Health inspection·September 27, 2023

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure 1. staff knew the correct time frame for reporting abuse allegations and injury of unknown source (source of the injury was not observed by any person; the source of the injury could not be explained by the resident; and the injury is suspicious because of the extent of the injury or the location of the injury) to the state, the Ombudsman (a person who investigates, reports on, and helps settle complaints) and the local law enforcement. 2. staff knew what injury of unknown source was 3. staff knew who to report abuse allegations and injury of unknown source 4. there was an SOC 341 (a form that documents the information given by the reporting party on the suspected incident of abuse) and 5 day investigative summary report completed for a report on injury of unknown source for one out of three sampled residents (Resident 1) 5. the facility provides in its reports, sufficient information to describe the allegation of abuse for two out of 3 sampled residents (Residents 2 and 3) and indicate what was the results of this investigations. These failures could lead to late reporting of abuse allegations and injury of unknown source, abuse to continue, inability to recognize injury of unknown source and injury to worsen. Findings: During a review of Resident 1 ' s face sheet (demographics), it indicated she was [AGE] years old with a diagnoses of Essential Hypertension (high blood pressure that is not due to another medical condition) and Displaced fracture- a break in the bone of the greater trochanter of right femur-thigh bone). Her Minimum Data Sheet Assessment (MDS, a standardized assessment tool that measures health status in nursing home residents) dated 9/5/2023, Brief Interview for Mental Status Assessment (BIMS, a screen used to assist with identifying a resident's current cognition and to help determine if any interventions need to occur) score was 9 indicating moderately impaired cognition (the conscious and unconscious processes involved in thinking, perceiving, and reasoning). Resident 1 needed limited to extensive assist of 1 to 2 staff when performing her Activities of Daily Living (ADLs, activities related to personal care. They include bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating). Resident 1 ' s X-ray (a type of radiation called electromagnetic waves. X-ray imaging creates pictures of the inside of your body) result on 9/9/23, indicated she had a new dislocation of the right hip arthroplasty. Staff did not know the source of this injury. During a review of Resident 2 ' s face sheet, it indicated she was [AGE] years old with a diagnoses of Essential Hypertension, Hyperlipidemia (an elevated level of lipids - like cholesterol and triglycerides - in your blood) and Obstructive Sleep Apnea (a disorder in which a person frequently stops breathing during his or her sleep). Her Minimum Data Sheet assessment dated [DATE], BIMS score was 8 indicating moderately impaired cognition. Resident 2 needed limited to extensive assistance of 1 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 555826 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 09/27/2023 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)