitation. 3. Review of Resident 90's clinical record indicated he was admitted on [DATE] and had diagnoses including end stage renal disease (a condition in which kidneys no longer function normally on their own), dependance on renal dialysis (a process of removing waste, toxins, and excess water from the blood). Review of Resident 90's physician orders dated 7/21/21, indicated hemodialysis at an outpatient dialysis center on Mondays, Wednesdays, Fridays, and Saturdays. Review of resident 90's MDS, dated [DATE] indicated the following: Section O0100 Special Treatments, Procedures, and Programs check all of the following treatments, procedures and programs that were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 8 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few performed during the last 14 days. Section J of O0100 Dialysis was unchecked (blank). Section Z The was coded None of the above, which indicated Resident 90 did not have any special treatments, procedures and programs that were performed during the last 14 days, which essentially meant Resident 90 did not have dialysis during the last 14 days. During an interview and concurrent record review with Minimum Data Set Coordinator Z (MDSC Z), on 2/13/23 at 10:37 a.m., she reviewed Resident 90's medical record and confirmed she had completed Resident 90's annual comprehensive assessment on 12/26/22 incorrectly. The MDSC Z stated, That was my mistake . I should check yes on the dialysis section J because he did have dialysis within the last 14 days when this annual assessment was completed. Review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1, dated October 2019, indicated, The RAI process has multiple regulatory requirements . Federal regulations at 42 CFR 483.20 (b)(1)(xviii), (g), and (h) require that (1) the assessment accurately reflects the resident's status. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 9 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on observation, interview and record review, the facility failed to develop and implement individualized, resident-centered care plans for three of 29 sampled residents when care plans for: Residents Affected - Few 1. bilateral upper side rails for Resident 6 were not followed, 2. risk for fall/further falls (to provide floor mat and keep bed in lowest position) was not followed for Resident 66, 3. skin discoloration was not developed for Resident 107. The failure to developed and/or follow care plans had the potential unmet care needs for residents. Findings: 1. During an observation with the director of nursing (DON), on 2/14/23 at 10:09 a.m., Resident 6 was in bed with bilateral side rails placed on the middle part of the bed. During a concurrent interview and record review, the DON verified the observation and confirmed a physician's order, dated 12/5/22, indicated, . may have 1/4 bilateral upper side rails up when in bed to assist resident on bed mobility . The DON confirmed Resident 6's care plan for multiple falls, dated 2/3/23, included bilateral upper side rails up for bed mobility, repositioning, and transfers. The DON stated the care plan and the physician's order were not followed. 2. Review of Resident 66's care plan for Risk of fall /further falls due to Left lower limb cellulitis, hemiparesis ( weakness on one side if the body)/hemiplegia (paralysis on one side of the body), contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) of the left and right knees, dated 2/11/21, indicated interventions to keep bed in lowest position when in bed to lessen impact of fall, and landing mat on floor to reduce impact of fall. During an observation, on 2/7/23 at 2:19 p.m., with certified nursing assistant Q (CNA Q), CNA Q verified that, while Resident 66 was in his bed awake, the bed was not in its lowest position and there was no landing pad (floor mat) on the floor. During an observation, on 2/9/23 at 10:37 a.m., with certified nursing assistant BB (CNA BB), CNA BB verified Resident 66's bed was not in its lowest position and there was no landing pad (floor mat) on the floor. During an interview and concurrent record review with the assistant director of nursing (ADON B), on 2/9/23 at 1:09 p.m., ADON B reviewed Resident 66's risk for fall care plan that and confirmed the care plan was not implemented. 3. During an observation, on 2/8/23 at 10:23 a.m., Resident 107 was noted with multiple skin discolorations. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 10 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with certified nursing assistant CC (CNA CC), on 2/8/23 at 10:50 a.m., CNA CC confirmed Resident 107 had skin discolorations on her right arm. During a record review and concurrent interview with the DON, on 2/9/23 at 5:05 p.m., after clinical record reveiw, the DON confirmed Resident 107's skin discoloration was initially identified on 1/31/23, that there was no follow-up assessment completed thereafter, and there was no documented evidence a care plan was developed for it. The DON stated, regarding Resident 107's skin discoloration, that the skin assessment for non-pressure injury should have been completed weekly, and a care plan should have been developed for it. Review of the policy and procedure Comprehensive Person-Centered Care Plans, revised December 2016, indicated a person-centered care plan is developed and implemented for each resident with interventions derived from a thorough analysis of the information gathered as part of the comprehensive assessment; assessments of resident are on-going and care plans are revised as information about the residents' condition change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 11 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide care and services in accordance with acceptable professional standards of quality for two of 29 sampled residents (Resident 15, 46) when: Residents Affected - Some 1. Nursing staff failed to clarify an unsafe insulin order for Resident 15, posing a risk of adverse outcomes such as severely low blood glucose (BG, or blood sugar) for the resident; and 2. Nursing staff failed to identify duplicate orders for Resident 46's Seroquel (generic name: quetiapine, an anti-psychotic medication to treat mental illnesses), resulting in Seroquel given in excess and more than prescribed for two months. Findings: 1. During a medication pass observation on 2/7/23 at 12:31 p.m., Licensed Vocational Nurse L (LVN L) was observed obtaining the BG level by pricking Resident 15's right ring finger. His BG reading was 142 milligrams/deciLiter (mg/dL, unit of measurement; normal BG is less than 100 mg/dL) at this time. LVN L stated Resident 15 needed 6 units of insulin (medication to lower BG) for the BG reading of 142 mg/dL. On 2/7/23 at 12:37 p.m., LVN L was observed drawing up 6 units of Novolog (a rapid-acting insulin that helps lower mealtime blood sugar spikes) from the Novolog vial and administered it to Resident 15 by injection. According to the Center for Disease Control and Prevention online publication titled Diabetes Basics, revised 12/30/22, it indicated, Blood sugar levels change often during the day. When they drop below 70 mg/dL, this is called having low blood sugar. At this level, you need to take action to bring it back up. (https://www.cdc.gov/diabetes/basics/low-blood-sugar.html; accessed 2/15/23) On 2/7/23, a review of Resident 15's medical record indicated a physician's order, start date of 10/10/22, for Novolog 100 units/mL, inject per sliding scale (SS, a set of instructions for administering insulin dosages based on specific BG readings): If [BG reading of] 0 - 150 = 6 UNITS, NOTIFY MD IF BS [blood sugar] <70 AND FOLLOW HYPOGLYCEMIC GUIDELINES . This order breakdown indicated for the nursing staff to give 6 units of insulin even when the BG was low, such as at 0 mg/dL, or 10 mg/dL. Further review of Resident 15's medication administration record (MAR) indicated the nursing staff had been carrying out this order since 10/10/22. During a concurrent interview and record review with Assistant Director of Nursing A (ADON A) on 2/7/23 at 2:40 p.m., she reviewed the above sliding scale order and stated the nursing staff should have clarified the SS breakdown order as they should not administer insulin if BG was below 70 mg/dL but to activate the hypoglycemic guidelines (procedures to manage low BG by assessing the resident for signs and symptoms and implementing interventions to raise the BG). ADON A acknowledged this was an unsafe order as giving insulin, as called for by the order, when the resident's BG is low would be lead to severe adverse outcomes for the resident. 2. On 2/8/23, a review of Resident 46's medical record indicated she had a physician's order, dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 12 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 9/14/22, for Seroquel 50 mg every 12 hours (total 100 mg/day) for vascular dementia (a condition characterized by memory loss) with behavior disturbance. A review of a nursing progress notes, dated 11/23/22, indicated, RNP [registered nurse practitioner] from [company name] here to assess resident with recommendation to increase seroquel to TID [short for three times daily] . MD [medical doctor] . notified and agreed. Orders noted and carried out. A review of Resident 46's medical record indicated a new physician's order, dated 11/23/22, for Seroquel 50 mg three times daily (total 150 mg/day) for psychosis related to stroke symptoms. However, the previous order of Seroquel 50 mg every 12 hours was not discontinued until 1/25/23, a period of two months. A review of Resident 46's November 2022 to January 2023 reflected the nursing staff administered the Seroquel five times daily (total 250 mg/day) starting 11/28/22, following the Seroquel every 12 hours (scheduled at 9 a.m. and 9 p.m.) and Seroquel TID orders (scheduled at 9 a.m., 1 p.m., and 5 p.m.). During a concurrent interview and record review with the director of nursing (DON) on 2/9/23 at 12:49 p.m., he reviewed Resident 46's electronic health record (eHR) and confirmed Resident 46's Seroquel 50mg every 12 hours order was not discontinued when Seroquel 50mg TID order was started. He reviewed the resident's November 2022 to February 2023 MARs and stated, They did not dc [discontinue] it [old order] back then. He acknowledged the nursing staff should have clarified the orders when there were duplicate orders on the MARs, and said I don't know what else to tell you. He verified the above-stated MARs indicated Resident 46 was receiving Seroquel 50 mg 5 times a day. A review of the facility's policy and procedures titled Administering Medications, revised 4/2019, indicated, If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician or the facility's Medical Director to discuss the concerns. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 13 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of Resident 122's facesheet indicated he was admitted on [DATE]. His brief interview for mental status (BIMS, an assessment tool for cognition), dated 11/17/22, indicated a score of 15 (intact cognition). Residents Affected - Few During the initial tour on 2/7/23 at 2:29 p.m., Resident 122 verbalized, I'm concerned about my medication, it's not given as it is supposed to be . my Niacin is given when I don't have anything in my stomach . this medicine makes my stomach upset. Resident 122 stated he was feeling unhappy because of his concerns regarding his medication, niacin, were not addressed. Resident 122 stated he mentioned his concern about the administration time for niacin to his nurses, but nothing changed. During a record review and concurrent interview, on 2/9/23 at 1:02 p.m., licensed vocational nurse X (LVN X) reviewed Resident 122's physician's order for niacin and confirmed this medication had not been given with meals. LVN X also confirmed the medication administration record (MAR) indicated niacin was given at 6:17 a.m. and 11:12 a.m that day. During an interview with the assistant director of nursing B (ADON B), on 2/9/23 at 1:15 p.m., the ADON B reviewed Resident 122's physician's order sheet (POS), dated 5/30/22, which indicated Niacin 500 mg. (milligrams, unit of measurement) one tablet three times a day with meals. ADON B, along with the other certified nursing assistants (CNAs ) at the nurses station stated breakfast was usually distributed around 8:00 a.m. and lunch at 1:00 p.m ADON B stated, if the medication was not given with meals, then the physician's order was not followed. Review of the facility's May 2019 revised policy and procedure Competency of Nursing Staff indicated competency in skills and techniques necessary to care for residents' needs includes but not limited to competency in areas such as carrying out physician's ordered. According to the Lexicomp (drug information website), Niacin should be taken with meals. The Warnings/Precautions, concerns related to adverse effects include: May cause GI (gastrointestinal) distress, vomiting, diarrhea, or aggravate peptic ulcer; GI distress may be attenuated with a gradual increase in dose and administration with food. Use is contraindicated in patients with active peptic ulcer disease; use with caution in patients with a past history of peptic ulcer. Consider discontinuation if unexplained abdominal pain/weight loss or other GI symptoms occur during therapy . (http://online.[NAME].com/lco/action/doc/retrieve/docid/patch_f/7598#f_adverse-reactions). Based on observation, interview and record review, the facility failed to ensure care and services were provided in accordance with professional standards of practice for three sampled residents (Residents 59, 90, and 122) when: 1. For Resident 90, there was no documentation or monitoring of the cardiac defibrillator. 2. For Resident 59, licensed nurses did not follow the physician's order and care plan to use the bed's 1/4 bilateral upper side rails up. 3. For Resident 122, licensed nurses did not follow the physician's order to administer the medication Niacin (B vitamin that's made and used by the body to turn food into energy) with meals. These failures had the potential to compromise the resident's health and well-being. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 14 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Findings: Level of Harm - Minimal harm or potential for actual harm 1. Review of Resident 90's clinical record indicated he was admitted on [DATE] with diagnoses including presence of automatic (implantable) cardiac defibrillator (small battery-powered device placed in the chest to detect and stop irregular heartbeats), obesity, end stage renal disease (kidney failure, kidneys no longer function to meet the body's needs), dependence on renal dialysis (dialysis: a procedure in which a machine filters wastes and fluid from the blood), and congestive heart failure (condition when the heart cannot pump and fill adequately) Residents Affected - Few Review of Resident 90's admission Skin Assessment, dated 7/19/22, included a diagram of the front and back of the human body. The diagram did not identify the presence of Resident 90's implanted cardiac defibrillator of his upper left chest. Review of Resident 90's clinical record indicated there was no documentation of the defibrillator's manufacturer, model number, date of implant, or the cardiologists address and telephone number. There were no physician orders to monitor Resident 90's defibrillator or observe for signs and symptoms of defibrillator failure. There was no care plan for Resident 90's implanted cardiac defibrillator. During an interview and concurrent record review with the assistant director of nursing B (ADON B), on 2/9/23 at 3:15 p.m., she confirmed Resident 90's diagnosis of the presence of automatic (implanted) cardiac defibrillator. She confirmed Resident 90's clinical records did not contain the defibrillator's manufacturer, model number, date of implant, or the cardiologists address and telephone number. The ADON B stated the information should be recorded in Resident 90's clinical record. The ADON B confirmed there were no physician orders to monitor the defibrillator or observe for signs and symptoms of defibrillator failure. The ADON B stated nursing staff should monitor residents every shift for signs and symptoms of defibrillator malfunction. The ADON B confirmed there was no care plan for Resident 90's implanted cardiac defibrillator and stated a care plan should be developed and implemented for residents with defibrillators. A review of the facility's policy Care of a Resident with Pacemaker, revised December 2015, indicated to monitor the resident for pacemaker failure by monitoring for signs and symptoms of bradyarrhythmias (slow heart rate) which include syncope (fainting), shortness of breath, dizziness, fatigue and confusion. The policy further indicated for each resident with a pacemaker, to document the following in the medical record: the name, address and telephone number of the cardiologist; Type of pacemaker; Type of leads; manufacturer and model; serial number; Date of implant; and Paced rate. A review of the U.S. Department of Health & Human Services' National Heart, Lung, and Blood Institute website, www.nhlbi.nih.gov, indicated a pacemaker can stop working properly over time because the wires get dislodged or broken, the battery gets weak or fails, the heart disease progresses, and other devices have disrupted its electrical signaling. 