Health inspection·February 18, 2022

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a concurrent interview and record review on 2/15/22 at 4:45 p.m., with Staff B and Staff Q, Resident 129's Electronic Medical Record (EMR) was reviewed. Staff B stated Resident 129 was admitted to the facility on [DATE]. Both Staff reviewed the EMR and were unable to find a baseline care plan for any nursing service focus. Staff B stated the baseline care plan was expected to be complete within the first 48 hours of a resident's admission. During a concurrent interview and record review on 2/15/22 at 5:18 p.m., with Staff B and Staff Q, Resident 130's Electronic Medical Record (EMR) was reviewed. Staff B stated Resident 130 was admitted to the facility on [DATE]. Both Staff reviewed the EMR and were unable to find a baseline care plan for any nursing service focus. Staff B stated the baseline care plan was expected to be complete within the first 48 hours of a resident's admission. During a concurrent interview and record review on 2/15/22 at 4:52 p.m., with Staff B and Staff Q, Resident 132's Electronic Medical Record (EMR) was reviewed. Staff B stated Resident 132 was admitted to the facility on [DATE]. Both Staff reviewed the EMR and were unable to find a baseline care plan for any nursing service focus. Staff B stated the baseline care plan was expected to be complete within the first 48 hours of a resident's admission. During a concurrent interview and record review on 2/15/22 at 5:08 p.m., with Staff B and Staff Q, Resident 133's Electronic Medical Record (EMR) was reviewed. Staff B stated Resident 133 was admitted to the facility on [DATE]. Both Staff reviewed the EMR and were unable to find a baseline care plan for any nursing service focus. Staff B stated the baseline care plan was expected to be complete within the first 48 hours of a resident's admission. Review of the facility policy and procedure titled Care Plans- Baseline dated 12/2016, indicated A baseline care plan to meet the resident's immediate needs shall be developed within forty eight (48) hours of admission. Based on observation, interview and record review, the facility failed to develop a baseline care plan for 5 out of 13 sampled residents (Resident 229, Resident 129, Resident 130, Resident 132, Resident 133) when: 1. Resident 229 had no baseline care plan for Percutaneous Endoscopic Gastrostomy (PEG-a device that allows nutrition, fluids and/or medications to be put directly into the stomach, bypassing the mouth and esophagus) Care Plan. This failure had the potential for Resident 229 not receiving adequate care because of staff not knowing what care to provide. 2. New admissions to the facility, Resident 129, Resident 130, Resident 132, and Resident 133, were all receiving skilled nursing care without an assessment of their care needs. This failure had to potential for needs to go unmet, continued health decline, and a lower quality of care for these residents. Findings: 1. During an observation on 2/14/22 at 3:21 p.m., Resident 229 was in bed, the head of the bed was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555826 If continuation sheet Page 2 of 23 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 555826 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods, A Community of Seniors 40 Camino Alto Mill Valley, CA 94941 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 0655 Level of Harm - Minimal harm or potential for actual harm elevated and a Tube feeding formula was running at 60 millimeter per hour via the PEG tube. The Tube feeding did not have Resident 229's name or indicate the time the tube feeding was initiated. Connected to the PEG was a water flush administration set tubing and it was dated 2/13/22. During a review of Resident 229's Medical Record on 2/15/22, there was no PEG tube care plan. Residents Affected - Many During an interview on 2/16/22, at 8:43 a.m., with the Director of Nursing (DON), she stated that she expected the staff to initiate care planning within 24 hours of admission and complete baseline care planning within 48 hours of admission. During a concurrent interview and record review on 2/17/22, at 4:00 p.m., with the DON and Staff N, the DON verified there was no PEG tube care plan for Resident 229 since his admission on [DATE]. Staff N concurred there was no baseline care plan for PEG tube feeding. The DON stated there were safety risks associated with staff not knowing where to find information on how to properly care for Resident 229 PEG tube. DON stated that the facility has no existing Policy and Procedure for PEG care. Review of the facility policy and procedure titled Care Plans- Baseline dated 12/2016, indicated A baseline care plan to meet the resident's immediate needs shall be developed within forty eight (48) hours of admission. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555826 If continuation sheet Page 3 of 23 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 555826 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods, A Community of Seniors 40 Camino Alto Mill Valley, CA 94941 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 - Many Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop comprehensive care plans for 3 sampled residents (Resident 14, Resident 20, and Resident 28) that were individualized and updated to show residents specific care related to their medical needs when: a. Resident 20 did not have a care plan for urinary catheterization. b. Resident 28 did not have a care plan for monitoring of antipsychotic medications and dementia behaviors c. Resident 14 did not have a Care Plan for Anti-Subluxation brace/sling (a medical device intended to protect the shoulder joint from partial dislocation cause by caused by paralysis or injury in the shoulder joint capsule). These failures possibly resulted in residents decline in health, harm, and negatively impact the residents' quality of care and services. Findings: a. During an interview on 2/15/22 at 11:13 a.m., Resident 20 stated nurses catheterize him about three times a day. A review of Resident 20's chart indicated there were no care plan with interventions to address Resident 20's intermittent catheterization. During a concurrent interview and record review on 2/18/22 at 10:50 a.m., Staff G confirmed Resident 20 did not have a care plan for urinary catheterization. When asked if there should be one, Staff G stated, Yes. A review of the facility policy titled, Care Plans, Comprehensive Person-Centered dated 12/2016, indicated the care planning process will include an assessment of the resident's strengths and needs, and to incorporate identified problem areas. b. Resident 28 was admitted to the facility on [DATE] from (name) (acute care) with a diagnosis that included: Unspecified Dementia without behavioral disturbance, mild cognitive impairment, Difficulty walking. Resident 28,was prescribed Seroquel (a mind-altering drug used to treat mood disorders), and had a BIMS (Brief Interview of mental Status) (an assessment tool) score of 8 (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). During an interview on 2/17/2022 at 10:00 a.m., Staff E stated, she usually worked in another area and was filling in today for staff. When asking Staff E how she monitored Resident 28's behaviors, Staff E stated the resident had a 1:1 sitter (one person who only monitored one resident) (A sitter is usually