Health inspection·April 23, 2025

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on observation, interviews and record reviews, the facility failed to provide written notice of transfer to the Long-Term Care Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) for two out of two sampled residents (Resident 1 and Resident 2), when they were transferred to the hospital in March of 2025 without the Ombudsman being notified. These failures could result in loss of residents ' advocacy and protection and prevent innapropriate transfers and discharges. Findings: During an interview on 4/23/25 at 3:14 p.m., the Director of Staff Development (DSD) stated she was not sure if the nurses were completing a written notice of transfer when residents were discharged or transferred to the hospital. The DSD also stated she was not sure whether the Ombudsman needed to be notified when residents were transferred to the hospital. During an interview on 4/23/25 at 3:30 p.m., the Administrator (Admin) stated she was not sure if the facility had to complete a written notice of transfer and notify the Ombudsman when residents were transferred to the hospital. The Admin stated as far as she knew, the Ombudsman did not need to be notified when residents get transferred or sent to the hospital. During an interview on 4/23/25 at 3:33 p.m., Licensed Nurse (LN) C stated she had discharged and transferred residents to the hospital but had never completed a notice of transfer nor had she notified the Ombudsman when residents were transferred to the hospital. LN C stated she was not aware they have to notify the Ombudsman if a resident was being transferred or discharged to the hospital. LN C stated the Ombudsman should be notified to protect residents ' rights. During an interview on 4/23/25 at 3:36 p.m., LN D stated she had discharged and transferred residents to the hospital but had never completed a notice of transfer. LN D stated she also had never notified the Ombudsman of any residents ' transfers to the hospital. LN D stated she was not aware the Ombudsman should be notified when residents ' gets transferred or discharged to the hospital. LN D stated the Ombudsman should probably need to be notified of residents ' discharges or transfers to the hospital to protect residents ' rights and assist residents with their needs. During an interview on 4/23/25 at 3:37 p.m., the Social Services Director (SSD) stated she oversaw notifying the Ombudsman of residents ' discharges however the SSD added, she had never notified the Ombudsman of any residents' transfers to the hospital. SSD stated she was not aware the facility had Page 1 of 2 555826 555826 04/23/2025 The Redwoods, A Community of Seniors 40 Camino Alto Mill Valley, CA 94941

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to notify the Ombudsman of residents ' transfers to the hospital. The SSD stated the Ombudsman should be notified of transfers and discharges to protect residents ' rights and to help prevent inappropriate discharges. During a telephone interview on 4/24/25 at 3:23 p.m., the Director of Nursing (DON) verified there was no notice of transfer completed nor had the Ombudsman been notified when Resident 1 was transferred to the hospital on 3/31/25 and when Resident 2 was transferred to the hospital on 3/30/25. A review of the facility ' s policy and procedure (P&P) titled Transfer and Discharge, last reviewed 7/2024, the P&P indicated, .Notice Before Transfer or discharge: In all cases of transfer or discharge, the resident/patient, their representative/responsible party (if applicable) .the State Long-Term Care (LTC) Ombudsman shall also be notified in accordance with applicable regulatory requirements . A review of the All Facilities Letter (AFL 17-27), dated 12/26/2017, indicate, . The facility must send notice to the local LTC Ombudsman for any transfer or discharge that is initiated by the facility . 555826 Page 2 of 2