Health inspection·May 25, 2023

F 0726 Level of Harm - Actual harm staff members who assisted Resident 1 back to his wheelchair. Licensed Staff C stated she called the MD1 and contacted the Resident ' s Representative after the fall. Licensed Staff C stated MD1 ordered an X-ray (picture) of Resident 1 ' s right femur but Resident 1 ' s pain was escalating so MD1 requested Resident 1 be transferred to the hospital immediately instead of waiting for Xray. Residents Affected - Few During an interview on 3/30/23 at 3:40 p.m., with Licensed Staff B, she stated, she was the primary nurse for Resident 1 on 3/24/23 at 8 a.m. Licensed Staff B stated on 3/24/23 around 8:00 a.m. she was busy passing medications to other residents when she heard Licensed Staff C call for help in room [ROOM NUMBER]. Licensed Staff B stated, when she entered the room, the nurses light was not on, and she saw Resident 1 lying on the floor in the bathroom. Licensed Staff B stated, she performed a neurological evaluation, and she asked Resident 1 if he hit his head and Resident 1 responded, no. Licensed Staff B stated Resident 1 ' s neurological exam was normal, so they moved Resident 1 back to his wheelchair. Licensed Staff B stated Resident 1 has a diagnosis of dementia and when staff instruct him to put on his call light on if he needs to get out of bed or another task Resident 1 forgets what you have instructed him to do. Licensed Staff B stated Resident 1 has a Wander guard but that doesn ' t help if he is getting out of bed when he doesn ' t put his nurses light on. During a review of Resident 1 ' s medical records, Post Fall Investigation dated, 3/24/23, authored by Licensed Staff B, indicated, resident lost his balance, found on floor alone and unattended, confused and disoriented at the time, and no meds given in last 8 hours. During an interview with Resident 1 ' s Family Representative on 3/30/23 at 4 p.m., Family representative expressed concerns that Resident 1 did not have his walker in his room for a few days before the fall that occurred on 3/24/23. Family Representative stated, she noticed that the staff at this facility are spread thin. When family representative queried if Resident 1 was using the walker to ambulate, she said no, he uses the wheelchair but sometimes transfers and pivots with the walker. During an interview with Resident 1 on 3/30/23 at 4:10 p.m., Resident 1 was queried by this surveyor if he knew where he was? Resident 1 said no. Resident 1 queried by this surveyor if he remembered falling recently. Resident 1 responded; no. Resident 1 queried by this surveyor if he knew who the Family Representative was standing next to his bed, Resident 1 smiled and said, yes. This surveyor noticed a yellow sign at the left side of Resident 1 ' s bed. The sign was observed to have written on it, Dad, don ' t get up, you have a broken leg. Family Representative stated, he forgets his leg is broken and tries to get up. During an interview with Unlicensed Staff E at 4/3/23 at 11 a.m., Unlicensed Staff E stated, he is employed directly by a health care agency and was filling in that day when Resident 1 fell. Unlicensed Staff E was queried by this surveyor about Resident 1 ' s fall and he stated, I had 8 residents at the time of breakfast and had to make sure they got their meals on time. Unlicensed Staff E stated, he had 2 residents who required me to feed them. Unlicensed Staff E stated, I was in the dining room with my back to Resident 1 while I was feeding Resident 3. Unlicensed Staff E stated, Resident 1 apparently left the dining room while my back was turned toward Resident 1 when I was busy feeding Resident 3. Unlicensed Staff E stated, he did not see Resident 1 leave the dining room. Unlicensed Staff E queried if there were any other staff assisting him in the dining room? Unlicensed Staff E responded yes, there was another CNA (Certified Nursing assistant) from the agency in the dining room off and on because he was also handing out breakfast trays. Unlicensed Staff E stated, Unlicensed Staff D was busy feeding Resident 2. Unlicensed Staff E stated Resident 1 has Dementia and is very forgetful and left the dining room when he was instructed to wait until someone could take him back to his room. Unlicensed Staff E queried by this surveyor if he had any Dementia training with his (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555826 If continuation sheet Page 2 of 5 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 05/25/2023 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 0726 current employer within the last year and he responded, no. Level of Harm - Actual harm During an interview with Unlicensed Staff D on 4/4/23 at 1:10 p.m., Unlicensed Staff D stated, he works directly for an agency and comes to work at the facility sometimes. Unlicensed Staff D stated, there was only Unlicensed Staff E and me in the dining room and we both had residents to feed and other residents to pass breakfast trays to on the unit. When Unlicensed Staff D was queried as to Resident 1 whereabouts after Resident 1 left the dining room, Unlicensed Staff D stated, I saw him in the hallway wheeling himself back to his room. Unlicensed Staff D stated, he asked him what do you want to do? Unlicensed Staff D stated, Resident 1 responded, he wanted to go to bed and take a nap, so I helped him back to bed. Unlicensed Staff D stated, he had to feed Resident 2, so he told Resident 1 to put his light on if he needed to get up. Unlicensed Staff D stated he had heard about Resident 1 ' s fall later on in his shift but was not involved with Resident 1 when it occurred. Unlicensed Staff D queried by this surveyor if he had any training in Dementia? Unlicensed Staff D stated, no, I just know residents with Dementia forget a lot. Residents Affected - Few During a review of Resident 1 ' s records, an email dated 4/3/23, authored by Unlicensed Staff I, indicated the facility has, no Dining Observation Policy but it is a standard practice to have staff (Licensed Nurse and Certified Nursing Assistant) present in the dining room during meals. During a review of Resident 1 ' s Neurological Assessment Flow Sheet, dated 3/24/23, authored by Licensed Staff B, Flow Sheet indicated Resident 1 ' s Neurological Assessment immediately following his fall were within normal limits. During a review of Resident 1 ' s MDS, Section C, dated 3/3/23, authored by Licensed Staff H, BIMS 9, Recall 1, Resident is a 2 person assist for transfers, Toilet use Resident is a 2 person assist. During a review of Resident 1 ' s Care Plan dated, 2/27/23, no Dementia interventions were noted for monitoring of safety precautions for Resident 1 ' s decrease memory recall of staff instructions