a staff member assigned to the task. In this case it was a privately hired person, hired by the family) all the time and the 1:1sitter reported any behavior or problems with Resident 28 to the staff. The resident did not like to have anyone come into her room, she could be aggressive and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555826 If continuation sheet Page 4 of 23 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 555826 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods, A Community of Seniors 40 Camino Alto Mill Valley, CA 94941 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 - Many shut the door in your face. The resident had done that at times when Staff E tried to administer her medications. She had refused to take her medications. Staff E stated the resident had been known to act out and become combative, the staff or sitter usually redirected the resident to calm her down. When requesting to speak with Resident 28, Staff E stated she may not let you in. Resident 28 did not want any visitors and stated, we are resting here. Staff E was questioned about Resident 28's antipsychotic medication and the process involved. Staff E stated, Resident 28 receives Seroquel 25 mg (milligrams) PO (orally) QPM (every evening). During an interview on 2/17/2022 at 10:20 a.m., the 1:1 sitter for Resident 28 stated I stay with the resident 3 days a week and the resident is often confused. When questioning the 1:1 sitter what type of behaviors Resident 28 exhibits, she stated, the resident often stated she wanted to go home and asked why she was here. The 1:1 sitter stated at times the resident could become anxious and combative. When asked what she did when the resident becomes anxious, the 1:1 sitter stated she tried to calm her down and redirects her behavior. She has the resident sit in her chair or takes her out on the patio, the resident also likes to read. Further questioning how Resident 28 interacts with the nursing staff, the 1:1 sitter stated sometimes the resident could become anxious and refuses her medication. The 1:1 sitter reported the resident's behaviors and dietary intake to the nursing staff and CNA each shift. During an interview on 2/17/2022 at 11:30 a.m., Staff S was asked how he assessed Resident 28's behavior, and he stated, the Resident had a 1:1 sitter and she provided a report to the CNA or the nurse.Staff S stated s/he would document her eating and drinking at meals. If there was a problem we would report to the nurse. During an interview on 2/18/2022 at 12:30 p.m., Staff G was asked how she monitored Resident 28's behaviors. Staff G stated, she checked Resident 28's behaviors in the AM and PM. She had not experienced behavior changes with Resident 28, and she knew the 1:1 sitter redirected the resident at times when she became anxious. The 1:1 sitter would give report to nursing and CNA every shift. A Review of the clinical records on 2/17/2022, indicated there was no care plan that was resident specific with measurable goals and interventions to address Resident 28's need for monitoring behaviors on Seroquel (a mind-altering drug used to treat mood disorders) or providing interventions for Dementia care. The clinical record did not show an IDT (Interdisciplinary Team) meeting or Physician notes addressing the Resident's behaviors or type of care that would be implemented. c. During concurrent interview and record review on 2/16/22 at 3:58 p.m. Director of Nursing (DON) verified there was no care plan for Anti-Subluxation brace/sling. Review of the facility Policy and Procedure titled Care Plans, Comprehensive Person-Centered, version 1.3, (no date), indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555826 If continuation sheet Page 5 of 23 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 555826 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods, A Community of Seniors 40 Camino Alto Mill Valley, CA 94941 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 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review the facility failed to ensure assistive devices for vision was provided for one resident (Resident 26). This failure resulted in the resident not having vision assistance to read (an activity the resident enjoys) and could contribute to his increased incidents of falls. Residents Affected - Few Findings: During an observation and concurrent interview on 2/14/2022 at 10:00 a.m., Resident 26 was resting in bed. When speaking with the resident, he did not respond to questions asked, but said, Thank-you when the Surveyor was leaving the room. During an interview on 2/14/2022 at 11:00 a.m., Staff G was asked about Resident 26 condition. Staff G stated Resident 26 speaks mostly Russian and very little English. The staff watches him closely because he has had an increased number of falls. Resident 26 was observed in his wheelchair motoring around the hallway. During an interview on 2/16/2022 at 1:35 p.m., Resident (26's) daughter stated her father had an ophthalmology visit last year and the Ophthalmologist told her he needed glasses due to a decline in his vision. The daughter stated there was a prescription for glasses, but the prescription was not filled. The facility told her there was a problem with the insurance that she did not understand. She stated she would ask again for another eye appointment. During an interview on 2/16/2022 at 15:00 p.m., the Social Services Director (SSD) stated, we have an Ophthalmologist that comes to the facility and provides eye exams and fits residents for glasses while in the facility. When reviewing the ophthalmology report for Resident (26) dated 3/2/21, a prescription for eyeglasses was written but not filled. When questioning the SSD about the eye glass prescription she stated, she spoke with the daughter, and she will schedule another eye appointment for Resident 26 and this resident should have had his eyeglass prescription filled. Review of the facility Policy and Procedure titled, Accommodation of Needs revised March 2021, In order to accommodate individual needs and preferences, staff attitudes and behaviors are directed towards assisting the residents in maintaining independence, dignity and well-being to the extent possible and in accordance with the residents' wishes ., c. maintaining hearing aids, glasses, and other adaptive devices for residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555826 If continuation sheet Page 6 of 23 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 555826 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods, A Community of Seniors 40 Camino Alto Mill Valley, CA 94941 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm Based on observation, interview and record review, the facility failed to assess, prevent, and treat a wound for one of thirteen residents (Resident 14) when the facility admitted Resident 14 with right shoulder Anti-subluxation brace/sling (a medical device intended to protect the shoulder joint from partial dislocation cause by caused by paralysis or injury in the shoulder joint capsule), and no weekly skin assessment was done. This failure resulted in Resident 14 developing a wound inside her right armpit with infection, and there was no current wound assessment and wound care order from the Physician. Residents Affected - Few Findings: During a review of Resident 14's medical record, the facility admitted Resident 14 on 