2. Review of Resident 59's admission RECORD, dated February 10, 2023, indicated, Resident 59 was admitted with diagnoses including metabolic encephalopathy (a problem in the brain cause by a chemical imbalance in the blood), and Alzheimer's disease (a progressive disease beginning with mild memory loss and possibly leading to loss of the ability to carry on a conversation and respond to the environment). Review of Resident 59's Order Listing Report, dated February 10, 2023, indicated, May have 1/4 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 15 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 bilateral (both) upper side rails up when in bed to assist resident in bed mobility every shift. Level of Harm - Minimal harm or potential for actual harm Review of Resident 59's care plan titled, LONG TERM: Resident 59 is at risk for falls/further falls, multiple falls, minor and major injuries ., dated 7/28/2021, indicated, May have 1/4 bilateral upper side rails up when in bed to assist resident in bed mobility, repositioning, and transfers as ordered. Residents Affected - Few Review of Resident 59's care plan titled, Resident 59 has an impaired physical functioning ADL (activities of daily living, such as bed mobility, transfer, toileting, eating, or dressing) self care deficit .May have 1/4 bilateral upper side rails up when in bed to assist resident in bed mobility. During an observation, on 2/6/2023 at 9:41 a.m., Resident 59 laid in bed, asleep, with bed rails raised up at the middle of the bed. During multiple observations, on 2/7/2023 at 1:10 p.m., 2/8/2023 at 10:15 a.m., and 2/9/2023 at 8:45 a.m., Resident 59 laid in bed with bed rails raised up in at the middle of the bed. During a concurrent observation of Resident 59's bed rails and interview with the licensed vocational nurse A (LVN A), on 2/9/2023 at 1:20 p.m., Resident 59 ate with both bed rails raised up at the middle of the bed. During a concurrent observation and interview with the assistant director of nursing A (ADON A) on 2/9/2023 at 1: 20 p.m., she stated they used the side rails to help resident with bed mobility and transfers. ADON A confirmed the side rails were fixed to the bed in the middle. During an observation in Resident 59's room, on 2/9/2023 at 1:26 p.m., two maintenance staff released both bed rails from the middle of the bed and lifted them up to the upper part of the bed. During an interview with the certified nursing assistant GG (CNA GG), on 2/10/2023 at 8:33 a.m., she stated when Resident 59's bed rails were up at the middle of the bed, Resident 59 was unable to transfer. Certified nursing assistant GG stated when Resident 59's bed rail was moved to the upper part of the bed, she was able to transfer. During a concurrent interview and record review with the director of nursing (DON), on 2/10/2023 at 1:30 p.m., the DON reviewed Resident 59's physician order and care plan related to the use of bed rails. The DON confirmed that having bedrails up at the middle of the bed was not what was ordered and care planned for Resident 59. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 16 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide appropriate care and services for a suprapubic catheter (SPC, a type of catheter that is inserted through a hole in an abdomen [tummy] directly to the bladder [the organ that stores urine] and left in place) when (1) Resident 93's SPC site was unclean and (2) the urinary drainage bag was not changed as ordered. This failure in care had the potential for the patient to develop a urinary tract infection (UTI, an infection caused by a bacteria (germs) that get into the bladder or kidneys (a pair of organs that are on either side of the spine, just below the rib cage of a person's back). Findings: 1. Review of Resident 93's hospital DISCHARGE SUMMARY, dated 1/18/2022, indicated Resident 93 had diagnoses including UTI, chronic (persisting for a long time or constantly recurring) paraplegia (paralysis of the lower half of the body) and neurogenic bladder (a urinary condition when people lack bladder control due to a brain and/o nerve problem) with a history of chronic suprapubic catheter placement. During a concurrent wound treatment observation and interview with the licensed vocational nurse L (LVN L), on 2/8/2023 at 2:04 p.m., Resident 93's suprapubic site was open to air, with dried crusty brown, black, and [NAME] matter. The LVN L stated there was no treatment order for the suprapubic site. During a concurrent interview and record review with the assistant director of nursing A (ADON A), on 2/9/2023 at 9:00 a.m., she reviewed Resident 93's physician's orders and confirmed there was no treatment order for the suprapubic site until 2/8/2023. Review of Resident 93's physician order sheet, dated 2/9/2023, indicated, Cleanse suprapubic site with NS (normal saline), then pat dry, apply dry dressing QD (every day) and PRN (pro re nata, which means as needed) every day shift, with date ordered on 9/16/2022. Review of the medication administration record (MAR, a record of medications given and task completed), for February 2023, indicated, Observe for s/s (signs and symptoms) of infxn (infection) & complic. (complications) r/t (related to) SP cath (suprapubic catheter): 0.None .8 encrustation (a crust or hard coating on the surface of something) .on the cath (catheter) site .every shift FOR EARLY DETECTION OF POSSIBLE INFECTION FOR USE OF SUPRAPUBIC CATHETER, start date was 9/16/2022. Further review of MAR indicated, all nurses in all three shifts (Days, Evenings and Nights) coded 0 for encrustation, from 2/1/2023 to 2/8/2023. Review of the facility's policy and procedure titled, Suprapubic Catheter Care, revised October 2010, indicated, The purpose of this procedure is to prevent skin irritation around the stoma (a surgically created opening from an area inside the body to the outside) site and to prevent infection of the resident's urinary tract (organs that make urine and remove it from the body). 2. During a concurrent treatment observation and interview with LVN L, on 2/8/2023 at 2:04 p.m., Resident 93's SPC was connected to a tubing leading down to a urinary drainage bag. The tubing of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 17 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few urinary drainage bag contained whitish and yellowish matter. LVN L stated, they changed the urinary drainage bag with the tubing every month. During a concurrent observation of Resident 93's urinary drainage bag tubing and interview with licensed vocational nurse P (LVN P), on 2/9/2023 at 8:55 a.m., the urinary drainage bag's tubing still whitish and yellowish matter; however, some yellow areas were of a darker tinge. LVN P stated, they changed the urinary drainage bag every month and as needed. LVN P stated, . if there are some sediments and cloudiness in the tubing, it needed to be changed. LVN P stated Resident 93's urinary drainage bag's tubing needed to be changed. During another concurrent observation of Resident 93's urinary drainage bag's tubing and interview with the ADON A, on 2/9/2023 at 9:00 a.m., she stated, . it needs to be changed right away. ADON A confirmed, the importance of monitoring and following the physician's orders for the care of a resident's suprapubic catheter due to the risk of infection. Review of Resident 93's physician orders, dated 2/9/2023, indicated, Change Suprapubic catheter drainage bag every month & PRN (pro re nata, which means as needed) every evening shift every 30 day(s). The original dated of this physician's order was 9/16/2022. Review of Resident 93's MAR for the month of February 2023, indicated, Observe for s/s (signs and symptoms) of infxn (infection) & complic.(complications) r/t (related to) SP cath (suprapubic catheter): 0. None .7. Excessive sediments in the SP tubing/drainage bag .every shift FOR EARLY DETECTION OF POSSIBLE INFECTION FOR USE OF SUPRAPUBIC CATHETER . This MAR also indicated all nurses in all three shifts coded 0 for number seven, from 2/1/2023 to 2/8/2023. Further review of the MAR indicated the last SP catheter urinary drainage bag changed was on 1/14/2023. During a review of the facility's policy and procedure titled, Catheter Care, Urinary, date revised September 2014, indicated, 1. Changing .drainage bags at routine, fixed intervals is not recommended. Rather, it is suggested to change catheters and drainage bags based on clinical indications such as infection, obstruction, or when closed system is compromised. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 18 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident 90's clinical record indicated he was admitted on [DATE] with diagnoses including end stage renal disease (kidney failure, kidneys no longer function to meet the body's needs), dependance on renal dialysis (dialysis: a procedure in which a machine filters wastes and fluid from the blood), congestive heart failure (condition when the heart cannot pump and fill adequately), and obesity. Resident 90 was scheduled for dialysis every Monday, Wednesday, Friday, and Saturday. Residents Affected - Few Resident 90's had an arteriovenous fistula (AVF, surgically created connection between an artery and vein to allow dialysis to occur) in his left forearm. Review of Resident 90's physician order, dated 2/9/23, indicated to monitor dialysis access site LFA (left forearm) QS (every shift) for S&S (signs and symptoms) of infection, bleeding, redness, pain, swelling, discharge (notify MD immediately if noted). There were no physician orders in Resident 90's clinical record to monitor dialysis access site for bruit (an audible vascular sound associated with turbulent blood flow) and thrill (vibration caused by blood flowing). During an interview and concurrent record review with assistant director of nursing B (ADON B), on 2/9/23 at 3:15 p.m., she indicated nursing staff monitor Resident 90's AVF for bruit and thrill on Mondays, Wednesdays, Fridays, and Saturday's before and after dialysis. When asked if the nursing staff check for bruit and thrill on non-dialysis days, the ADON B stated there was no documentation that nursing staff checked bruit and thrill on Tuesdays, Thursdays or Sundays for Resident 90. The ADON B stated nursing staff should check bruit and thrill every shift, every day to assess the AVF. Review of the facility' s policy Hemodialysis access Care, revised September 2021, indicated Care of AVF's . h. Check the patency of the site at regular intervals. Palpate the site to feel the thrill, or use a stethoscope to hear the whoosh or bruit of blood flow through the access. Based on interview and record review, the facility failed to ensure: 1. adequate communications with the dialysis center for one of three residents (Resident 9), when the communication form sections which are to be filled out by the facility and dialysis center were not completed on numerous forms; and, 2. proper assessment of dialysis access site as performed every shift for one of three residents (Resident 90). These failures had the potential of residents having a negative health outcome. Findings: 1. Resident 9 was admitted with diagnoses which included Type 2 diabetes, end stage renal disease, and dependence on renal dialysis. During a review of Resident 9's dialysis communications forms for 12/2022 through 2/4/2023, the forms indicated some sections, for either the dialysis center or the receiving nurse at the facility, were not filled out properly: For December 2022, of the eight forms, six had not been filled out by the receiving nurse and one by the dialysis center. On the back, eight of the 16 skin assessment sections had not been filled out. For January 2023, of the eight forms, seven were not filled out by the receiving nurse and two were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 19 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 not filled out by the dialysis center. On the back, five of the 14 skin assessment sections were not filled out. Level of Harm - Minimal harm or potential for actual harm For the February 2023, there were two forms for when Resident 9 went to dialysis; and, neither of the two sections of these two forms had been filled out on the front by the receiving nurse, and one had not been filled out by the dialysis center. On the back, two of the four skin assessment sections had not been filled out. Residents Affected - Few During an interview on, 2/10/23 at 9:14 a.m. with RN AA, she stated the top section gets filled out by the facility nurse before Resident 9 goes to dialysis. The second section is filled out by the dialysis center, and the bottom section is filled out by the facility nurse who receives him from dialysis. On the back, the top section is to assess Resident 9's skin before he goes to the dialysis center and the second section is where the receiving nurse documents the skin assessment upon return. RN AA stated if dialysis does not fill out their section, we have to call them and then fax the form to them. The dialysis center fills out their section and faxes it back. The receiving nurse should check to see if it is filled out. Medical records will also check. Medical records should make sure the form is filled out correctly. If the receiving nurse does not, then medical records should find out who the receiving nurse was, and have them fill it out. The facility did not supply a copy of a policy and procedure which addressed the use of the communication forms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 20 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on observation, interview, and record review, the facility failed to ensure its nursing staff was competent and knowledgeable about the proper disinfection of shared glucometers (blood glucose meter to measure and display the amount of sugar [glucose] in your blood) according to the manufacturer's instructions and accepted professional standards of practice. Seven nursing staff in three out of three nursing stations, the director of nursing (DON), and the Infection Preventionist/Director of Staff Development (IP/DSD) did not know about the appropriate disinfectant product to use and/or the allowance of wet time (the amount of time disinfectants need to remain wet on surfaces to properly disinfect) when disinfecting shared glucometers. The failure had the potential for widespread transmission of bloodborne diseases (such as Hepatitis B [a serious liver infection caused by the hepatitis B virus that is most commonly spread by exposure to infected body fluids], Hepatitis C, and HIV [human immunodeficiency virus, is a virus that attacks the body's immune system]) among residents. Findings: During a review of the Food and Drug Administration (FDA)'s Letter to Manufacturers of Blood Glucose Monitoring Systems Listed With the FDA, dated 12/27/17, it indicated, The disinfection solvent you choose should be effective against HIV, Hepatitis C, and Hepatitis B virus. Outbreak episodes have been largely due to transmission of Hepatitis B and C viruses. However, of the two, Hepatitis B virus is the most difficult to kill. Please note that 70% ethanol solutions are not effective against viral bloodborne pathogens. (https://www.fda.gov/medical-devices/in-vitro-diagnostics/letter-manufacturers-blood-glucose-monitoring-systems-listed-fda accessed 2/13/23) According to the online publication titled Infection Prevention during Blood Glucose Monitoring and Insulin Administration by the Center for Disease Control and Prevention (CDC), dated 3/2/2011, it indicated, An underappreciated risk of blood glucose testing is the opportunity for exposure to bloodborne viruses (HBV [hepatitis B virus], hepatitis C virus, and HIV) through contaminated equipment and supplies if devices used for testing and/or insulin administration (e.g., blood glucose meters, fingerstick devices, insulin pens) are shared. Outbreaks of hepatitis B virus (HBV) infection associated with blood glucose monitoring have been identified with increasing regularity, particularly in long-term care settings . Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. (https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html; accessed 2/15/23) During a review of the manufacturer's instructions for cleaning and disinfecting of the Assure Platinum glucometer, provided by the facility, it indicated, The meter [glucometer] should be cleaned and disinfected after use on each patient . our testing confirmed the wipes listed will not damage the functionality or performance of the meter .[manufacturer] recommends using these wipes to clean and disinfect the [glucometer]: Clorox Healthcare Bleach Germicidal Wipes, Dispatch Hospital Cleaner Disinfectant Towels, Super Sani-Cloth Germicidal Disposable Wipes, CaviWipes . please read the manufacturers' instructions before using their wipes on the meter. The manufacturer's instructions indicated, To disinfect nonfood contact surfaces . thoroughly wet surface . allow treated surface to remain wet for a full two (2) minutes . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 21 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some a) During a medication administration observation on 2/6/23 at 8:36 a.m., with Licensed Vocational Nurse A (LVN A), a registry nurse, at Station 2, LVN A completed a blood sugar (BS) check on Resident 25 with a shared glucometer. She placed the glucometer on the top of the medication cart without cleaning or disinfecting it. At 8:49 a.m., LVN A prepared medications for Resident 9 and brought the unclean glucometer (same one used for Resident 25) to Resident 9's bedside. After the medications were given to Resident 9, LVN A was asked by a surveyor to exit Resident 9's room before completion of the BS check. During a concurrent observation and interview on 2/6/23 at 8:53 a.m., with LVN A, when asked by a surveyor how the shared glucometer was disinfected between Resident 25 and Resident 9, LVN A stated she used the alcohol wipes. LVN A stated she did not know the facility's procedure for glucometer disinfection. LVN A was observed as she reached for the Lysol wipes (a common household disinfecting wipe typically found at grocery stores) in the medication cart and wiped the glucometer with a Lysol wipe. LVN A stated she needed to ask a supervisor about the glucometer disinfection procedure because she did not know. After a few minutes, LVN A returned to the medication cart and stated, They [supervisor] said Lysol wipe is ok. At 9:08 a.m., LVN A completed the BS check for Resident 9 with the shared glucometer. b) During an interview on 2/6/23 at 9:45 a.m., with LVN B, at Station 3, when asked about the glucometer disinfection method, LVN B stated she used alcohol wipes to clean and disinfect it, and the wet time should be three minutes. She stated the glucometers were shared among residents. During an interview on 2/6/23 at 10:35 a.m., with LVN C (a registry nurse), at Station 1, LVN C was asked about the glucometer disinfection method, LVN C stated she used Lysol wipes to clean and disinfect it. During an interview on 2/6/23 at 4:05 p.m., with LVN E, at Station 2, LVN E stated the glucometer had been used for all residents in the nursing station and alcohol wipes had been used to clean the glucometer between residents. LVN E stated she did not know the wet time. During an interview on 2/6/23 at 5:01 p.m., with RN D, at Station 1, when asked by a surveyor about the facility's glucometer disinfection method, RN D stated, he used Lysol wipe with a two-minute wet time. RN D stated he did not remember when an in-service about glucometer disinfection was provided but he remembered there was one. During a concurrent observation and interview on 2/6/23 at 5:05 p.m., with LVN E, at Station 1, LVN E was observed using alcohol wipes to clean a glucometer after a BS check had been completed. LVN E placed the glucometer inside the medication cart after it had been wiped with alcohol. When asked by a surveyor how to disinfect shared glucometers, LVN E stated she had used alcohol, or would use Lysol, or whatever was available in the cart. When asked about the wet time, LVN E stated, It dries by itself. During an interview on 2/6/23 at 5:11 p.m., with LVN F, at Station 2, when asked by a surveyor about the facility's glucometer disinfection method, LVN F stated she used alcohol wipes, then dried it with a tissue, and stated it could take 5 to 10 minutes to dry. LVN F stated an in-service on glucometer cleaning was provided in 2022. During an interview on 2/6/23 at 5:14 a.m. with LVN G (a registry nurse), at Station 3, LVN G stated it was her first day working in the facility, and she had not completed a BS test yet but had to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 22 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some do one later. When asked how to clean and disinfect the glucometer, LVN G stated she will use alcohol swabs to clean the glucometer. LVN G showed a small basket which contained the glucometer and the alcohol swabs. LVN G stated no in-service was given regarding glucometer disinfection upon orientation. c) During a concurrent interview and record review on 2/6/23 at 4:09 p.m., with the IP/DSD, the IP/DSD reviewed the facility's binder that contained documentation of nursing staff in-services/training completed between January 2021 to February 2023. The IP/DSD confirmed there were no in-services/training or competencies completed by licensed nurses regarding the facility's procedure for cleaning and disinfecting shared glucometers. During an interview on 2/6/23 at 5:22 p.m., with the IP/DSD, the IP/DSD stated there were no in-services since 2021. When asked by a surveyor how staff cleaned and disinfected glucometers, the IP/DSD stated, with the Lysol yellow [package] or purple [top] disinfectant wipes. The IP/DSD stated, We tell the staff to use Lysol disinfectant. The IP/DSD stated alcohol is not an antiviral or disinfectant and should not be used. The IP/DSD was asked by a surveyor if Lysol kills hepatitis or HIV, the IP/DSD reviewed the Lysol package instructions and stated, No, it doesn't. The IP/DSD stated she did not know what the glucometer manufacturer recommended to use for disinfection. The IP/DSD stated she was not aware that the nursing staff used alcohol to disinfect the glucometers. She said glucometer disinfection instructions were not part of the orientation for registry nursing staff. During a review the product labeling for the Lysol disinfectant wipes, provided by the facility, it indicated, Kills Salmonella [a bacteria that can cause an infection in the intestinal tract through contaminated water or food], Influenza A Virus (H1N1) [a virus that causes an infection of the nose, throat and lungs], Herpes Simplex Virus Type 1 [a virus that causes herpes infection], Staphylococcus aureus [a bacteria found on human skin], Escherichia coli [E.Coli, a bacteria that is commonly found in the lower intestine] and Respiratory Syncytial Virus [RSV, a common respiratory virus that causes cold-like symptoms] on hard, non-porous surfaces in 4 minutes . To Disinfect: Allow [surface] to remain wet for 4 minutes. Allow surface to air dry . The Lysol disinfectant wipes did not contain a disinfectant that would protect against bloodborne infectious diseases such as Hepatitis B, Hepatitis C, or HIV. d) During an interview on 2/7/23 at 9:44 a.m., with the DON and IP/DSD, in the presence of the Administrator and the AIT, the DON and IP/DSD were asked to explain the wet time during glucometer disinfection and to describe how nurses would maintain wet time. The IP/DSD stated they will wipe [the glucometer] and let it dry for two minutes. The DON stated, they wipe [the glucometer] with solution, then leave to dry. When asked by a surveyor, How does the glucometer stay wet?, the IP/DSD reviewed and read the manufacturer instructions on the Super Sani-Cloth (disposable disinfection wipes for hard surfaces and medical devices) disinfectant wipe container out loud, Allow surface to remain wet for two minutes. The DON stated, We will repeat the in-service [for glucometer disinfection]. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 23 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure person-centered care and services for one of eight residents (Resident 248), when a negative behavior was not care planned or monitored. This failure had the potential of a decline in Resident 248's physical and emotional well-being. Findings: Resident 248 was admitted with diagnoses which included Traumatic subdural hemorrhage, Encephalopathy, Unspecified Psychosis, Cognitive communication deficit, and Unspecified dementia. During an interview, on 2/7/23 at 11:51 a.m., with Resident 248's family member, he stated he wanted staff to focus on Resident 248, since she had taken all of her clothes and taken the blankets off of the bed. During an interview, on 2/9/23 at 1:48 p.m., with registered nurse O (RN O), she stated Resident 248 had behaviors of talking gibberish, coming close to pulling her feeding tube out, and taking her clothes off. During an interview, on 2/9/23 at 2:17 p.m. with RN O, she stated Resident 248 had these behaviors since admission on [DATE]. RN O stated the medication administration Record (MAR, a record of when a medication is given) indicated monitoring for resisting of activities of daily living (ADL, activities related to personal care, like dressing, brushing teeth). RN O stated no other behavior was being monitored. During an interview, on 2/9/23 at 2:44 p.m,. with MDS EE, she stated she did not code Resident 248's behavior on the minimum data set (MDS, an assessment tool), because the behaviors were not documented, so she could not code them. During an interview, on 2/9/23 at 2:50 p.m. with RN O, she stated Resident 248 was started on Seroquel (an anti-psychotic, used to treat certain mood/behavior disorders) which was ordered/started on 1/11/23, this was for resisting of ADLs, not taking her clothes off. During an interview, on 2/10/23 at 8:33 a.m. with physician FF (MD FF), he stated he was aware that Resident 248 had aggressive behavior, screaming, removing lines, resisting ADL care, and was also aware of her taking her clothes off. MD FF stated the Seroquel would help with her resisting ADLs and also her taking her clothes off. Review of Resident 248's physician orders lacked indication for monitoring Resident 248 for taking her clothes off. Also, there was no alert charting documentation that indicated Resident 248 had a behavior of taking her clothes off. Resident 248's orders indicated that Seroquel was ordered for Resident 248 resisting ADL care, not taking her clothes off. A review of the facility's policy and procedure (P&P) Behavioral Assessment, Intervention, and Monitoring, revised March 2019, indicated,2. Behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment . ASSESSMENT 3. The nursing staff will identify, document, and inform the physician about specific details regarding changes . 7. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 24 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interventions will be individualized and part of an overall care environment that supports physical, functional and psychosocial needs . 8. Interventions and approaches will be based on a detailed assessment of physical, psychological, and behavioral symptoms and their underlying causes . The care plan will include . a. A description of the behavioral symptoms . b. Targeted and individualized interventions for the behavioral and/or psychosocial symptoms . D. Specific and measurable goals for targeted behaviors . and how staff will monitor for effectiveness of the interventions. MONITORING 1. If the resident is being treated for altered behavior or mood, the IDT will seek and document any improvements or worsening in the individual's behavior, mood, and function. Event ID: Facility ID: 056212 If continuation sheet Page 25 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on interview and record review, the facility failed to ensure controlled medications (those with high potential for abuse and addiction) were fully accounted when: Residents Affected - Some 1. Four of four controlled drug sign-in/sign out sheets (a sheet used to reconcile inventory of controlled medications in the medication cart) by the incoming and outgoing nurses during a shift change were missing signatures; 2. Random as-needed controlled medication use audits for three of five sampled residents (Residents 13, 14, and 139) did not reconcile. The medications were signed out of the controlled drugs accountability sheet (Count Sheet, an inventory sheet that keeps record of the usage of controlled medications), but not documented on the Medication Administration Records (MAR) to indicate they were given to the residents. These failures had the potential for misuse or diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber) and inaccurate accountability of controlled medications. Findings: 1. Four controlled drug sign-in/sign out sheets from random medication carts were reviewed during the survey. a) On 2/6/23, at 9:45 a.m., a review of the January 2023 and February 2023 controlled drug sign-in/sign-out sheets for Medication Cart 3B was conducted with Licensed Vocational Nurse (LVN B). The review identified 25 missing initials between 1/1/23 to 1/31/23 and 3 missing initials between 2/1/23 to 2/6/23. LVN B acknowledged the sheets were incomplete. b) On 2/6/23, at 10:35 a.m., a review of the January 2023 and February 2023 controlled drug sign-in/sign-out sheets for Medication Cart 1B was conducted with LVN C. The review identified 43 missing initials between 1/1/23 to 1/31/23 and 6 missing initials between 2/1/23 to 2/6/23. LVN C acknowledged the sheets were incomplete. During a concurrent interview and record review on 2/10/23, at 11:17 a.m., with the Director of Nursing (DON), the DON stated each nurse had been expected to verify the correct [controlled drug] counts at each change of shift every time and both nurses (the incoming and outgoing nurse) were expected to initial the sheet. The DON reviewed the controlled drug sign-in/sign-out sheets for January 2023 and February 2023 for Medication Carts 1B and 3B and verified they were missing initials. The DON stated, Will re [repeat]-in-service nurses on the process and will audit all count verification sheets. A review of facility's policy and procedure (P&P) titled Controlled Substances, revised April 2019, indicated, Controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift. 2. The controlled medication Count Sheets for five random residents receiving as-needed controlled medications were requested for review during the survey. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 26 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some a. Resident 13 had a physician's order for lorazepam (a controlled medication for anxiety) give 1 milligrams (mg, unit of measurement) by mouth every 8 hours as needed for anxiety, start date 12/27/22. During a concurrent interview and record review on 2/8/23, at 4:21 p.m., with the DON, a review of Resident 13's Count Sheet for Lorazepam and the 1/2023 and 2/2023 MARs reflected the nursing staff removed 1 tablet on 1/25/23 at 1:50p.m., on 1/27/23 at 5:42 a.m., 1/31/23 at 10:30 a.m., and on 2/2/23 at 10:30 a.m. from the medication cart and documented on the Count Sheet without documenting the respective administration on the MAR. The DON validated the missing documentation. b. Resident 139 had a physician's order for Norco (hydrocodone-acetaminophen, a controlled medication for pain) tablet 5-325mg, give 1 tablet by mouth every 6 hours as needed for moderate to severe pain, start date 1/4/23. During a concurrent interview and record review with the DON on 2/8/23, at 4:29 p.m., a review of Resident 139's Count Sheet for Norco and the 2/2023 MAR reflected the nursing staff removed 1 tablet on 2/3/23 at 4:07 a.m. from the medication cart and documented on the Count Sheet without documenting the administration on the MAR. The DON validated the missing documentation. c. Resident 14 had a physician's order for Dilaudid (hydromorphone, a controlled medication for pain) tablet 8 mg, give 1 tablet by mouth every 8 hours as needed for severe pain, start date 9/22/22. During a concurrent interview and record review with the DON on 2/8/23 at 4:33 p.m., a review of Resident 139's Count Sheet for Dilaudid and the 12/2022 and 1/2023 MARs reflected the nursing staff removed 1 tablet on 12/29/22 at 7:40 a.m., 12/30/22 at 8:00 a.m., 1/1/23 at 8:00 a.m., 1/2/23 at 8:00 a.m., 1/2/23 at 10:00 p.m., 1/23/23 at 9:00 a.m., 1/24/23 at 12:44 a.m., and 1/28/23 at 9:00 p.m. from the medication cart and documented on the Count Sheet without documenting the respective administration on the MAR. The DON validated the missing documentation. The DON stated, I will look for documentation elsewhere in the chart, it should be on the MAR, sometimes they get busy and forget. During a follow-up interview with the DON on 2/9/23, at 12:47 p.m., he stated he could not locate documentation for the missing documentation of controlled medications for Residents 13, 14, and 139. A review of facility's P&P titled Administering Medications, revised April 2019, indicated, The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next dose. A review of facility's P&P titled Controlled Substances, revised April 2019, indicated, Upon administration: The nurse administering the medication is responsible for recording . Name of resident receiving the medication; name, strength and dose of the medication; time of administration; method of administration . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 27 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on observation, interview, and record review, the facility's consultant pharmacist (CP) failed to identify and report to the facility irregularities in the residents' monthly drug regimen review (DRR) for two of 29 sampled residents (Residents 15 and 32). Undetected medication irregularities had the potential for unsafe medication use and/or residents not achieving highest therapeutic outcomes. Findings; 1. During a medication administration observation on 2/7/23 at 12:31 p.m., Licensed Vocational Nurse L (LVN L) was observed pricking Resident 15's right ring finger to obtain a blood sample to measure his blood glucose (BG) level. The BG reading was 142 milligrams/deciLiter (mg/dL, unit of measurement; normal BG is less than 100 mg/dL) at this time. LVN L stated Resident 15 needed 6 units of insulin (medication to lower BG) for the BG reading of 142 mg/dL. On 2/7/23 at 12:37 p.m., LVN L was observed administering 6 units of Novolog (a rapid-acting insulin that helps lower mealtime blood sugar spikes) to Resident 15 by injection on his abdomen. According to the Center for Disease Control and Prevention online publication titled Diabetes Basics, revised 12/30/22, it indicated, Blood sugar levels change often during the day. When they drop below 70 mg/dL, this is called having low blood sugar. At this level, you need to take action to bring it back up. (https://www.cdc.gov/diabetes/basics/low-blood-sugar.html; accessed 2/15/23) On 2/7/23, a review of Resident 15's medical record indicated a physician's order, start date of 10/10/22, for Novolog (a rapid-acting insulin that helps lower mealtime blood sugar spikes) 100 units/mL, inject per sliding scale (SS, a set of instructions for administering insulin dosages based on specific BG readings): If [BG reading of] 0 - 150 = 6 UNITS, NOTIFY MD IF BS [blood sugar] <70 AND FOLLOW HYPOGLYCEMIC GUIDELINES . This SS breakdown indicated for the nursing staff to give 6 units of insulin even when the BG was extremely low, such as at 0 mg/dL, or 10 mg/dL. Further review of Resident 15's medication administration record (MAR) indicated the nursing staff had been carrying out this order since 10/10/22. During a concurrent interview and record review with Assistant Director of Nursing A (ADON A) on 2/7/23 at 2:40 p.m., she reviewed the above sliding scale order and stated the nursing staff should have clarified the SS breakdown as they should not administer insulin if BG was below 70 mg/dL but to activate the hypoglycemic guidelines (procedures to manage low BG by assessing the resident for signs and symptoms and implementing interventions to raise the BG). ADON A acknowledged this was an unsafe order as giving insulin, as called for by the order, when the resident's BG is low would be lead to severe adverse outcome for the resident. During a telephone interview with the CP on 2/10/23 at 11:08 a.m., when relaying about Resident 15's SS breakdown order, the CP stated,Is that what the order read? When asked whether she identified and reported to the facility this unsafe SS insulin order as an irregularity in her monthly DRR, the CP stated, No. She confirmed she should have identified it as an irregularity. 