as it pertains to ambulation and transfers. During a review of Resident 1 ' s Physical Therapy Note, dated 3/23/24, authored by Licensed Staff G, indicated Resident 1, was weight bearing as tolerated but Resident 1 demonstrates ability to weight bear only partially on right lower extremity due to right hip pain. Precautions: Fall risk and Dementia. During a review of Resident 1 ' s Interdisciplinary Note, dated 3/24/23, authored by DON, This morning Resident 1 attempted to self-transfer from wheelchair to the bathroom and fell, and landed on the same surgical side. A staff from nearby location heard the noise and ran to check and found the resident was already on the floor lying on this right side. At first the doctor ' s advice to get an Xray and applied Lidocaine patch to area. Nursing applied Lidocaine patch and ice immediately to area of pain. The resident also received Tylenol 100 mg and Oxycodone 5 mg. Then the doctor decided to send the resident to the ED instead, for further evaluation. Family was also notified. Nursing staff called ED (emergency department) instead, for further evaluation. Nursing staff called ED and found that the resident had re-injured previously repaired right hip fracture. Per resident ' s son, a surgical procedure is scheduled on the next day. During a review of Resident 1 ' s nurses note, dated 3/29/23, authored by Licensed Staff F, indicated, admitted from hospital via Gurney after stay in the hospital due to right hip fracture post fall 3/24/23. Current Conditions indicate, Cognitive status: Alert with confusion and forgetfulness (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555826 If continuation sheet Page 3 of 5 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 05/25/2023 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 0726 Level of Harm - Actual harm During a review of the facility ' s policy and procedure titled, Sufficient and Competent Staffing, dated 2/2023, indicated, it is the policy of The Redwoods, A community of Senior to provide sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and facility assessment. Residents Affected - Few Applicable Redwoods personnel will develop, implement, and maintain an effective training program for all new existing staff; individuals providing services under a contractual arrangement; and volunteers, consistent with their expected roles. We determine the amount and types of training necessary based on their facility assessment. Definitions: Staff: Includes employees, consultants, contractors, volunteers, caregivers who provide care and services to residents on behalf of the facility. Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident ' s plan of care. Personnel hired for positions in this facility shall meet the qualification of the job or be trained to perform those duties. Training Program: Competency Based Education and Training is defined as a measurable pattern of knowledge, skills, abilities, behaviors, communication abilities to perform specific tasks and assignments with success. A continuing competency-based education program is conducted for all staff at the facility, to promote and measure specific competencies and skill sets necessary to provide related services to meet resident needs, safety of the resident while considering the resident ' s choices, rights, physical, mental, and psychosocial well-being based on the facility assessment. Orientation and ongoing training and competency will include, but not be limited to (as applicable to job duties) Resident rights and facility responsibilities, person-centered care, behavioral health, care of the cognitively impaired and dementia management. Pertinent information pertaining to staffing in the facility (e.g., turnover trends, staffing levels, CMS data NNPPD data, etc.) shall be routinely reviewed at the QAA Committee meetings. On an as-needed basis, the committee may initiate performance improvement projects in response to negative trends/patterns. During a review of facility ' s policy and procedure titled, Accident Prevention / Mitigation and Response, dated, 1/2023, indicated, It is the policy of The Redwoods to the extent possible/feasible/practicable ensure that the environment remains free of accident hazards, make proactive efforts to eliminate or reduce the risk of accidents occurring in the facility, provide each resident with adequate supervision and assistance devices so as to prevent accidents, as well as to comprehensively respond when an accident occurs. Avoidable Accidents: means that an accident occurred because the facility failed identify environmental hazards and/or assess individual resident risk of an accident, including the need for supervision and/or assistive devices; and/or Evaluate analyze the hazards and risks and eliminate them, if possible, or , if not possible, identify and implement measures to reduce the hazards/risks as much as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555826 If continuation sheet Page 4 of 5 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 05/25/2023 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 0726 Level of Harm - Actual harm Residents Affected - Few possible, and / or Implement interventions, including adequate supervision and assistive devices, consistent with a resident ' s needs, goals, care plan and current professional standards of practice in order to eliminate the risk, if possible, and, if not, reduce the risk of an accident; and or monitor the effectiveness of the interventions and modify the care plan as necessary, in accordance with current professional standard of practice. Personnel shall conduct/complete routine and as-needed safety walks/inspections/audits of the facility. In general, all staff are responsible for identifying, reporting, and/or resolving any hazards/unsafe conditions within the facility. Based on previous evaluations and current data, the staff will identify interventions related to the resident specific risks and causes to try to prevent the resident from falling and to try to minimize complication from falling. The nursing staff, in conjunction with the attending physician, consultant, pharmacist therapy staff and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan abased on relevant passement information. The staff, with the support of the attending physician, will evaluate functional psychological factors that may increase fall risk, including ambulation, mobility, gait, balance, excessive motor activity, activities of daily living capabilities, activity tolerance, continence, and cognition. The staff, with the input of the attending physician will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555826 If continuation sheet Page 5 of 5