12/30/21. The Skin Evaluation Form dated 12/30/22, indicated Resident 14's skin had no existing issues. The Baseline care plan dated 1/3/22, indicated Resident 14 was at risk for skin breakdown and skin would be checked weekly and new skin concerns would be reported to the doctor for treatment and follow up. The Nursing Notes dated 2/11/21, indicated there was an open wound with pus on Resident 14's right armpit and her Physician was notified. Resident 14 had a physician order for Cephalexin (a medication) for wound infection ordered on 2/11/22. During an interview on 2/14/22, at 2:52 p.m., Staff M stated Resident 14 had a wound on her right armpit, and it was caused by the brace digging into her skin. During an interview on 2/15/22, at 10:06 a.m., Staff H stated Resident 14 has an unhealed wound on her right armpit, and it was caused by the brace digging to her skin. Staff H stated that Resident 14 did not have treatment orders for her wound. Staff H stated staff would sometimes use saline on the wound and then covere it with a dressing. Staff H stated treatments were completed by the afternoon staff. When asked how staff knew if a wound is getting better or worse, Staff H did not verbalize a response. During an interview on 2/16/22, at 2:40 p.m., with the Director of Rehab (DOR), she stated Resident 14 was admitted to the facility with the right anti-subluxation brace. The DOR stated her department did not provide training to direct staff on the use of the brace. The DOR stated the brace might have contributed to Resident 14's right armpit wound development. During an interview on 02/16/22, at 3:47 p.m. the DON stated the right armpit wound was possibly due to the sling digging through her skin, and it was possible staff did not know how to use it appropriately. The DON also stated there was no need to investigate the cause of the wound because we already knew it was from the sling. During interview and concurrent Resident 14's record review, on 2/16/22, at 3:58 p.m., the DON verified Resident had one Skin Evaluation Form dated 12/30/21. The DON verified there was no documentation to show weekly skin assessments were completed. The DON verified there was no Care plan for the right armpit wound and the Anti-Subluxation brace/sling. The DON verified there was no documentation for wound care treatment. · During an observation and concurrent interview on 2/17/21 at 4:30 p.m. with the DON and Staff C, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555826 If continuation sheet Page 7 of 23 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 555826 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods, A Community of Seniors 40 Camino Alto Mill Valley, CA 94941 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 0686 Level of Harm - Actual harm Staff C looked at Resident 14's right armpit. DON and Staff C verbalized that the wound presented with slough (yellow/white material in the wound bed). The DON directed Staff C to call the doctor for wound treatment order. The DON did not provide policies and procedures for Brace/Sling use and Pressure Ulcer Prevention when requested. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555826 If continuation sheet Page 8 of 23 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 555826 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods, A Community of Seniors 40 Camino Alto Mill Valley, CA 94941 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A review of Resident 26's face-sheet indicated, Resident 26 was admitted with a diagnosis that included Parkinson's disease (a progressive brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination), history of Falling, and unsteadiness on feet. During an interview on 2/16/2022 at 1:35 p.m., Resident 26's daughter stated she is worried about her father's increased number of falls. The daughter stated her father just returned two days (2/12/22) ago from (name) (acute care) hospital because of a fall. The staff told her, the CNA (Certified Nursing Assistant) could not watch her father all the time and suggested that she might consider getting a 1:1 (one-on one) sitter (one person who will only monitor one resident), but we would have to pay out of pocket for that care. During an interview on 2/17/2022 at 4:17 p.m., Staff Q was asked what they do to monitor Resident 26 for falls. Staff Q stated when a resident fell, she completed an assessment of the Resident and made sure they were not injured. She stated they called the physician, DON (Director Of Nursing), and responsible party and placed the resident on neuro checks (assessment of mental status and motor responses, including reflexes, to determine whether the nervous system is impaired including vital signes) following the facility process. Staff Q showed the documented records for the fall, and the neuro checks she completed for the 2/11/22 fall. When asked to see the other documentation for previous falls that occurred for Resident 26, Staff Q stated she did not find them in the medical record. Review of Resident 26's care plan and interventions for falls revealed dates of falls that had occurred. Review of the clinical records did not show any documentation for the interventions or monitoring that were performed for each of the falls listed in the Care Plan. There were no IDT notes or Physician notes to show a cause analysis was conducted for the increased falls. Review of the facility Policy and Procedure titled, Fall Monitoring dated January 14, 2014, indicated, vital signs including neuro check will be monitored for 72 hours post fall. Procedure: 1. Vital signs, including neuro checks, will be obtained and documented . 2. Charting will be performed every shift for 3-days post fall. Based on observation, interview and record review, the facility failed to provide adequate supervision and assistance to prevent falls for 5 out of 13 sampled residents (Resident 130, Resident 133, Resident 26, Resident 13, and Resident 20) when the facility did not accurately assess residents for their risk of falls, did not timely implement, or attempt to implement, appropriate fall prevention interventions, and did not revise or update fall prevention care plans with additional or different interventions after a fall. These failures resulted in significant injury when Resident 130 sustained a broken right hip after a fall and placed at risk residents at a greater risk for falls, harm, and possibly cause a decline in Residents' health condition. Findings: Resident 130 During a review of the clinical record for Resident 130, the Minimum Data Set ([MDS] a comprehensive, standardized assessment of each resident's functional capabilities and health needs), dated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555826 If continuation sheet Page 9 of 23 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 555826 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods, A Community of Seniors 40 Camino Alto Mill Valley, CA 94941 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 0689 Level of Harm - Actual harm Residents Affected - Few 2/9/22, indicated Resident 130 was admitted to the facility on [DATE]. The Care Area Assessment ([CAA] reflects conditions, symptoms, and other areas of concern identified or suggested by MDS findings) section indicated Resident 130's assessment triggered 8 care areas. The assessment identified dementia, falls, and rehabilitation potential as