2. A review of Resident 32's medical record indicated she was admitted to the facility with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 28 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few diagnoses including Type 2 diabetes (an impairment in the way the body regulates and uses sugar as a fuel). A review of the physician's orders indicated she had been receiving 4 medications to manage this medical condition: three oral medications, glipizide, metformin, Actos; and Lantus (a long acting insulin). The glipizide order, dated 12/23/22, indicated: Glipizide 10 mg [milligrams, unit of measurement], Give 1 tablet by mouth two times daily related to Type 2 diabetes. A review Lexi-comp, a nationally recognized drug information resource, indicated to administer glipizde 30 minutes before a meal (preferably before breakfast if once-daily dosing) to achieve greatest reduction in postprandial hyperglycemia [high blood sugar after meals]. A review of the medication administration record indicated the nursing staff scheduled it to be given daily at 9 a.m., and 5 p.m. A review of the facility's Meal Service Times indicated: breakfast was from 7 a.m. to 8 a.m.; lunch: 12 p.m. to 1 p.m.; and dinner: 5 p.m. to 6 p.m. During an interview with the director of nursing (DON) and the CP via speaker phone, on 2/10/23 at 10:45 a.m., the DON stated breakfast is scheduled at around 7:30 a.m., and dinner is at 5 p.m. The DON and CP verified Resident 32's glipizide was scheduled after breakfast and at around dinner time, and not 30 minutes before meals, as specified by the manufacturer to achieve the best therapeutic outcome for the resident. The CP confirmed she had not identified it as an irregularity in her monthly DRR and stated she should have identified it. A review of the facility's policy and procedures titled Consultant Pharmacist Services Provider Requirement, dated 11/2017, indicated the CP Communicate to the responsible prescriber, the facility's medical director and the director of nursing potential or actual problems detected and other findings related to medication therapy orders . Assist in the identification and evaluation of medication-related issues. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 29 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interview and record review, the facility failed to ensure one of 29 sampled residents (Resident 46) was free from unnecessary psychotropic medication (drugs that affects brain activities associated with mental processes and behavior). Resident 46 received Seroquel (generic name quetiapine, an antipsychotic medication to manage mental illnesses) in excessive doses, higher than prescribed, for 2 months. This failure had the potential for the resident to suffer severe adverse effects such as excessive sedation, drowsiness, blurred vision, loss of appetite, urinary retention, low blood pressure, seizure, diabetes, and abnormal involuntary movements. Findings: Resident 46 was admitted to the facility in September 2022 with diagnoses including vascular dementia (a condition characterized by memory loss), aphasia (loss of ability to understand or express speech, caused by brain damage), hemiplegia (paralysis of one side of the body), and cerebral infarction (stroke). A review of the Minimum Data Set (MDS, a care area assessment and screening tool), dated 9/1/22, indicated Resident 46 had a BIMS score of 2 (Brief Interview for Mental Status, is a mandatory tool used to screen and identify the cognitive condition of residents upon admission into a long term care facility. A score of 0 to 7 suggests severe impairment), indicating she had severe cognitive impairment. On 2/8/23, a review of Resident 46's medical record indicated she had a physician's order, dated 9/14/22, for Seroquel 50 mg every 12 hours (total 100 mg/day) for vascular dementia with behavior disturbance. A review of the behavior care plan, initiated 9/15/22, indicated the staff to monitor for side effects related to the use of antipsychotic medication (Seroquel) including sedation, drowsiness, blurred vision, loss of appetite, urinary retention, seizure, diabetes, and abnormal involuntary movements. A review of the psychiatric nurse practitioner's (NP's) Patient Visit Information, dated 11/18/22, indicating Resident 46 was receiving quetiapine 50 mg every 12 hours but Patient continues to display agitation and verbal aggression . In the Medication Changes, the NP wrote, Recommend to increase frequency of quetiapine to 50 mg TID [short for three times daily] due to continued angry outbursts, difficult to redirect. A review of a nursing progress notes, dated 11/23/22, indicated, RNP [registered NP] from [company name] here to assess resident with recommendation to increase seroquel to TID . MD [medical doctor] . notified and agreed. Orders noted and carried out. Resident 46's medical record indicated a new physician's order, dated 11/23/22, for Seroquel 50 mg three times daily (total 150 mg/day) for psychosis related to stroke symptoms. However, the previous order of Seroquel 50 mg every 12 hours was not discontinued until 1/25/23, a period of two months. A review of Resident 46's November 2022 to January 2023 MARs indicated the nursing staff carried (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 30 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm out Seroquel 50 mg TID starting 11/28/22. There were two entries of Seroquel orders on the MAR: one for 50 mg every 12 hours, scheduled at 9 a.m. and 9 p.m.; and one for 50 mg TID, scheduled at 9 a.m., 1 p.m., and 5 p.m. The Seroquel 50 mg every 12 hours was discontinued on 1/25/23. Thus, for a period of 59 days from 1/28/22 to 1/25/23, the MARs indicated the nursing staff administered Seroquel 50 mg five times daily (total 250 mg/day; a high dose) following both Seroquel orders. Residents Affected - Few Further review of the above MARs indicated, during this 59-day period, the nursing documented they administered 115 extra doses from the Seroquel 50 mg every 12 hours order: 6 times in November 2022 (from 11/28 to 11/30/22), 60 times in December 2022, and 49 times in January 2023 (from 1/1 to 1/25/23). According to Lexi-comp, a nationally recognized drug information resource, it indicated the maximum dose for psychosis associated with dementia was 75 mg twice daily (or 150 mg/day). The resident was receiving 250 mg per day, or 100 mg over this maximum daily dose. On 2/9/23, the pharmacy delivery records for Resident 46's Seroquel, from September 2022 to survey date of 2/9/23, was requested for review. During a concurrent interview and record review with RN AA on 2/10/23 at 8:10 a.m., she reviewed Resident 46's January 2023 MAR and confirmed she documented she administered both Seroquel every 12 hours and Seroquel TID doses, two doses at 9 a.m. and 1 dose at 1 p.m. on 1/3, 1/13, 1/14, 1/16, 1/20, and 1/22/23. When asked whether she should have questioned the duplicate orders and actually administered those doses as documented, RN AA replied, As far as I know, I follow on the eMAR [electronic MAR] what's on the orders. Yes, I thought it was helping keep her level, I know her history she gets hysterical . During a concurrent interview and record review with Licensed Vocational Nurse K (LVN K) on 2/10/23 at 8:23 a.m., LVN K reviewed Resident 46's January 2023 MAR and confirmed she documented she administered both Seroquel every 12 hours and Seroquel TID doses, 5 times per day (both AM and PM shifts), on 1/9, 1/18, 1/19, and 1/21/23. She stated, Yes, if I document then I gave it. During a concurrent interview and record review with the director of nursing (DON) on 2/9/23 at 12:49 p.m., he reviewed Resident 46's electronic health record (eHR) and confirmed Resident 46's Seroquel 50 mg every 12 hours order was not discontinued when Seroquel 50 mg TID order was started. He reviewed the resident's November 2022 to January 2023 MARs and stated, They did not dc [discontinue] it [old order] back then. He acknowledged the nursing staff should have clarified the orders when there were duplicate orders on the MARs, and said, I don't know what else to tell you. He verified the above-stated MARs indicated Resident 46 was receiving Seroquel 50 mg 5 times a day during the above-stated period. During a telephone interview with Resident 46's attending physician and Medical Director (MD) on 2/9/23 at 1:44 p.m., he stated he expected the first Seroquel order to be discontinued when the Seroquel TID was ordered. He stated he had never seen any residents given an order for Seroquel to be given 5 times per day. He confirmed he would expect the resident to be on Seroquel three times only after the order was changed on 11/23/22. During a concurrent interview and record review with the DON and the consultant pharmacist (CP) via speaker phone, on 2/10/23 at 10:45 a.m., the CP stated she identified the duplicate Seroquel orders for Resident 46 on 1/25/23, the day the first Seroquel order was discontinued. The CP stated she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 31 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reviewed the pharmacy delivery records from September 2022 to February 2023 and the corresponding MARs for those months, the number of doses delivered did not match with the number of times documented by the nurses on the MARs. Both the DON and the CP stated they did not know and could not find any information whether the resident came in with her own Seroquel supply in September 2022. The CP stated she could not conclusively say whether the resident did or did not receive Seroquel 5 times per day. A review of the MD's Progress Notes for Resident 46, signed on 2/10/23, the MD wrote, Seroquel dose was increased to 50 mg tid (from 50 mg bid [meaning twice daily]) in 11/2022 as recommended by the psych NP . I was informed that the patient was receiving seroquel 50 mg 5 times per day after the dose was increased by the NP in November. The pharmacist noticed the mistake and corrected the dose to 50 mg tid in January . there has not been any adverse effects or untoward outcome. Continue to monitor. A review of the facility's policy and procedures (P&P) titled Administering Medications, revised 4/2019, indicated, If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician or the facility's Medical Director to discuss the concerns. A review of the facility's Antipsychotic Medication Use P&P, revised 12/2016, it indicated, Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective . All antipsychotic medications will be used within the dosage guidelines . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 32 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the facility medication error rate did not exceed five percent or greater when observation of 25 opportunities during the medication pass resulted in three errors. The calculated medication error rate was 12 percent. Residents Affected - Some These failures placed Residents 9 and 25 at risk for not receiving the full therapeutic effects of medications when medications were not given according to the physician's orders and/or the manufacturer's specifications. Findings: 1. During a medication administration observation on [DATE], at 8:36 a.m., with Licensed Vocational Nurse (LVN A), she was observed drawing 5 units of Admelog (fast-acting insulin, medication to lower blood sugar level) from the Admelog vial stored in the medication cart. At the resident's bedside, she injected the insulin in the resident's right upper arm. A review of the Admelog vial with LVN A shortly after the medication administration revealed it had a small sticker indicating it was opened on [DATE]. The pharmacy auxiliary label (a label added on to a dispensed medication package by a pharmacist that displays additional warnings, information, or instructions) indicated to discard the vial 28 days after opened. LVN A verified the Admelog vial was opened on [DATE] and would have expired on [DATE]. A review of the Prescribing Information (PI, detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians) for Admelog (insulin lispro), dated [DATE], it indicated, In-use (opened) Admelog vials . should be stored at room temperature (below 86°F [30°C]) and must be used within 28 days. On [DATE], a review of Resident 25's clinical record indicated a physician's order, dated [DATE], for Admelog Insulin, inject as per sliding scale (a set of instructions for administering insulin dosages based on specific blood glucose readings) three times a day, give within 10-15 minutes before meals. During an interview on [DATE], at 9:15 a.m., with LVN A, she verified breakfast was given to Resident 25 at 7:30 a.m. When asked if Admelog insulin should be given before or after meals, LVN A stated, It should be before meals, [at] 7:30 a.m. 2. During a medication administration observation for Resident 9 on [DATE], at 9:07 a.m., with LVN A, she was observed administering six medications to Resident 9 including 14 units of Humulin N (Insulin NPH, an intermediate-acting insulin) and 10 units of Humulin R (Regular, a short-acting insulin). The two insulin vials were stored in the medication cart, at room temperature. Shortly after the medication administration, a review of the Humulin N and the Humulin R vials with LVN A reflected each had a sticker that indicated they both were opened on [DATE]. The pharmacy auxiliary label that indicated to discard vial 31 days after opened. LVN A acknowledged both insulin vials expired on [DATE]. On [DATE], a review of Resident 9's clinical record indicated a physician's order, dated [DATE], (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 33 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 for Humulin R Insulin, inject as per sliding scale, before meals. Level of Harm - Minimal harm or potential for actual harm During an interview on [DATE], at 9:15 a.m., with LVN A, she verified breakfast was given to Resident 9 at 7:30 a.m. When asked if Humulin R insulin should be given before or after meals, LVN A stated, I just gave it, but supposed to be at 7:30 a.m., it should be before meals. Residents Affected - Some During a follow-up interview on [DATE], at 12:07 p.m., with LVN A regarding the late administration of insulin for Residents 9 and 25, she stated, I am aware of the effects insulin was given late, blood sugar was high and I gave it still because it is better to give rather than not. I understand it was late, by the time I received endorsement it was already late. A review of the PI for Humulin N (insulin NPH), dated [DATE], it indicated, When stored at room temperature, Humulin N vial can only be used for a total of 31 days including both not in-use (unopened) and in-use (opened) storage time. A review of the PI for Humulin R (Regular, insulin human), dated [DATE], it indicated, When stored at room temperature, Humulin R vial can only be used for a total of 31 days including both not in-use (unopened) and in-use (opened) storage time. During a review of the facility's policy and procedure titled, Administering Medications, dated [DATE], the P&P indicated, Medications are administered in accordance with prescriber's orders, including any required time frame . Medications are administered within one (1) hour of their prescribed time, unless otherwise specified (for example before and after meal orders) . The expiration/beyond use date on the medication label is checked prior to administering. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 34 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure two of 29 sampled residents (Residents 9 and 46) and Residents 13, 25, 45, and 250 were free of a significant medication errors when: Residents Affected - Some 1. Five residents (Resident 9, 13, 25, 45, and 250) received insulin past the discard (expiration) date. These failures had the potential for ineffective use of the insulin, resulting in uncontrolled high blood sugar for the residents; and, 2. Resident 46 received excessive doses of Seroquel (generic name quetiapine, an antipsychotic medication to manage mental illnesses) more than prescribed for 2 months. This had the potential for the resident to suffer severe adverse effects such as excessive sedation, drowsiness, blurred vision, loss of appetite, urinary retention, low blood pressure, seizure, diabetes, and abnormal involuntary movements. Findings: 1a. During a medication administration observation on [DATE], at 8:36 a.m., with Licensed Vocational Nurse (LVN A), she was observed drawing 5 units of Admelog (fast-acting insulin, medication to lower blood sugar level) from the Admelog vial stored in the medication cart. At the resident's bedside, she injected the insulin in the resident's right upper arm. A review of the Admelog vial with LVN A shortly after the medication administration revealed it had a small sticker indicating it was opened on [DATE]. The pharmacy auxiliary label (a label added on to a dispensed medication package by a pharmacist that displays additional warnings, information, or instructions) indicated to discard the vial 28 days after opened. LVN A verified the Admelog vial was opened on [DATE] and would have expired on [DATE]. A review of the Prescribing Information (PI, detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians) for Admelog (insulin lispro), dated [DATE], it indicated, In-use (opened) Admelog vials . should be stored at room temperature (below 86°F [30°C]) and must be used within 28 days. On [DATE], a review of Resident 25's clinical record indicated a physician's order, dated [DATE], for Admelog Insulin, inject as per sliding scale (a set of instructions for administering insulin dosages based on specific blood glucose readings) three times a day, give within 10-15 minutes before meals. During a concurrent interview and record review on [DATE], at 12:07 p.m., with LVN A, she reviewed Resident 25's Medication Administration Records (MAR), dated [DATE] and February 2023. LVN A verified the expired Admelog insulin was administered by nursing staff fifteen (15) times since [DATE]. On [DATE], a review of Resident 25's [DATE] and February 2023 MARs indicated Resident 25 was administered Admelog 28 dosages past the expiration date, from [DATE] to [DATE]. 1b. During a medication administration observation for Resident 9 on [DATE], at 9:07 a.m., with LVN A, she was observed administering six medications to Resident 9 including 14 units of Humulin N (Insulin NPH, an intermediate-acting insulin) and 10 units of Humulin R (Regular, a short-acting (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 35 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 insulin). The two insulin vials were stored in the medication cart, at room temperature. Level of Harm - Minimal harm or potential for actual harm Shortly after the medication administration, a review of the Humulin N and the Humulin R vials with LVN A reflected each had a sticker that indicated they both were opened on [DATE]. The pharmacy auxiliary label that indicated to discard vial 31 days after opened. LVN A acknowledged both insulin vials expired on [DATE]. Residents Affected - Some A review of the PI for Humulin N (insulin NPH), dated [DATE], it indicated, When stored at room temperature, Humulin N vial can only be used for a total of 31 days including both not in-use (unopened) and in-use (opened) storage time. A review of the PI for Humulin R (Regular, insulin human), dated [DATE], it indicated, When stored at room temperature, Humulin R vial can only be used for a total of 31 days including both not in-use (unopened) and in-use (opened) storage time. During a concurrent interview and record review on [DATE], at 12:13 p.m., with LVN A, she reviewed Resident 9's MAR, dated February 2023. LVN A verified the expired Humulin R was administered by nursing staff seven (7) times and the expired Insulin NPH was administered by nursing staff five (5) times since [DATE]. On [DATE], a review of Resident 9's clinical record indicated the following physician's orders: -dated [DATE], for Humulin R, inject as per sliding scale, before meals and at bedtime -dated [DATE], for Insulin NPH, inject 14 units subcutaneously (under the skin) in the morning and 12 units at bedtime every Monday, Wednesday, and Sunday; -dated [DATE], for Insulin NPH, inject 12 units subcutaneously in the morning and 10 units at bedtime every Tuesday, Thursday, and Saturday. On [DATE], a review of Resident 9's MAR, dated February 2023, the MAR indicated Resident 9 received 10 doses of Humulin R and 10 doses of Insulin NPH past the expiration date, from [DATE] to [DATE]. 1c. During a medication cart inspection on [DATE], at 9:45 a.m., with LVN B, at Medication Cart 3B, two (2) vials of Admelog that belonged to Resident 45 were observed labeled as opened on [DATE] and [DATE], respectively. Both Admelog vials had a pharmacy auxiliary label that indicated to discard 28 days after opened. LVN B confirmed both the Admelog vials expired on [DATE] and [DATE], respectively. During a concurrent interview and record review on [DATE], at 10:19 a.m., with LVN B, she reviewed Resident 45's MAR, dated February 2023. LVN B verified the expired Admelog was administered by nursing staff twelve (12) times from [DATE] to [DATE]. On [DATE], a review of Resident 45's clinical record indicated a physician's order, dated [DATE], for Admelog insulin, inject as per sliding scale before meals and at bedtime. On [DATE], a review of Resident 45's MAR, dated [DATE] and February 2023, the MAR indicated Resident 45 received 67 doses of Admelog past the expiration date, from [DATE] to [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 36 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 1d. During a medication cart inspection on [DATE], at 9:45 a.m., with LVN B, at Medication Cart 3B, Resident 13's Novolog (fast-acting insulin) vial was identified with an open date of [DATE]; the pharmacy auxiliary label indicated to discard it 28 days after opening. LVN B confirmed the Novolog vial would have expired on [DATE]. A review of the PI for Novolog (insulin aspart), dated [DATE], indicated, Opened [In-use] NovoLog vials can be stored in the refrigerator at 36°F to 46°F (2°C to 8°C) or at room temperature below 86°F (30°C) . throw away all opened NovoLog vials after 28 days. During a concurrent interview and record review with LVN B on [DATE], at 10:24 a.m., she reviewed Resident 13's [DATE] and February 2023 MARs and verified the expired Novolog insulin was administered by nursing staff many times since [DATE]. On [DATE], a review of Resident 13's clinical record indicated a physician's order, dated [DATE], for Novolog insulin, inject as per sliding scale, before meals. On [DATE], a review of Resident 13's MAR, dated [DATE] and February 2023, the MAR indicated Resident 13 received 59 doses of Novolog past the expiration date, from [DATE] to [DATE]. 1e. During a medication cart inspection on [DATE] at 10:35 a.m., with LVN C, at Medication Cart 1A, Resident 250's Admelog was dated opened on [DATE] with a pharmacy auxiliary label that indicated to discard vial 28 days after opened. LVN C confirmed the Admelog vial would have expired on [DATE]. On [DATE], a review of Resident 250's clinical record indicated a physician's order, dated [DATE], for Admelog Insulin, inject as per sliding scale before meals. On [DATE], a review of Resident 250's February 2023 MAR indicated Resident 250 received 13 doses of Admelog past the expiration date, from [DATE] to [DATE]. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated [DATE], the P&P indicated, The expiration/beyond use date on the medication label is checked prior to administering. When opening a multi-dose container, the date opened is recorded on the container. 2. Resident 46 was admitted to the facility in [DATE] with diagnoses including vascular dementia (a condition characterized by memory loss) and hemiplegia (paralysis of one side of the body), and cerebral infarction (stroke). A review of the Minimum Data Set (MDS, a care area assessment and screening tool), dated [DATE], indicated Resident 46 had a BIMS (Brief Interview for Mental Status, is a mandatory tool used to screen and identify the cognitive condition of residents. A score of 0 to 7 suggests severe impairment) score of 2, indicating she had severe cognitive impairment. On [DATE], a review of Resident 46's medical record indicated she had a physician's order, dated [DATE], for Seroquel 50 mg every 12 hours (total 100 mg/day) for vascular dementia with behavior disturbance. A review of the behavior care plan, initiated [DATE], indicated the staff to monitor for side effects related to the use of antipsychotic medication (Seroquel) including sedation, drowsiness, blurred (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 37 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 vision, loss of appetite, urinary retention, seizure, diabetes, and abnormal involuntary movements. Level of Harm - Minimal harm or potential for actual harm A review of the psychiatric nurse practitioner's (NP's) Patient Visit Information, dated [DATE], indicated Resident 46 was receiving quetiapine 50 mg every 12 hours. In the Medication Changes, the NP wrote: Recommend to increase frequency of quetiapine to 50 mg TID [short for three times daily] due to continued angry outbursts, difficult to redirect. Residents Affected - Some A review of a nursing progress notes, dated [DATE], indicated, RNP [registered NP] from [company name] here to assess resident with recommendation to increase seroquel to TID . MD [medical doctor] . notified and agreed. Orders noted and carried out. Resident 46's medical record indicated a new physician's order, dated [DATE], for Seroquel 50 mg three times daily (total 150 mg/day) for psychosis related to stroke symptoms. However, the previous order of Seroquel 50 mg every 12 hours was not discontinued until [DATE], a period of two months. A review of Resident 46's [DATE] to [DATE] MARs indicated the nursing staff carried out Seroquel 50 mg TID starting [DATE]. There were two entries of Seroquel orders on the MAR: one for 50 mg every 12 hours, scheduled at 9 a.m. and 9 p.m.; and one for 50 mg TID, scheduled at 9 a.m., 1 p.m., and 5 p.m. The Seroquel 50 mg every 12 hours was discontinued on [DATE]. Thus, for a period of 59 days from [DATE] to [DATE], the MARs indicated the nursing staff administered Seroquel 50 mg five times daily (total 250 mg/day; a high dose) following both Seroquel orders. Further review of the above MARs indicated, during this 59-day period, the nursing documented they administered 115 extra doses from the Seroquel 50 mg every 12 hours order: 6 times in [DATE] (from 11/28 to [DATE]), 60 times in [DATE], and 49 times in [DATE] (from 1/1 to [DATE]). According to Lexi-comp, a nationally recognized drug information resource, it indicated the maximum dose for psychosis associated with dementia was 75 mg twice daily (or 150 mg/day). The resident was receiving 250 mg per day, or 100 mg over this maximum daily dose. On [DATE], the pharmacy delivery records for Resident 46's Seroquel, from [DATE] to survey date of [DATE], was requested for review. During a concurrent interview and record review with RN AA on [DATE] at 8:10 a.m., she reviewed Resident 46's [DATE] MAR and confirmed she documented she administered both Seroquel every 12 hours and Seroquel TID doses, two doses at 9 a.m. and 1 dose at 1 p.m. on 1/3, 1/13, 1/14, 1/16, 1/20, and [DATE]. When asked whether she should have questioned the duplicate orders and actually administered those doses as documented, RN AA replied, As far as I know, I follow on the eMAR [electronic MAR] what's on the orders. Yes, I thought it was helping keep her level, I know her history she gets hysterical . During a concurrent interview and record review with Licensed Vocational Nurse K (LVN K) on [DATE] at 8:23 a.m., LVN K reviewed Resident 46's [DATE] MAR and confirmed she documented she administered both Seroquel every 12 hours and Seroquel TID doses, 5 times per day (both AM and PM shifts), on 1/9, 1/18, 1/19, and [DATE]. She stated, Yes, if I document then I gave it. During a concurrent interview and record review with the director of nursing (DON) on [DATE] at 12:49 p.m., he reviewed Resident 46's electronic health record (eHR) and confirmed Resident 46's Seroquel 50 mg every 12 hours order was not discontinued when Seroquel 50 mg TID order was started. He (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 38 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some reviewed the resident's [DATE] to [DATE] MARs and stated, They did not dc [discontinue] it [old order] back then. He acknowledged the nursing staff should have clarified the orders when there were duplicate orders on the MARs, and said, I don't know what else to tell you. He verified the above-stated MARs indicated Resident 46 was receiving Seroquel 50 mg 5 times a day during the above-stated period. During a telephone interview with Resident 46's attending physician and Medical Director (MD) on [DATE] at 1:44 p.m., he stated he expected the first Seroquel order to be discontinued when the Seroquel TID was ordered. He confirmed he would expect the resident to be on Seroquel three times only after the order was changed on [DATE]. During a concurrent interview and record review with the DON and the consultant pharmacist (CP) via speaker phone, on [DATE] at 10:45 a.m., the CP stated she identified the duplicate Seroquel orders for Resident 46 on [DATE], the day the first Seroquel order was discontinued. The CP stated she reviewed the pharmacy delivery records from [DATE] to February 2023 and the corresponding MARs for those months, the number of doses delivered did not match with the number of times documented by the nurses on the MARs. Both the DON and the CP stated they did not know and could not find any information whether the resident came in with her own Seroquel supply in [DATE]. The CP stated she could not conclusively say whether the resident did or did not receive Seroquel 5 times per day. A review of the MD's Progress Notes for Resident 46, signed on [DATE], the MD wrote, Seroquel dose was increased to 50 mg tid (from 50 mg bid [meaning twice daily]) in 11/2022 as recommended by the psych NP . I was informed that the patient was receiving seroquel 50 mg 5 times per day after the dose was increased by the NP in November. The pharmacist noticed the mistake and corrected the dose to 50 mg tid in January. A review of the facility's P&P titled Administering Medications, revised 4/2019, indicated, If a dosage is believed to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the resident or is suspected of being associated with adverse consequences, the person preparing or administering the medication will contact the prescriber, the resident's Attending Physician or the facility's Medical Director to discuss the concerns. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 39 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure proper medication storage and labeling of medications in three of three medication carts inspected and one of two medication rooms inspected when: a) Medication Cart 3B contained eight (8) expired medications, two (2) opened medications without an open date label, and two (2) test strip (thin plastic strips which measures blood sugar levels) vials opened without an open date label; b) Medication Cart 1A contained two (2) expired medications, four (4) opened medications without an open date label, and one (1) test strip vial opened without an open date; c) Medication Cart 2A contained two (2) expired medications and two (2) opened medications without an open date label; d) Station 3 Medication Room contained one (1) expired emergency kit and one (1) opened Aplisol (a solution for skin test to help diagnose tuberculosis infections) vial without an open date. The deficient practices had a potential for residents to receive medications with unsafe and ineffective medications (reduced potency) from being used past their discard (expiration) date and medication errors due to medications not being labeled or removed from active stock. Findings: a) On 2/6/23 at 9:45 a.m., an inspection of Medication Cart 3B with Licensed Vocational Nurse B (LVN B) identified a house supply (use for multiple residents) bottle of calcium chewable tablets (used to prevent or treat low blood calcium levels), which had an expiration date of 10/2022; one expired Novolog (fast-acting insulin, medication to lower blood sugar level) vial dated opened on 12/9/22; two expired Ademlog (fast-acting insulin) vials dated opened on 12/3/22 and 12/7/22 respectively; and four opened and expired latanoprost (used to treat glaucoma) eye drop bottles were . LVN B confirmed the calcium chewable tablets, Novolog vial, two Admelog vials, and four Latanoprost bottles were expired. Also, a medication cup filled with loose pills labeled as MagOx (Magnesium oxide, antacid to relieve heartburn) was identified. LVN B acknowledged the loose pills in the medication cup were not labeled with the medication strength or expiration date. Additionally, two test strip vials were opened but did not have an open date and one insulin glargine (Basaglar, a long-acting insulin) pen was opened but was not labeled with an open date. LVN B acknowledged the two opened test strip vials and the opened Basaglar pen should have been labeled with an open date. A review of the Prescribing Information (PI, detailed description of a drug's uses, dosage range, side effects, drug-drug interactions, and contraindications that is available to clinicians) for Admelog (insulin lispro), dated December 2020, indicated, In-use (opened) Admelog vials . should be stored at room temperature (below 86°F [30°C]) and must be used within 28 days. A review of the PI for Novolog (insulin aspart), dated October 2021, indicated, Opened [In-use] Novolog vials can be stored in the refrigerator at 36°F to 46°F (2°C to 8°C) or at room temperature below 86°F (30°C) . throw away all opened NovoLog vials after 28 days. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 40 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm A review of the PI for Latanoprost drops, dated December 2021, indicated, Once a bottle is opened for use, it may be stored at room temperature up to 25°C (77°F) for 6 weeks. A review of the PI for Basaglar Kwikpen (insulin glargine), dated July 2021, indicated, In-use [opened] Basaglar prefilled pens must be used within 28 days or be discarded. Residents Affected - Some b) On 2/6/23 at 10:35 a.m., an inspection of Medication Cart 1A with LVN C identified a house supply bottle of omega-3 (fatty acids) capsules, which had an expiration date of 7/2022; and one expired Admelog vial dated opened on 1/6/23. LVN C confirmed the medications were expired. One medication inhaler Serevent Diskus (medication for lung disease) inhaler and one Latanoprost eye drop bottle were opened but not labeled with an open date. LVN C verified the inhaler and eye drop bottle were opened and should have been dated. Additionally, one Lantus (a long-acting insulin) pen and one Latanoprost eye drop bottle were unopened but stored at room temperature. LVN C acknowledged room temperature affects the medication. Also, one test strip vial was opened but did not have an open date. LVN C verified the test strips were good for 90 days when opened per vial label. A review of the PI for Serevent Diskus (salmeterol powder), dated February 2022, retrieved indicated, Discard Serevent Diskus 6 weeks after opening the foil pouch or when the counter reads 0 (after all blisters have been used), whichever comes first. A review of the PI for Lantus Solostar (insulin glargine) prefilled pen, dated June 2022, indicated, Unopened [not In-use] (pen) can be stored at room temperature below 86°F (30°C) for 28 days. c) On 2/6/23 at 11:37 a.m., an inspection of Medication Cart 2A with LVN A identified 17 expired Florastor capsules (a probiotic), which had an expiration date of 1/2023. LVN A acknowledged the Florastor capsules were expired. Additionally, an expired medication inhaler Breo Ellipta (an inhaled medication to treat breathing problems) was opened on 11/11/22. LVN A verified the Breo Ellipta was expired 6 weeks after opened. LVN A stated, if used it is bad for health because it is expired. Also, one medication inhaler Trelegy Ellipta (medication for lung disease) was opened and undated. LVN A acknowledged the inhaler was undated. She said, I don't know if it is expired because it is not dated, it is important to know the open date to know if it is expired. One medication inhaler Advair Diskus (medication for lung disease) was opened and undated. LVN A verified there was no open date and stated, we don't know the expiration date. A review of the labeling from the manufacturer for Breo Ellipta and Trelegy Ellipta with LVN A indicated to discard it 6 weeks after opening the foil tray or when the counter reads 0 (after all blisters have been used), whichever comes first. A review of the PI for Advair Diskus (fluticasone and salmeterol powder), dated October 2020, indicated, Discard Advair Diskus 1 month after opening the foil pouch or when the counter reads 0 (after all blisters have been used), whichever comes first. d) On 2/6/23, at 12:21 p.m., an inspection of the medication room at Station 3, with LVN B, identified one expired emergency kit, which had an expiration date of 1/31/23. LVN B acknowledge the emergency kit was expired. Also, one opened Aplisol vial was identified without an open date. LVN B verified the vial was undated and stated it should have been dated with an open date. During an interview on 2/7/23, at 9:44 a.m., with the Director of Nursing (DON), the DON stated we (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 41 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some had an in-service and reordered expired insulins. He said opened medications should be labeled with an open date and expiration date. During a telephone interview on 2/10/23, at 10:45 a.m., with the Consultant Pharmacist (CP), she stated, I do random audits of medication carts and medication rooms every other month, if I find something I remove it and let the nurse know. The CP stated she was at the facility on 12/14/22 and completed a random inspection, she removed medications which expired on that day. When asked about the loose MagOx pills stored in the medication cart in a medication cup, the CP said, I don't know why the nurse did that. During a review of the facility's policy and procedures (P&P) titled, Labeling of Medication Containers, dated April 2019, the P&P indicated, Any medication packaging or containers that are inadequately or improperly labeled are returned to the issuing pharmacy . Labels for over-the-counter drugs include all necessary information, such as: The original label indicating the name, strength, and quantity of the medication; The expiration date when applicable; and Directions for use and appropriate accessory/cautionary statements. During a review of the facility's P&P titled, Storage of Medications, dated April 2019, the P&P indicated, .outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. During a review of the facility's P&P titled, Administering Medications, dated April 2019, the P&P indicated, When opening a multi-dose container, the date opened is recorded on the container. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 42 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food services safety when: 1. Resident 139's opened condensed milk (a sweetened cow's milk product) was not properly labeled and stored in the refrigerator (Cross reference F813), 2. An unlabeled bucket of white powder was in dry storage, 3. Cutting boards with deep cuts with stains, food residuals and and loose plastic particles were found on a clean storage rack, 4. A can opener had black matter on its cutting surface, and 5. A serving scoop storage drawer contained crumbs and orange matter. Theses failures had the potential to harbor the growth of microorganisms that could cause foodborne illness or cross contamination of food (cross contamination occurs when unclean surfaces or serving scoops spread germs to food that may cause foodborne illness) for the residents eating at the facility. Findings: 1. During an observation, on 2/6/23 at 8:29 a.m., in Resident 139's room, a bottle of half full condensed milk was on the resident's overbed table without an open date label. Resident 139 stated the bottle of condensed milk was open for a week. Review of Resident 139's clinical record included a face sheet (a document that gives a resident's information at a quick glance, including contact details and a brief medical history) that indicated Resident 139 was admitted on [DATE]. Resident 139's Minimum Data Set (MDS, a resident assessment tool), dated 1/11/23, indicated, Resident 139 had a Brief Interview for Mental Status (BIMS, a screening tool for resident's cognitive condition) score of 14, which indicated Resident 139 was cognitively intact. During an interview on 2/6/23 at 9:07 a.m., with Certified Nursing Assistant (CNA) J, she stated the bottle of condensed milk had been on the overbed table for about four days. During a concurrent observation and interview, on 2/7/23 at 9:03 a.m., with Resident 139 in her room, the bottle of opened condensed milk was still on the resident's overbed table. The back of the condensed milk bottle indicated, Refrigerate after opening. Resident 139 stated the condensed milk was for her coffee, and she had been using it. During an interview, on 2/7/23 at 9:22 a.m., with the Registered Dietitian (RD), she confirmed the condensed milk should be refrigerated per instruction on the bottle and verified there was no date written on the bottle to indicate when it was opened. She stated in addition to an open date, resident's name should be labeled on the bottle. She stated it was not properly stored and should be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 43 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 discarded. Level of Harm - Minimal harm or potential for actual harm Review of the facility's Policy and Procedure (P&P) Bringing in Food for Residents, revised 6/2020, indicated, All food or beverages must be labeled and dated with residents' name upon arrival to monitor for food safety . Any suspicious or obviously contaminated food or beverages will be thrown away immediately. Residents Affected - Some 2. During a concurrent observation and interview, on 2/6/23 at 9:00 a.m., in the dry storage room with the Dietary Services Supervisor (DSS), an unlabel a plastic bucket of 4 quarts (qt, a unit of liquid capacity) contained white powder. The DSS stated it was flour and he confirmed it should be labeled. During an interview, on 2/8/23 at 1:23 p.m., with RD, she confirmed the bucket of white powder should be labeled. A review of the facility's undated P&P Labeling and Dating it indicated, 11. Labeling and dating are to be done on all items whether they are in refrigerator/dry storage or freezer. Review of the Food and Drug Administration (FDA) Food Code 2022, Section 3-302.12 indicated, Food Storage Containers . Identified with Common Name of Food. Except for containers holding FOOD that can be readily and unmistakably recognized such as dry pasta, working containers holding FOOD or FOOD ingredients that are removed from their original packages for use in the FOOD ESTABLISHMENT, such as cooking oils, flour, herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the FOOD. 3. During a concurrent observation and interview, on 2/6/23 at 9:07 a.m., with Dietary Aide M (DA M, a clean cutting board rack contained one green cutting board with dried tomato seeds, one white cutting board stained with dark brown cuts, and one red cutting board with deep cuts and loose plastic particles. DA M confirmed the cutting board rack was for clean cutting boards and that the cutting boards should on it should not have had any of the observed particles on them. During an interview, on 2/6/23 at 9:10 a.m., with DSS, he confirmed the cutting board rack's green and white cutting boards should be cleaned, and the red cutting board should be replaced. Review of the Food and Drug Administration (FDA) Food Code 2022, Section 4-501.12, indicated, Cutting Surfaces . Surfaces such as cutting blocks and boards that are subject to scratching and scoring shall be resurfaced if they can no longer be effectively cleaned and sanitized, or discarded if they are not capable of being resurfaced . Cutting surfaces such as cutting boards and blocks that become scratched and scored may be difficult to clean and sanitize . As a result, pathogenic microorganisms transmissible through food may build up or accumulate . These microorganisms may be transferred to foods that are prepared on such surfaces. Review of the Food and Drug Administration (FDA) Food Code 2022, Section 4-601.11, indicated, Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils . Equipment food-contact surfaces and utensils shall be clean to sight and touch. 4. During a concurrent observation and interview, on 2/6/23 at 10:28 a.m., with [NAME] N, she confirmed black matter could be wiped off from the can opener tip. [NAME] N verified the can opener was dirty and should be cleaned. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 44 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview, on 2/6/23 at 10:30 a.m., with the DSS, he confirmed the can opener was dirty and needed to be cleaned. Review of the facility's P&P Can Opener and Base, dated 8/29/2018, indicated, Proper sanitation and maintenance of the can opener and base is important to sanitary food preparation . Cleaning Procedure: 1. The can opener must be thoroughly cleaned each work shift and, when necessary, more frequently. Review of the Food and Drug Administration (FDA) Food Code 2022, Section 4-602.11, indicated, Clean Food Contact Surface . It is the standard of practice to ensure food contact surfaces of equipment shall be cleaned at any time during the operation when contamination may have occurred. 5. During a concurrent observation and interview, on 2/6/23 at 10:39 a.m., with DSS, a drawer with clean serving scoops had buildups of crumbs and orange material along the inside of the drawer. Drawer's buildup was be wiped off with a paper towel. The DSS confirmed this observation and stated the serving scoops drawer should be cleaned. Review of the facility's P&P Cabinets and Drawers, Version 8.27, indicated, Clean cabinets and drawer on a weekly basis. During an interview, on 2/8/23 at 1:17 p.m., with DSS, he stated cabinets and drawers should not have old food particles; and that, he needed to update the cleaning schedules. Review of the Food and Drug Administration (FDA) Food Code 2022 indicated, Clean - Non-Food Contact Surfaces . It is the standard of practice to ensure non-food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris . Additionally, the presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food . If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 45 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to develop and implement a policy to ensure safe and sanitary storage, handling, and consumption for the food brought in by family when Resident 139's room had multiple unlabeled open food items. This failure had the potential to limit the resident rights and enjoyment of the food brought in by the family (Cross reference F812). Residents Affected - Few Finding: During an observation and interview, on 2/6/23 at 8:29 a.m., in Resident 139's room, a half full bottle of condensed milk (a sweetened cow's milk product) on the resident's overbed table was without a labeln for its open dates. Resident 139 stated the bottle of condensed milk had been opened for a week and she used it for coffee every day. Review of Resident 139's Face Sheet (a document that gives a resident's information at a quick glance, including contact details and a brief medical history), indicated she was was admitted on [DATE]. Review of Resident 139's Minimum Data Set (MDS, a resident assessment tool), dated 1/11/23, indicated Resident 139's Brief Interview for Mental Status (BIMS, a screening tool for resident's cognitive condition) score was 14, which indicated Resident 139 was cognitively intact. During an interview, on 2/6/23 at 9:07 a.m., with Certified Nursing Assistant J (CNA J), she stated the bottle of condensed milk was on the overbed table for about four days. During an interview, on 2/6/23 at 12:59 p.m., with Registered Nursing (RN) O, she stated the facility did not have a refrigerator to store resident food and that residents' leftovers were thrown away. During a concurrent observation and interview, on 2/7/23 at 9:03 a.m., with Resident 139 in her room, the bottle of opened condensed milk was still on the resident's overbed table. The back of the opened condensed milk bottle indicated, Refrigerate after opening. Resident 139 stated she had been using the condensed milk for coffee everday. During an interview, on 2/7/23 at 9:13 a.m., with Licensed Vocational Nurse P (LVN P), she stated the facililty did not store food for residents. LVN P stated if a resident could not finish the food brought in by family after two hours, the food would be discarded. During an interview, on 2/7/23 9:16 a.m., with LVN B, she stated she was not sure if they could store leftovers for residents and she had to ask a supervisor. During an interview, on 2/8/23 9:50 a.m., with CNA R, she stated if family brought food to a resident, such as a bottle of milk, resident had to finish it or else the facility would throw it out after two hours [arriving at facility]. CNA R stated the facility did not have a refrigerator to store residents' food, and they did not usually label resident's food because food would be thrown out after two hours [arriving at facility]. During an interview, on 2/7/23 at 9:19 a.m., with the (Registered dietitian) RD, she stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 46 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0813 Level of Harm - Minimal harm or potential for actual harm facility did not want to be responsible for storing or reheating residents' food. The RD sated the facility did not have a refrigerator for residents' food brought in by family. She confirmed Resident 139 condensed milk should be refrigerated per instruction on the bottle and verified there was no date written on the bottle to indicate when it was opened. She stated an open date and resident's name should be on the bottle. She stated the bottle of condensed mily was not properly stored and it would be discarded. Residents Affected - Few A review of facility's Policy and Procedure (P&P) Bringing in Food for Residents, revised 6/2020 , indicated, Perishable foods or prepared foods are highly recommended to be served to the residents as soon as possible (within 1 hour of receiving it) to ensure the freshness and to prevent foodborne illness. All food or beverages must be labeled and dated with residents' name upon arrival to monitor for food safety . Any suspicious or obviously contaminated food or beverages will be thrown away immediately. The facility's lacked a P&P and/or guidelines for refrigerated storage of resident's food brought in by family. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 47 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program to prevent the spread of infections as evidenced by: Residents Affected - Some 1. The facility failed to use the proper disinfectant to disinfect shared (used for multiple residents) glucometers (blood glucose meter to measure and display the amount of sugar [glucose] in your blood) according to manufacturer's instructions and accepted professional standards for 41 of 41 residents when: 1a. Licensed Vocational Nurse A (LVN A) failed to properly disinfect a shared glucometer during observation for two of 41 residents (Residents 9 and 25) according to manufacturer's instructions; 1b. Licensed nurses in three out of three nursing stations: LVN B, LVN C, LVN E, LVN F, LVN G and Registered Nurse D (RN D), did not know the proper disinfectant product to use for the disinfection of shared glucometers according to manufacturer's instructions; and, 1c. The Infection Preventionist/Director of Staff Development (IP/DSD) did not know the proper disinfectant product to use for the disinfection of shared glucometers according to manufacturer's instructions. Furthermore, concurrent interview and record review with the IP/DSD reflected there had been no staff in-services provided regarding proper disinfection of shared glucometers since 2021. The facility identified 41 residents that had active physician orders for Finger Stick Blood Glucose (FSBG, a procedure where the finger is pricked with a poking device to obtain a blood sample to measure blood glucose level) checks. One out of 41 residents (Resident 90) also had a diagnosis of Chronic Viral Hepatitis B (a serious liver infection caused by the hepatitis B virus that is most commonly spread by exposure to infected body fluids) at the time of admission on [DATE]. As of 2/6/23, Resident 90 did not have a designated glucometer and had been given FSBG checks daily with a shared glucometer. The facility's noncompliance with infection control procedures had the potential to cause the development and the widespread transmission of bloodborne diseases (such as HIV [human immunodeficiency virus, is a virus that attacks the body's immune system], Hepatitis B, and Hepatitis C) to 41 of 41 residents. It was unknown when the noncompliance began according to an interview with the DON. Due to the widespread lack of knowledge of proper disinfection procedures demonstrated by eight (8) nursing staff, including IP/DSD, the facility needed to take immediate action to correct the non-compliance. On 2/6/23 at 5:45 p.m., an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident) was identified and declared, in the presence of the facility's Administrator and Administrator In Training (AIT), due to the facility's failure to ensure that LVN A properly disinfected a shared glucometer for two of 41 residents (Residents 9 and 25) according to manufacturer's instructions; failure to ensure LVN B, LVN C, LVN E, LVN F, LVN G and RN D knew the proper disinfectant product to use for the disinfection of shared glucometers according to manufacturer's instructions; failure to ensure the IP/DSD knew the proper disinfectant product to use for the disinfection of shared glucometers according to manufacturer's instructions; and not having staff in-services provided regarding proper disinfection of shared glucometers since 2021. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 48 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some On 2/7/23, at 3:30 p.m., the Administrator submitted an acceptable IJ Removal Plan ([IJRP], a plan with interventions to immediately correct the deficient practices). The acceptable IJRP included the following corrective actions: 1. Identify residents whose blood sugars (BS) need to be monitored. All residents (41 residents) on FSBG checks will be monitored for the following symptoms (ascites [condition in which fluid collects in spaces within your abdomen], tremors, confusion, vomiting of blood, blood in the stool and fatigue) per the Medical Director for 14 days. Resident[s] directly affected will have lab works done on 2/7/2023 for hepatitis B and C. 2. IP/DSD/Designee in-service and educated facility and/or registry licensed nursing staff (nurses employed through a contracted agency) on the glucometer manufacturer's guidelines for proper cleaning and disinfecting and return demonstration done to ensure it is done correctly. a. Glucometer to be cleaned and disinfected immediately after resident use (Sani-Cloth or equivalent) with 2 minutes wet time. b. Check if glucometer is in proper working condition prior to use. c. Daily QA (quality assurance) maintenance of each glucometer and to ensure glucometer is in proper working condition and if Licensed Nurses are cleaning/disinfecting it according to manufacturer's guidelines and proper use of recommended wipes. 3. IP/DSD/Designee will randomly perform spot check on all shifts daily × 2 weeks then monthly, and findings will be reported to QAPI (Quality Assurance and Performance Improvement) Committee. 4. IP/DSD/Designee in-service and education will be completed with the licensed nursing staff prior to the start of their shift and by 02/07/2023. 5. Corrective Action Plan reviewed at QAPI Committee Meeting on 02/07/2023. 6. A separate glucometer machine was provided for the resident identified with hepatitis, cleaned after each use and routine QA started. (forms/Sig [signature] attached) 7. Skills competency glucometer cleaning/disinfectant in serviced to Licensed nurse by IP/DSD/Designee. 8. P and P [Policy and Procedure] on bloodborne pathogens updated according to updated systemic changes and discussed and approved by QAPI Committee. On 2/8/23, at 9:48 a.m., the Department of Public Health removed the IJ while onsite after the surveyors verified the facility implemented the facility's IJRP by observations, interviews, and record reviews. The DON, Administrator, AIT and DSD/IP were informed. 2. The Director of Nursing (DON) and IP/DSD did not know the disinfectant wipe manufacturer's instructions for wet time (the amount of time disinfectants need to remain wet on surfaces to properly disinfect); and LVN B and RN H did not allow enough wet time, according to the manufacturer's instructions, during the disinfection of a shared glucometer for three of 41 residents (Residents 25, 39, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 49 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 and 97). Level of Harm - Immediate jeopardy to resident health or safety 3. A nurse (LVN I) failed to perform hand hygiene between tasks during medication administration for one of 6 residents (Resident 72). Residents Affected - Some 4. Four nursing staff (Certified Nursing Assistants R, S, U and LVN X) failed to wear proper PPE (Personal Protective Equipment - protective equipment used when caring for patients to prevent the spread of diseases) when working in facility areas that required them. 5. A nurse (LVN X) failed to take her temperature with a thermometer and screen for COVID-19 upon entering the facility to start work. 6. Nursing and maintenance staff failed to maintain oxygen concentrators in good working condition for two of two residents (Residents 15 and 24) with oxygen concentrators when the filters of their oxygen concentrators had a layer of grayish matter buildup on them. These failures placed residents at increased risk of healthcare-associated infections. Findings: 1a. During a medication administration observation on 2/6/23, at 8:36 a.m., with Licensed Vocational Nurse A (LVN A), a registry nurse, at Station 2, LVN A completed a blood check on Resident 25 with a glucometer. She placed the glucometer on the top of the medication cart without cleaning or disinfecting it. At 8:40 a.m., LVN A moved down the hall to Resident 9's room and prepared medications for Resident 9. She brought the prepared medications along with the same glucometer used for Resident 25, without wiping it down first, to Resident 9's bedside. At 8:49 a.m., LVN A administered the medications. After medications were given to Resident 9, LVN A was asked to exit Resident 9's room before completion of the BS check. During a concurrent observation and interview on 2/6/23, at 8:53 a.m., with LVN A, when asked how the shared glucometer was disinfected between Resident 25 and Resident 9, LVN A stated she used alcohol wipes. LVN A stated she did not know the facility's procedure for glucometer disinfection. LVN A reached for the Lysol wipes (a common household disinfecting wipe typically found at grocery stores) in the medication cart and wiped the glucometer with a Lysol wipe. LVN A stated she needed to ask a supervisor about the glucometer disinfection procedure because she did not know it. After a few minutes, LVN A returned to the medication cart and stated, They [supervisor] said Lysol wipe is ok. At 9:08 a.m., LVN A completed the BS check for Resident 9 with the shared glucometer. 1b. During an interview on 2/6/23, at 9:45 a.m., with LVN B, at Station 3, when asked about the glucometer disinfection method, LVN B stated she used alcohol wipes to clean and disinfect it, and the wet time should be three minutes. She stated the glucometers were shared among residents. During an interview on 2/6/23, at 10:35 a.m., with LVN C (a registry nurse), at Station 1, LVN C was asked about the glucometer disinfection method, LVN C stated she used Lysol wipes to clean and disinfect it. During an interview on 2/6/23, at 4:05 p.m., with LVN E, at Station 2, LVN E stated the glucometer was used for all residents at the nursing station and alcohol wipes were used to clean the glucometer between residents. LVN E stated she did not know the wet time. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 50 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some During an interview on 2/6/23, at 5:01 p.m., with RN D, at Station 1, when asked about the facility's glucometer disinfection method, RN D stated, he used Lysol wipes with a two-minute wet time. RN D stated he did not remember when an in-service about glucometer disinfection was provided, but he remembered there was one. During a concurrent observation and interview on 2/6/23, at 5:05 p.m., with LVN E, at Station 1, LVN E used alcohol wipes to clean a glucometer after a BS check was completed. LVN E then placed the glucometer inside the medication cart. When asked how to disinfect shared glucometers, LVN E stated she used alcohol, Lysol, or whatever was available in the cart. When asked about the wet time, LVN E stated, It dries by itself. During an interview on 2/6/23, at 5:11 p.m., with LVN F, at Station 2, when asked about the facility's glucometer disinfection method, LVN F stated she wiped the glucometer with alcohol wipes and dried it with the tissue. LVN F stated it could take 5 to 10 minutes to dry. LVN F stated an in-service on glucometer cleaning was provided in 2022. During an interview on 2/6/23, at 5:14 p.m. with LVN G (a registry nurse), at Station 3, LVN G stated it was her first day of work at the facility. LVN G stated she had not completed a BS test yet, but had to do one later. When asked how to clean and disinfect the glucometer, LVN G stated she would use alcohol swabs to clean the glucometer. LVN G showed a small basket that contained a glucometer and alcohol swabs. LVN G stated no in-service was given regarding glucometer disinfection upon orientation. 1c. During a concurrent interview and record review on 2/6/23, at 4:09 p.m., with the IP/DSD, the IP/DSD reviewed the facility's binder that contained documentation of nursing staff in-services/training completed between January 2021 to February 2023. The IP/DSD confirmed there were no in-services/training or competencies completed by licensed nurses regarding the facility's procedure for cleaning and disinfecting shared glucometers. During an interview on 2/6/23, at 5:22 p.m., with the IP/DSD, the IP/DSD stated, there were no in-services since 2021. When asked how staff cleaned and disinfected glucometers, the IP/DSD stated, with the Lysol yellow [package] or purple [top] disinfectant wipes. The IP/DSD stated, We tell the staff to use Lysol disinfectant. The IP/DSD stated alcohol is not an antiviral (A drug used to treat infections caused by viruses) or disinfectant and should not be used. The IP/DSD was asked by a surveyor if Lysol kills hepatitis or HIV, the IP/DSD reviewed the Lysol package instructions and stated, No, it doesn't. The IP/DSD stated she did not know what the glucometer manufacturer recommended to use for disinfection of the glucometer. The IP/DSD stated she was not aware that the nursing staff used alcohol to disinfect the glucometers. She said glucometer disinfection instructions were not part of the orientation for registry nursing staff. During a review the product labeling for the Lysol disinfectant wipes provided by the facility, it indicated, Kills Salmonella [a bacteria that can cause an infection in the intestinal tract through contaminated water or food], Influenza A Virus (H1N1) [a virus that causes an infection of the nose, throat and lungs], Herpes Simplex Virus Type 1 [a virus that causes herpes infection], Staphylococcus aureus [a bacteria found on human skin], Escherichia coli [E.Coli, a bacteria that is commonly found in the lower intestine] and Respiratory Syncytial Virus [RSV, a common respiratory virus that causes cold-like symptoms] on hard, non-porous surfaces in 4 minutes .To Disinfect: Allow [surface] to remain wet for 4 minutes. Allow surface to air dry . The Lysol disinfectant wipes did not contain a disinfectant that would protect against bloodborne infectious diseases such as Hepatitis B, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 51 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Hepatitis C, or HIV. Level of Harm - Immediate jeopardy to resident health or safety On 2/6/23, the facility provided a list of residents with physician's orders for FSBG in the facility. The list identified 41 residents. Residents Affected - Some During a review of Resident 90's admission Record, dated 7/19/21, it indicated, Resident 90 was admitted to the facility with diagnoses including Chronic Viral Hepatitis B and Diabetes. Resident 90 had a BIMS of 15 (Brief Interview for Mental Status, is an assessment tool used to screen and identify the cognitive condition of residents upon admission into a long term care facility. A score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment), which indicated he was cognitively intact. During an interview with Resident 90 on 2/6/23, at 4:40 p.m., he stated his BS was checked daily. When asked whether he had his own glucometer, Resident 90 stated, No, the girls [nurses] use the machine they have here. I don't have my own machine. During a review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfection of Resident-Care Items and Equipment, dated October 2018, the P&P indicated, Reusable items are cleaned and disinfected or sterilized between residents . Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturers' instructions. During a review of the Food and Drug Administration's (FDA) Letter to Manufacturers of Blood Glucose Monitoring Systems Listed With the FDA, dated 12/27/17, it indicated, The disinfection solvent you choose should be effective against HIV, Hepatitis C, and Hepatitis B virus. Outbreak episodes have been largely due to transmission of Hepatitis B and C viruses. However, of the two, Hepatitis B virus is the most difficult to kill. Please note that 70% ethanol (alcohol) solutions are not effective against viral bloodborne pathogens. (https://www.fda.gov/medical-devices/in-vitro-diagnostics/letter-manufacturers-blood-glucose-monitoring-systems-listed-fda According to the online publication titled Infection Prevention during Blood Glucose Monitoring and Insulin Administration by the Centers for Disease Control and Prevention (CDC), dated 3/2/2011, it indicated, An underappreciated risk of blood glucose testing is the opportunity for exposure to bloodborne viruses (HBV [hepatitis B virus], hepatitis C virus, and HIV) through contaminated equipment and supplies if devices used for testing and/or insulin (medication to lower blood glucose) administration (e.g., blood glucose meters, fingerstick devices, insulin pens) are shared. Outbreaks of hepatitis B virus (HBV) infection associated with blood glucose monitoring have been identified with increasing regularity, particularly in long-term care settings . Blood glucose meters are devices that measure blood glucose levels. Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. (https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html) During a review of the manufacturer's instructions for cleaning and disinfecting of the glucometer provided by the facility, it indicated, The meter [glucometer] should be cleaned and disinfected after use on each patient . our testing confirmed the wipes listed will not damage the functionality or performance of the meter . [manufacturer] recommends using these wipes to clean and disinfect the [glucometer]: Clorox Healthcare Bleach Germicidal Wipes, Dispatch Hospital Cleaner Disinfectant Towels, Super Sani-Cloth Germicidal Disposable Wipes, CaviWipes . please read the manufacturers' (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 52 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some instructions before using their wipes on the meter. The manufacturer's instructions indicated, To disinfect nonfood contact surfaces . thoroughly wet surface . allow treated surface to remain wet for a full two (2) minutes . 