areas Resident 130 needed further assistance with. The assessment indicated the facility marked all 8 triggered areas as Addressed in Care Plan. During a review of the facility policy and procedure titled, Fall Risk Assessment, updated 3/2018, indicated the facility would document risk factors for falls and establish a resident-centered falls prevention plan. The policy indicated staff and attending physician would collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. During an observation, on 2/14/22, at 11 a.m., Resident 130 was lying in bed with his eyes closed. The bed was flat and approximately 3 feet off the ground, not in its lowest position. No observation of any indication Resident 130 had been identified as a resident at risk for falls. The bed in the lowest position, padded mats placed on either side of the bed and alarms with sensors that alert if a resident attempted to change positions were seen in use throughout the building. None of those interventions were seen in Resident 130's room. During a concurrent observation and interview on 2/15/22, at 3 p.m., with Staff L, in the hallway in front of Resident 130's room, Staff L looked into the room at the empty bed and stated Resident 130 was sent out to the hospital because he fell. During a concurrent interview and record review on 2/15/22 at 5:18 p.m., with Staff B and Staff Q, Resident 130's Electronic Medical Record (EMR) was reviewed. Staff Q reviewed the Interdisciplinary Notes and confirmed the notes indicated Resident 130 had fallen on 2/5/22, 2/12/22, and 2/14/22. Staff Q reviewed Resident 130's Care Plan and stated there was no nursing care plan to address Resident 130's risk for falls. Staff B and Staff Q reviewed Resident 130's care plan and stated there was no nursing care plan created to address Resident 130's actual falls until 2/14/22. Staff B stated there should have been a nursing care plan since his admission on [DATE] to address Resident 130's risk for falls. Staff B stated the documentation reviewed did not meet the facilities expectations for processing new admissions or for resident falls. Staff Q stated doctors orders, the care plan and its interventions were used as indicators to add specific tasks to the Point of Care section of the EMR. Staff Q stated the Point of Care section listed all the tasks and vital information Certified Nurses Assistants (CNA) used for them to provide adequate assistance and supervision during tasks of daily living. Staff B was unable to provide documentation to show Resident 130's functional abilities and limitations were input into Resident 130's EMR Point of Care section for direct care staff to review. The point of Care section of Resident 130's EMR was blank. When asked how a CNA would know what assistance or safety precautions Resident 130 needed, Staff B stated the staff all talk to each other, they knew from verbal report. Staff B stated the lack of documentation could have contributed to Resident 130's 3 falls in 13 days. During a review of the Electronic Medical Record (EMR) for Resident 130, the Profile Face Sheet indicated his admission date was 2/2/22. The record indicated Resident 130 was admitted with a diagnosis of Squamous Cell Carcinoma (cancer that develops in the thin, flat cells that make up the outermost layer of your skin). During a review of the Electronic Medical Record (EMR) for Resident 130, the admission History and Physical, dated 2/2/22, indicated on 1/25/22 Resident 130 was seen at an acute hospital after he (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555826 If continuation sheet Page 10 of 23 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 555826 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods, A Community of Seniors 40 Camino Alto Mill Valley, CA 94941 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 0689 fell at home. Level of Harm - Actual harm During a review of the EMR for Resident 130, the Interdisciplinary Note, dated 2/3/22, indicated Resident 130 was confused and attempted to get out of bed many times. There was no documentation of the fall on 2/5/22, Staff B was unable to show a post fall assessment, or a care plan, or a new change of condition incident note. Staff B stated all 3 of those documents were expected for every fall. Staff B Staffed in addition to the original assessments, nurses should chart a note related to the fall every shift for 72 hours. Staff Q reviewed the ID notes and found one that indicated charting for multiple reasons including a fall on the previous shift. Residents Affected - Few During a review of the EMR for Resident 130, the Interdisciplinary Note, dated 2/13/22, indicated Resident 130 was found on the floor next to his bed on 2/12/22 at 6 p.m. The note indicated a significant amount of blood was observed on the floor near Resident 130's head. The note indicated Resident 130 stated he got out of bed to go to the hospital because they have good coffee there. A review of the care plan indicated Resident 130's risk for falls was not identified or care planned at the time of admission or after the first fall on 2/3/22. The facility did not put any interventions in place to reduce the risk of falls. The EMR indicated the post fall assessment and charting was not done. No interventions were put into place to prevent Resident 130 from additional falls. During a review of the EMR for Resident 130, the Interdisciplinary Note, dated 2/14/22, indicated at 10 a.m. Resident 130 was found on the floor close to his bed on his back with his legs bent. The note indicated Resident 130 stated he was going to the roof. The note indicated Resident 130 complained of right hip and knee pain after the fall. The note indicated Resident 130's pain had gotten worse over time; x-rays were ordered. During a review of the physical medical chart for Resident 130, the Physicians Orders page, dated 2/14/21 indicated portable x-rays of the right hip and right knee after the fall were ordered. The page indicated at 4:30 p.m. the doctor ordered the x-rays to be upgraded to STAT (a common medical abbreviation for urgent or rush) status. The page indicated at 7 p.m. the doctor ordered Oxycodone (a narcotic medication used to treat moderate to severe pain) Five milligrams (mg a unit of weight measurement) to be given by mouth every four hours as needed for moderate pain. The page further indicated the doctor ordered Oxycodone ten mg to be given by mouth every four hours as needed for severe pain. The page indicated on 2/15/22 the doctor ordered the facility to transfer Resident 130 to the acute hospital for evaluation. During a review of the Electronic Medical Record (EMR) for Resident 130, the Discharge summary, dated [DATE], indicated Resident 130 fell out of bed on 2/14/22 and sustained an intertrochanteric right femoral neck fracture (the right hip bone fractured in the area between the ball joint and the leg bone). Resident 133 During a concurrent interview and record review on 2/15/22 at 5:08 p.m., with Staff B and Staff Q, Resident 133's EMR was reviewed. Staff Q reviewed the ID notes and confirmed the notes indicated Resident 133 had fallen on 2/12/22 while attempting to walk by herself to the bathroom. Staff Q reviewed the record and stated the facility had identified Resident 133 as being at risk for falls. Staff Q was unable to find documentation to show the facility had interventions in place to prevent falls. Staff B stated she was not aware Resident 133 had sustained a fall since admission on [DATE]. Staff B stated the fall was not reported to management and therefore not discussed at the daily Stand up (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555826 If continuation sheet Page 11 of 23 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 555826 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods, A Community of Seniors 40 Camino Alto Mill Valley, CA 94941 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 0689 Level of Harm - Actual harm Residents Affected - Few meeting. Staff Q reviewed the EMR and was unable to find a Change of Condition assessment, or an incident tracking note, or a post fall assessment. Staff B confirmed those reports should have been completed by the licensed nurse on the shift the fall occurred. Staff B confirmed this did not meet facility expectations for nursing responsibilities after a fall. Staff Q reviewed the care plan and stated Resident 133 did not have a nursing care plan the EMR. Staff B reviewed the blank page and stated there should be a nursing care plan for every identified care area. During an interview on 2/15/22 at 10:34 a.m., Family Member 1 stated Resident 13's multiple falls in the past year was a factor in hiring a part-time private caregiver for him. Family Member 1 stated, We understand the staff could get busy, and thought the private caregiver could help keep Resident 13 company. A review of Resident 13's face sheet indicated he was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease (a progressive brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination), and unspecified dementia without behavioral disturbance (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems, but does not include disruptive mood and behavior such agitation, aggression, disinhibition, and sleep disturbances). During an interview on 2/16/22 at 2:13 p.m., Staff J stated Resident 13's last fall was a long time ago. Staff J stated she would try and sit close to him [Resident 13], or always check on his room when the private caregiver leaves. Staff J confirmed it was not always possible to stay at Resident 13's bedside if other residents were calling for help. A review of Resident 13's Care Plans and interventions revealed: a. Falls Care Plan, dated 05/27/21, indicated, unwitnessed fall with no apparent injuries . Check on resident frequently when care partner if not present . b. Falls Care Plan, dated 06/02/21, indicated, Unwitnessed Fall - no injuries . Do not leave resident [sic] in room by himself when awake if companion [sic] is not present . c. Falls Care Plan, dated, 06/10/21, indicated, unwitnessed fall in the bathroom with no injury . Monitor resident in the bathroom at all times . Continue to monitor resident . Monitor resident while using the toilet . Check resident. d. Falls Care Plan, dated 08/28/21, indicated, unwitnessed [sic] fall with no apparent injuries . Keep bed in lowest position and call light within reach. Ensure resident is toileted accordingly . e. Falls Care Plan, dated 01/5/22, indicated, unwitnessed fall in his room with no injury . ensure resident is dry and clean, toileted and is comfortable. Lower bed in lower position. Monitor resident Q-shift (every shift) and PRN (as needed) . During a concurrent interview and record review of Resident 13's care plans on 2/18/22 at 10:30 a.m., Staff B confirmed Resident 13 had repeated falls and stated she expected the staff to frequently round and check on him [Resident 13] after his private caregiver leaves. When asked if the facility has identified such efforts as effective and adequate for Resident 13's pattern of unwitnessed falls, Staff B did not respond. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555826 If continuation sheet Page 12 of 23 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 555826 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods, A Community of Seniors 40 Camino Alto Mill Valley, CA 94941 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 0689 During an interview on 2/15/22 at 11: 17 a.m., Resident 20 stated he had a fall about two months ago. Level of Harm - Actual harm Record review revealed Resident 20 was admitted to the facility on [DATE], with diagnoses that included Parkinson's disease (a progressive brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination), and generalized weakness. Residents Affected - Few During an interview on 2/16/22 at 2:25 p.m., Staff O stated Resident 20 was at risk for falls. When asked how the staff knows which interventions were needed to prevent Resident 20 from further falls, Staff O stated, It's general -- lowering the bed, keeping the call lights close, removing clutter in the room, and ensuring the residents get adequate sleep. Staff O stated, I don't think there's any specific interventions for [Resident 20]. A review of Resident 20's chart revealed IDT (Interdisciplinary Team) Notes indicating Resident 20 sustained falls without injuries on 12/21/21, 12/19/21 and 12/7/21. Further record review revealed there were no care plans developed or revised to address Resident 13's multiple falls during December 2021. During an interview and concurrent record review on 2/16/22 at 10:35 a.m., Staff B confirmed Resident 20 did not have any fall care plans initiated. When asked if there should have been one, Staff B stated, Yes. During an interview on 2/18/22 at 2:59 p.m., Staff A confirmed resident falls continue to be a concern in the facility. Staff A stated they had new bed- and chair-pad alarms, but were currently not being used, as they have been broken since last fall [season]. A review of the facility policy titled, Falls and Fall Risk, Managing, dated March 2018, indicated, The staff, with the input of the attending physician, will implement a resident-centered fall prevention pan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls . Staff will try various interventions, based on assessment of the nature or category or falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable . The staff will monitor and document each resident's response to interventions intended to reduce calling or the risks of falling . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555826 If continuation sheet Page 13 of 23 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 555826 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods, A Community of Seniors 40 Camino Alto Mill Valley, CA 94941 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 - Many Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide medications as ordered by the physician to one of six residents sampled for medication administration (Resident 129). This delayed acquisition resulted in Resident 129 to not receive 11 doses and increased his potential to develop complications. Findings: During an observation on 2/16/22 at 3:55 p.m., Staff H marked Resident 129's Alvesco aerosol inhaler (used to treat asthma) and stated, That medication is not available. A review of Resident 129's face sheet indicated he was admitted to the facility on [DATE] for diagnoses that included combined systolic and diastolic heart failure (a condition in which the heart does not pump blood as well as it should), chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), and chronic respiratory failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide). A review of Resident 129's MAR (Medication Administration Record), dated 02/2022, indicated the order Alvesco 160 mcg/actuation aerosol inhaler [Ciclesonide] - 1 puff Inhalation Twice daily For COPD. Said medication had a Start Date 02/08/22, and a scheduled time of 08:00 (8 a.m.) and 16:00 (4 p.m.). Further review of the document indicated the medication was marked as the following: 1. 