2. During an interview on 2/7/23, at 9:44 a.m., with the DON and IP/DSD, the DON and IP/DSD were asked to explain the wet time during glucometer disinfection and to describe how nurses would maintain wet time. The IP/DSD stated they will wipe [the glucometer] and let it dry for two minutes. The DON stated, they wipe [the glucometer] with solution, then leave to dry. When asked, How does the glucometer stay wet?, the IP/DSD reviewed and read the manufacturer instructions on the Super Sani-Cloth (disposable disinfection wipes for hard surfaces and medical devices) disinfectant wipe container out loud, allow surface to remain wet for two minutes. The DON stated, We will repeat the in-service [for glucometer disinfection]. When asked how long the nursing staff had been using alcohol swab or Lysol to disinfect the glucometers, the DON stated, I do not know when it started .when I started [employment here], we were supposed to use Sani-Cloth . when I started in December 2022, I did a spot check and we had Sani-Cloth; so in my mind, the nurses were using that . the Lysol is new to me. During an interview on 2/7/23 at 9:55 a.m. with the DON, he stated the manufacturer instructions for the sanitizing wipes indicated the wet time is 2 minutes; so, we wipe the glucometer and let it sit for two minutes to let it dry before it can be used again (instead of properly keeping it wet for the two minutes). During an observation on 2/7/23, at 11:42 a.m., with LVN B, at Station 2, LVN B completed a BS check for Resident 39. LVN B wiped the glucometer with a Sani-Cloth disposable wipe for approximately 30 seconds before she proceeded to perform a BS check for Resident 25. After completion of the BS check, LVN B wiped the glucometer with a Sani-Cloth disposable wipe for approximately 30 seconds. During an interview on 2/7/23, at 12:00 p.m., LVN B stated she was given an in-service about glucometer disinfection, was instructed to wipe it for two minutes with the Purple wipe [Sani-Cloth] and to let it air dry. LVN B said she did not understand why the glucometer needed to stay wet. LVN B stated she thought that letting the glucometer dry was included in the two minutes, During a concurrent observation and interview on 2/7/23, at 12:09 p.m., with RN H, at Station 2, RN H completed a BS check for Resident 97. RN H wiped the glucometer with a Sani-Cloth disposable wipe for approximately 30 seconds. RN H stated, We had an in-service yesterday on how to wipe the glucometer with Sani-Cloth wipes . I knew that already . wipe for two minutes . then let air dry . important to keep it wet to remove microorganisms and sanitize . I did not time it . I let it wet for about 1 minute. During a review of the manufacturer's instructions for cleaning and disinfecting of the glucometer provided by the facility, it indicated, To disinfect nonfood contact surfaces . thoroughly wet surface . allow treated surface to remain wet for a full two (2) minutes . 3. During a medication administration observation on 2/8/23, at 8:19 a.m., with LVN I, at Station 3, LVN I prepared medications for Resident 72. LVN I went into Resident 72's room, put on new gloves at bedside, touched the bed remote to elevate the head of bed and turned off the feeding pump (machine that delivers nutrition into the stomach) with her right gloved hand. LVN I proceeded to administer medications to Resident 72 via the G-tube (a tube inserted through the abdomen that delivers nutrition and medications directly to the stomach) without changing gloves. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 53 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Immediate jeopardy to resident health or safety During an interview on 2/8/23 at 8:44 a.m., with LVN I, LVN I acknowledged she should have changed gloves after touching the bed remote and feeding pump. During a review of the facility's P&P titled, Handwashing/Hand Hygiene, dated 5/2020, the P&P indicated, Handwashing: soap .and water for the following situations . Before preparing or handling medications . After contact with objects (e.g. [example] medical equipment) in the immediate vicinity of the resident . Residents Affected - Some 4a. During an observation on 2/6/23 at 5:28 p.m., certified nursing assistant (CNA) R was observed inside an isolation resident room wearing a face mask and gloves. The signs outside of the isolation room indicated anyone entering the room should wear face mask, face shield, gown, and gloves. During an interview on 2/6/23 at 5:28 p.m., with RN D, RN D stated, the room was still in isolation; therefore, CNA R should have had on the required PPE (Personal Protective Equipment - protective equipment used when caring for patients to prevent the spread of diseases) as posted. During an interview on 2/7/23 at 10:56 a.m. with CNA R, CNA R stated, regarding her entrance into an isolation room yesterday evening, in addition to the PPE she had on, she should have had a gown and face shield on. CNA R stated there was an isolation cart outside of the room, and one of the residents in the room was COVID-19 positive. She accidentally went in the room without proper PPE. 4b. During an observation on 2/8/2023 at 1:20 p.m., CNA S went inside the isolation room wearing an N95 (a particulate-filtering facepiece respirator that filters at least 95% of airborne particles) only. CNA S picked up the lunch tray from Bed A, went outside carrying the tray with her bare hands, walked along the hallway and passed the tray to another CNA. There were three postings near the outside the isolation room. The first post indicated, STOP, CHECK WITH CHARGE NURSE BEFORE ENTERING ROOM. VISIT NURSE. It also had pictures of a surgical mask, N95, Gloves, Face shield, and Disposable Gowns. The second post indicated, STOP Transmission Based Precautions STOP. Donning. 1. Hand Hygiene; 2. Gown; 3. Mask; 4. Goggles/Face shield; 5. Gloves. The third posting indicated, STOP Transmission Based Precaution STOP. DOFFING. 1. Gloves; 2. Goggles/Face shield; 3. Gown; 4. Mask; 5. Hand Hygiene. There was an isolation drawer (storage unit containing PPE, such as gowns, gloves, face shields and masks) near the outside the isolation room with a sign that indicated, RED ZONE (a dedicated area for COVID-19 residents). During an interview with CNA S, on 2/8/2023 at 1:25 p.m., she confirmed the isolation room had residents with Coronavirus disease (COVID-19, a disease caused by a contagious virus). CNA S stated, I just picked up the tray . Should I gown up? During a concurrent interview and review of the postings of the isolation room, on 2/9/2023 at 9:28 a.m., LVN T stated the isolation room was their Red Zone. LVN T confirmed there were residents with COVID-19 in the isolation room. LVN T stated any staff who entered the isolation room should wear the proper personal protective equipment (PPE, such as: N95, disposable gown, gloves, face shield or goggles) prior to entry. 4c. During an observation on 2/9/2023 at 12:37 p.m., certified nurse assistant U (CNA U) entered the isolation room wearing N95, disposable gown, and gloves. CNA U did not wear a face shield or goggles inside the isolation room. During an interview with CNA U on 2/9/2023 at 1:30 p.m., CNA U stated she needed to wear N95, gown, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 54 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some gloves and face shield every time she entered the isolation room. The CNA U stated, I'm sorry. I should have worn it (face shield). During an interview with the infection preventionist (IP) on 2/9/2023 at 1:48 p.m., the IP confirmed the isolation room had residents with COVID-19. The IP stated all staff and visitors should wear full PPE prior to entering the isolation room. The IP stated full PPE should be worn when trays are picked up from the isolation room because it was their Red Zone. 4d. During an observation on 2/9/23 at 1:30 p.m., LVN X was observed wearing a mask with ear loops (straps that go around each ear). LVN X was questioned about wearing a mask with ear loops instead of an N95 (which has straps that are placed behind the neck and at the crown of the head). LVN X stated This is my first day here . I am a registry nurse . No one told me I could not wear this mask with ear loops. During an interview with the IP/DSD on 2/13/23 at 8:12 a.m., she stated the facility instituted the wearing of N95s due to an outbreak of Covid-19 and that all staff were required to wear N95s until the positive resident's isolation had been completed on 2/10/23. The IP/DSD stated the facility did not allow staff to wear KN95s (masks with ear loops). She stated LVN X should be wearing an N95. A review of the All Facilities Letter (AFL) 23-12 titled Coronavirus Disease 19 (COVID-19) Recommendations for Personal Protective Equipment (PPE), Resident Placement/Movement, and Staffing in Skilled Nursing Facilities, dated 1/24/2023, referenced a chart of COVID-19 recommendations titled COVID-19 PPE, Resident Placement/Movement, and Staffing Considerations by Resident Category that indicated, COVID Positive Residents . N95 respirator - Yes . Eye Protection - Yes . Gowns - Yes . 5. Review of the facility's COVID-19 Self Screening form for employees, dated 2/9/23, indicated there was no evidence that LVN X completed self-screening on 2/9/23. LVN X was listed on the daily staffing assignment of 2/9/23 as assigned to station 2B for the day shift. During a concurrent interview with the IP/DSD, on 2/13/23 at 8:45 a.m., she stated staff are instructed to take their temperature and to complete the COVID-19 screening questionnaire at the start of their work shift. The IP/DSD confirmed there was no evidence LVN X took her temperature or completed either the screening questionnaires for staff or for visitors on 2/9/23. The IP/DSD stated LVN X should take her temperature and complete the questionnaire. 6a. Review of Resident 24's clinical records indicated, Resident 24 was admitted to the facility with diagnoses including critical illness polyneuropathy (condition involving damage to many nerves in different parts of the body), other pulmonary embolism (occurs when a clump of material, most often a blood clot, gets stuck in an artery (a blood vessel that carries blood from the heart to tissues and organs in the body) in the lungs, blocking the flow of blood) and dependence on supplemental oxygen (a continuous flow of oxygen delivered to people deficient in oxygen). During an initial observation on 2/6/2023 at 9:48 a.m., Resident 24 laid in bed with oxygen delivered to him via (through) nasal cannula (NC - a device that consists of plastic tube that fits behind the ears, and with two prongs that are placed in the nostrils for oxygen administration) at 2.5 liters (L- a metric unit of capacity) per minute. The dust filter located at the back of the oxygen concentrator (a machine that concentrates the oxygen from air to supply an oxygen-enriched gas stream) had a buildup of grayish matter. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 55 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some During another observation inside Resident 24's room, on 2/7/2023 at 11:45 a.m., Resident 24's oxygen concentrator's dust filter still had the grayish matter build up. 6b. Review of Resident 15's admission RECORD, dated February 10, 2023, indicated Resident 15 was admitted to the facility with diagnoses including unspecified atrial fibrillation (an irregular and often very rapid heart rhythm that can lead to blood clots in the heart), congestive heart failure (a weakness of the heart that leads to a buildup of fluid in the lungs and surrounding body tissues), and chronic obstructive pulmonary disease (COPD - a long lasting lung disease). During an initial observation on 2/6/2023 at 9:55 a.m., Resident 15 laid in bed, with oxygen in placed via NC at 2.5 L per minute. Resident 15's oxygen concentrator's dust filter located at the right side of the machine had some grayish matter build up. During a follow up observation on 2/7/2023 at 11:47 a.m., Resident 15's oxygen filter still had some grayish build up. During an interview with LVN L, on 2/7/2023 at 11:50 a.m., LVN L stated it was the responsibility of both nursing and maintenance staff to keep oxygen concentrators in good working condition. During a concurrent observation and interview with LVN L, on 2/7/2023 at 11:55 a.m., LVN L confirmed the oxygen filters of Resident 24 and Resident 15 were dirty and needed to be cleaned. LVN L further stated the oxygen filters should be cleaned to provide clean air to residents on supplementary oxygen. During an interview with LVN P, on 2/7/2023 at 12:02 p.m., LVN P stated nurses should change the oxygen humidifiers (device used to increase the level of moisture in the oxygen) and maintenance should change or clean the filters. During a concurrent observation of oxygen concentrator filters and interview with assistant director of nursing A (ADON A) on 2/7/2023 at 12:07 p.m., ADON A confirmed the oxygen filters of Resident 24 and Resident 15 needed to be changed. ADON A stated the oxygen filters should be clean. ADON A further stated one staff was assigned to check all oxygen concentrators every two weeks. During a concurrent interview and record review regarding the oxygen log checks, on 2/7/2023 at 12:15 p.m., the central supply staff (CSS) stated he checked the resident's oxygen every other week. The CSS reviewed the log and confirmed he missed checking Resident 24 and Resident 15's oxygen filters for the month of February, 2023. A review of the oxygen log indicated the last time the oxygen filters were cleaned for Resident 24 and Resident 15 was on January 21, 2023. Review of the facility's policy and procedure titled, Oxygen Administration, date revised October 2010, indicated, The purpose of this procedure is to provide guidelines for safe oxygen administration. General Guidelines . 3. For concentrators, clean lint and dust filters every 2 weeks and PRN (pro re nata - is a Latin phrase meaning as the circumstances arises) basis. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 56 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, sanitary, and comfortable environment for residents when: 1. Bed side rails were not stable or installed properly; 2. Toilet doorknobs were either missing, broken and/or loose, and a tissue holder was broken; 3. A Doorknob was missing and a tissue holder broken; 4. Cabinet drawers were broken and a tray table had chipped paint and chipped edges; 5. A bathroom door was out of order and had stains; 6. Four bed footboards were loose; 7. Window blinds were broken; 8. The Bathroom of Room F lacked a door. These failures had potential to compromise residents' safety, well-being and health. Findings: 1. During room rounds and concurrent observation and interview, on [DATE] at 9:12 a.m., with the director of nursing (DON), the DON confirmed the following: 1.a. In Room H, Resident 69's bilateral bed rails were loose. 1.b. In Room I, Resident 101's bedrails were loose. 2.a. In Room J, the shared bathroom for four residents, had a broken knob, with a hole on the door. 2.b In Room K, the bathroom doorknob was loose 2.c. In Room N, the bathroom doorknob was missing, with a hole on the door. 3. In Room L, the bathroom doorknob was missing and a tissue holder was broken. 4.a In Room M, the cabinet drawers were broken and a tray table had chipped paint and chipped edges. During a concurrent interview following the above observations, the DON acknowledged repairs were needed and called for the Maintenance Director (MD) to check on and repair the broken items. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 57 of 58 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056212 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods Post-Acute 1267 Meridian Avenue San Jose, CA 95125 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 4.b During an observation and interview with the maintenance director (MD) inside Room F), on [DATE] at 2:55 p.m., Resident 15's bedside cabinet's top-drawer handle was broken. The handle was missing a screw to the left side, which made it dangle to the right side of the drawer. The MD confirmed Resident 15's bedside cabinet's top-drawer handle was broken and stated, Oh yes, we just need a screw for that. I'll fix it. 5. During an observation and interview with the MD in Room O, on [DATE] at 1:11 p.m., the door was hard to open and was stained with what the MD referred to as coffee stains. The MD cleaned the stain from the door. Resident 66 stated, the door had been like that for almost six months. The MD removed the door and stated he would fix it. 6. During a observation and interview with the medical record director (MRD) covering for the MD, on [DATE] at 1:26 p.m., the following footboards of the beds were loose and wobbly for Room A Bed A (an empty bed); Resident 59, Resident 24, and Resident 15. The MRD confirmed the condition of these footboards and acknowledged they needed to be fixed. 7. During an observation, on [DATE] at 9:08 a.m., in Room B, the window blinds were broken. During an observation, on [DATE] at 9:23 a.m., in Room C, the window blinds were broken. During an observation, on [DATE] at 1:30 p.m., in Room D, the bottom part of the window blinds was broken. During an observation on [DATE] at 10:11 a.m., in Rooms E and F, the window blinds were broken. The lower part of the window blinds in Room F was broken into pieces. During a concurrent observation and interview with the MRD, on [DATE] 11:14 a.m., he confirmed the window blinds were broken and needed to be fixed in the following rooms: Room E, Room D, Room B, Room C, and Room F. 8. During an initial observation and interview with Resident 15, on [DATE] at 9:55 a.m., inside Room F, a bathroom door was not installed and was covered with a curtain instead. Resident 15 stated the bathroom door was missing for 3 months and the staff just replaced it with a curtain. During an observation, on [DATE] at 11:42 a.m., Room F still did not have a bathroom door. During a concurrent observation and interview with the MRD, on [DATE] at 11: 21 a.m., he confirmed the bathroom door in Room F was missing. During an interview with the assistant director of nursing A (ADON A), on [DATE] at 9:30 a.m., she stated the previous resident in Room F preferred to not have a bathroom door. ADON A stated the previous resident expired and then Resident 15 was transferred to Room F. Review of the facility's policy and procedure Maintenance Service, revised [DATE], indicated, 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . 3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner . 10. Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056212 If continuation sheet Page 58 of 58