02/08/22 16:00 - Med Not Available 2. 02/09/22 16:00 - Med Not Available 3. 02/10/22 16:00 - Med Not Available 4. 02/11/22 16:00 - Med Not Available 5. 02/12/22 16:00 - Med Not Available 6. 02/13/22 16:00 - Med Not Available 7. 02/14/22 16:00 - Med Not Administered, [pharmacy] called 8. 02/15/22 08:00 - Med Not Available 9. 02/15/22 16:00 - Med Not Available 10. 02/16/22 08:00 - Med Not Available 11. 02/16/22 16:00 - Med Not Available During an interview on 2/16/22 at 4:15 p.m., Staff H, an afternoon nurse, stated following up on missing medications is usually the morning nurse's job. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555826 If continuation sheet Page 14 of 23 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 555826 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods, A Community of Seniors 40 Camino Alto Mill Valley, CA 94941 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 - Many During an interview on 2/17/22 at 3:25 p.m., Staff C confirmed the medication has been unavailable since Resident 129's admission nine days ago. Staff C stated the pharmacy was notified of the missing medication as the new electronic charting system automatically sends faxes when medications were clicked as 'Not Available'. When queried about following up on missing medications, Staff C stated she had called the pharmacy on 2/16/22 after not receiving a response. Staff C confirmed she did not notify the physician and stated, I know, I should have notified the doctor. The order could have been changed if that was the issue. Staff C added she usually notifies the physician if a medication was missed for one or two days. During an interview and concurrent record review on 2/17/22 at 3:40 p.m., Staff B confirmed Resident 129 did not receive his Alvesco inhaler doses for days. Staff B stated, This is not acceptable of that long of a wait. During an interview on 2/17/22 at 4:19 p.m., Staff I stated he was not aware of the automatic notifications to the pharmacy. Staff I stated, I expected the staff to call or send an actual fax to the pharmacy to notify us of missing medications. A review of the facility policy titled Medication Shortages, dated 2007, indicated, The facility nurse must make every effort to ensure that a medication ordered for the resident is available to meet their needs . Nursing staff shall, if the shortage will impact the patient's immediate need of the ordered product: a. Notify the attending physician of the situation, explain the circumstances, expected availability and optional therapy (ies) that are available . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555826 If continuation sheet Page 15 of 23 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 555826 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods, A Community of Seniors 40 Camino Alto Mill Valley, CA 94941 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor, re-evaluate, and document clinical rationale for continued use of a psychotropic drug for one of five sampled residents for medication regimen review (Resident 13) despite the resident not exhibiting behaviors the medication was originally prescribed for. This failure placed Resident 13 at a higher risk for adverse side effects associated with psychotropic medications. Findings: During an observation on 2/14/22 at 11:13 a.m., Resident 13 was asleep in bed. During an interview on 2/14/22 at 11:15 a.m., Private Staff stated he was Resident 13's private caregiver for a few months now and provides care and companionship for four hours during the day, five days a week. When queried about Resident 13's condition, Private Staff stated, He has dementia. He's very nice, just very confused. A review of Resident 13's face sheet indicated he was last admitted to the facility on [DATE], with diagnoses that included Parkinson's disease (a progressive brain disorder that leads to shaking, stiffness, and difficulty with walking, balance, and coordination), and unspecified dementia without behavioral disturbance (a mental disorder in which a person loses the ability to think, remember, learn, make decisions, and solve problems, but does not include disruptive mood and behavior such agitation, aggression, disinhibition, and sleep disturbances). Further review of Resident 13's chart indicated the physician's order: Seroquel (a mind-altering drug used to treat mood disorders) 12.5 mg (milligrams) PO (orally) daily for hallucination (sensory experiences that appear real but are not) and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily functioning) with an Order Date: 3/29/21. During observations on 2/15/22 at 9:30 a.m. and 1:15 p.m., Resident 13 was asleep in bed. During an observation on 2/16/22 at 10 a.m., Resident 13 was asleep in bed. During an interview on 2/16/22 at 2:13 p.m., Staff J described Resident 13 as confused but calm. A review of the facility binder titled, Monthly Medication Regimen Review, revealed a Gradual Dose Reduction note, dated 5/5/21, written by the pharmacist to the physician regarding Resident 13's use of Seroquel with his history of dementia. The physician's response indicated, Med benefit outweighs risks. There were no documented, subsequent GDRs for Resident 13 after 5/5/21. A review of Resident 13's MDS ([Minimum Data Set] a standardized, primary screening and assessment tool of health status of long-term care residents) Sections D (Mood) and E (Behavior) dated 4/23/21, 10/8/21 and 12/30/21 indicated he did not exhibit hallucinations nor depressive behaviors. During an interview on 2/17/22 at 9:54 a.m., Staff E stated Resident 13 as very confused, but pleasant. During a concurrent record review, Staff E confirmed the Seroquel order. When asked how often Resident 13 has expressed hallucinations or exhibited depression, Staff E stated she does not know. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555826 If continuation sheet Page 16 of 23 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 555826 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods, A Community of Seniors 40 Camino Alto Mill Valley, CA 94941 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 Staff E confirmed that Resident 13's recent MDS assessments did not indicate the targeted behaviors for the Seroquel order and stated, The behavior is not there, but we can't just discontinue the meds. We should at least notify the doctor. When asked if there have been any notifications sent to the physician, Staff E stated she did not know. When asked how the facility assessed Resident 13's need for continued use of Seroquel without tracking behavior, Staff E did not respond. Residents Affected - Few The facility's policies on the use of antipsychotic medications was requested, but not provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555826 If continuation sheet Page 17 of 23 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 555826 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods, A Community of Seniors 40 Camino Alto Mill Valley, CA 94941 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 Based on observation, interview, and record review, the facility failed to ensure medication error rate was lower than 5% when staff made five medication errors out of 27 opportunities. This failure resulted in a medication error rate of 18.5%, which had the potential of unsafe provision of medications to residents. Residents Affected - Some Findings: During an observation on 2/16/22 at 8:32 a.m., after checking Resident 300's vital signs, Staff D dispensed the following medications into a medicine cup: 1. One tablet of Carvedilol (used to treat high blood pressure), 2. One tablet of Methenamine (used to treat or prevent urinary tract infections), 3. One tablet of Aspirin (used to ease pain and/or prevent blood clots), and 4. One tablet of Sodium Chloride (used to treat low sodium levels in the blood). Staff D knocked on the door, entered the room and handed Resident 300 the medicine cup and a glass of water. Staff D looked on as Resident 300 drank the pills, then exited the room. During an observation on 2/16/22 at 9:13 a.m., Staff D dispensed the following medications into a medicine cup: 1. One capsule of Creon (used to help break down food when the pancreas is not working the right way), 2. One tablet of Eliquis (used to treat or prevent blood clots), 3. Half a tablet of Estradiol (used to prevent soft, brittle bones [osteoporosis] after menopause), and 4. One tablet of Metoprolol (used to treat high blood pressure). Staff D knocked on the door, entered the room and gave the medicine cup to Resident 23. Staff D exited the room after Resident 23 drank the pills. During an interview on 2/16/22 at 9:27 a.m., Staff D stated it was the fourth day on the unit but had medication administration training before. When queried, Staff D confirmed he did not explain to Residents 300 and 23 what medications were in the cup. Staff D stated, They have been taking it regularly; they know their meds. During a concurrent interview, at Staff D's response, Staff C stated informing the residents what medications they were given was part of medication rights. Staff C stated, You still have to explain what you are giving the residents, every time, even if they take it regularly. That is part of right medication. That is standard of practice. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555826 If continuation sheet Page 18 of 23 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 555826 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods, A Community of Seniors 40 Camino Alto Mill Valley, CA 94941 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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the literature Fundamentals of Nursing, with a copyright date 2000, under Chapter 26 Medication Administration indicated, Explain medication's purpose to client. Rationale: Protects the client's rights and encourages client's participation in care and compliance. During an observation on 2/16/22 at 5:20 p.m., Staff F administered one-and-a-half tablets of Glucotrol (used to lower blood sugar levels), four tablets of Metformin (also used to lower blood sugar levels), and a half-tablet of Magnesium Oxide (used to treat or prevent low magnesium levels) to Resident 6. A concurrent record review of Resident 6's MAR (Medication Administration Record) indicated scheduled administration times for all three medications as 1600 (4 p.m.). During an interview on 2/16/22 at 5:30 p.m., Staff F stated today was not her regular schedule and that she had just came in after there was a staff call-off. Staff F confirmed Resident 6's medications were given late. A review of the facility policy titled Administering Medications, dated April 2019, indicated, Medications are administered in a safe and timely manner . Medications are administered within one (1) hour of their prescribed time, unless otherwise specified . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555826 If continuation sheet Page 19 of 23 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 555826 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods, A Community of Seniors 40 Camino Alto Mill Valley, CA 94941 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 - Few 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe medication storage when: 1. Expired medications, including an eye drop belonging to one unsampled resident (Resident 2) were found in medication storage, and 2. Temperature logs were not maintained in the medication refrigerator. These failures had the potential for contamination and altered integrity of stored medications. Findings: During an observation on 2/15/22 at 3:29 p.m., an opened, multi-dose bottle of Latanoprost (a medication used to lower high eye pressure) belonging to Resident 2 was found inside a drawer of Medication Cart 2. The eye drop bottle, dated 12/26, had an affixed label that read, *DISCARD 6 WEEKS AFTER OPENING*. During an interview with Staff B and Staff G on 2/15/22 at 3:44 p.m., Staff C stated 12/26 was the date when the medication was opened. Staff C confirmed the discard instructions and stated, This [bottle] should have been discarded last week. Staff B then proceeded to dispose of the bottle. During an observation on 2/16/22 at 10:21 a.m., a 1000-ml (milliliter) bag of 5% Dextrose and 0.45% Sodium Chloride Injection USP (an intravenous solution used as source of electrolytes, calories, and hydration) was found on a shelf in the medication room. The bag was labeled EXP 04/21. During an observation on 2/16/22 at 10:34 a.m., a document was affixed to the door of the locked medication refrigerator. A concurrent review of the document, titled Refrigerator/Storage Space: Medication Temperature Log, dated [DATE] indicated a table with headings Date, NOC Shift Temp, Signature, AM Shift Temp, Signature. Further review of the log indicated twice-daily entries for dates 2/1/22-2/5/22, 2/7/22, 2/14/22 and 2/15/22. During an interview on 2/16/22 at 10:42 a.m., Staff B stated the medication storage room was checked by staff at least weekly and the medication storage temperatures were checked at least daily. Staff B stated, It is important to keep medications in proper storage to stabilize the contents and maintain their efficacy. Upon observation of the intravenous bag, Staff B confirmed that it was expired and should have been removed from the shelf. During a concurrent log review, Staff B confirmed the log was incomplete and was not acceptable. A review of the facility policy titled Storage of Medication, dated 9/18, indicated, Medications requiring refrigeration . are kept in a refrigerator with a thermometer to allow temperature monitoring . A temperature log or tracking mechanism is maintained to verify that temperature has remained within acceptable limits . Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555826 If continuation sheet Page 20 of 23 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 555826 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods, A Community of Seniors 40 Camino Alto Mill Valley, CA 94941 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 0867 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Based on interview and record review, the facility failed to develop comprehensive action plans for identification, analysis, correction, and evaluation of systemic care issues, including high-risk, high-volume concerns, and repeat survey deficiencies. This failure had the potential to precent timely recognition and improvement of care services that do not meet standards for quality for all 31 residents. Findings: A review of the facility's CASPER 3 ([Certification and Survey Provider Enhanced Reporting] a report compiled of survey findings that demonstrate the facility's performance) indicated a pattern of repeat deficiencies related to quality of care and falls, from 2018 to 2019. During an interview on 2/18/22 at 2:59 p.m., Staff A stated QAPI meetings were conducted at least quarterly. Staff A stated that while the pandemic and staffing turnovers were a big focus for the facility in the last year, Staff A confirmed falls continue to be part of the facility's QAPI projects. A concurrent review of the binder titled QAPI, indicated attendance sheets and meeting minutes for 2020 and 2021. Staff A stated a Falls Committee was started back in November 2020. However, when queried about details of the facility's QAPI plans to address falls, such as goals and metrics and progress evaluation, since the Falls Committee's inception, Staff A was unable to provide further information. When asked how the QAPI committee would be able to effectively monitor their efforts to improve care concerns without data tracking and methods to evaluate the effectiveness of interventions, Staff A stated, Yes, I understand that that's a concern. When queried if the QAPI committee has identified resident care planning as another high-volume concern, Staff A stated, Now we know. Staff A stated, The pandemic and staff turnovers, that transition really affected our projects. A review of the facility policy titled, Quality Assurance and Performance Improvement (QAPI) Program-Government and Leadership, dated January 2022, indicated, The responsibilities of the QAPI Committee are to: a. Collect and analyze performance indicator data and other information; b. Identify, evaluate, monitor and improve facility systems and processes that support the delivery of care and services . f. Establish benchmarks and goals by which to measure performance improvement; g. Coordinate the development, implementation, monitoring, and evaluation of performance improvement projects to achieve specific goals . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555826 If continuation sheet Page 21 of 23 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 555826 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods, A Community of Seniors 40 Camino Alto Mill Valley, CA 94941 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 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to develop and implement clinical criteria protocols, infection surveillance protocols, and antibiotic use protocols that promoted antibiotic stewardship. These failures had the potential for inconsistent and ineffective antibiotic stewardship (a coordinated program that promotes the appropriate use of antimicrobials [including antibiotics], improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms) services for all residents in the facility. Residents Affected - Some Findings: During an interview on 2/18/22, at 10:40 a.m., with Staff W, she confirmed she was the facility Infection Preventionist. Staff W stated she worked as a floor nurse 3 shifts a week. Staff W stated the other 2 days her priority was infection control. Staff W stated she was working on the facility's infection surveillance for December. Staff W stated she had not had time to complete January's surveillance. Staff W stated she would be verbally informed by the Director of Nurses (DON) if there was a new antibiotic order for a resident. The DON confirmed a verbal report was the facility process for identifying antibiotic use in the facility. During an interview on 2/18/22, at 10:45 a.m., with Staff W, she stated the admission nurse was expected to complete the antibiotic monitoring form for new residents. Neither Staff W or the DON could provide documentation to show floor nurses had been trained on McGeer criteria (an infection surveillance tool that looks at symptoms of infection), or any aspect of the antibiotic stewardship process. Staff W was unable to show documentation that all residents admitted with orders for antibiotics had reviewed for antibiotic stewardship. During an interview on 2/18/22, at 10:50 a.m., with Staff W stated the doctors decided if they wanted to use antibiotics or not. Staff W stated the facility sent out a letter that described the antibiotic stewardship process approximately 3 years ago. Staff W stated no further information had been passed onto the doctors. During a review of the facility policy and procedure titled, Antibiotic Stewardship dated 12/16, indicated the facility would monitor all residents on antibiotics. The policy indicated lab results would be communicated to the doctor to determine if antibiotic therapy should be started, continued modified or discontinued. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555826 If continuation sheet Page 22 of 23 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 555826 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/18/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Redwoods, A Community of Seniors 40 Camino Alto Mill Valley, CA 94941 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility failed to ensure 3 out of 5 sampled residents Residents Affected - Some (Resident 133 Resident 129 and Resident 28) immunization status was assessed and accurately documented in their medical record. These failures had the potential to result in higher risk for infection due to lack of immunization or side effects from an additional dose of vaccine been given. Findings: During a review of the Electronic Medical Record (EMR) for Resident 133, the pneumonia immunization status was blank. The EMR had no indication to show the facility had offered the vaccine. The EMR had no indication if Resident 133 was already vaccinated or had refused. During a review of the Electronic Medical Record (EMR) for Resident 28, the pneumonia immunization status was blank. The EMR had no indication to show the facility had offered the vaccine. The EMR had no indication if Resident 28 was already vaccinated or had refused. During a concurrent interview and record review, on 2/18/2,2 at 11:12 a.m., with Staff W, she reviewed Resident 28's immunization status and stated the pneumonia vaccine information was not where it should be. Staff W stated accurate assessment and documentation of vaccine status was not audited by the Infection Preventionist because there was not enough time. Staff W stated maybe Staff N completed audits. During a concurrent interview and record review, on 2/18/2,2 at 12:30 p.m., with Staff G, Resident 28's Immunization Status was reviewed. The pneumonia status was blank. Staff G reviewed Resident 28's physical chart and stated the pneumonia vaccine status was not in the physical chart. Staff G stated Resident 28's pneumonia status should be in the electronic record. During a review of the facility policy and procedure titled, Vaccination of Residents, dated 10/2019, indicated all residents would be offered vaccines unless the vaccine was medically contraindicated, or the resident had already been vaccinated. The policy indicated residents' refusal to a vaccine would be documented in their medical record. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555826 If continuation sheet Page 23 of 23