Health inspection·July 29, 2025

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete verified the information on Resident 1s POLS, dated [DATE], and the MDS assessment section S, dated [DATE], did not match. The DON confirmed Resident 1's MDS assessment section S dated [DATE] was inaccurate. The DON stated the facility did not have a policy and procedure on MDS assessment. A review of the American Association of Post Acute Care Nursing article titled understand the MDS trickle-down effect dated [DATE], it indicated, . well maintained and accurate source of documentation . are essential for MDS accuracy. 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 07/29/2025 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure one resident (Resident 1) received treatment and care in accordance with the facility's Infection Control policy for influenza (flu- an illness caused by a virus [a germ] that is spread from person to person) when: Licensed Nurses (LNs) did not notify Resident 1's doctor (MD) that Resident 1 had symptoms of the flu and a report of Resident 1had been exposed to a family member who tested positive for flu; LNs did not notify the MD the facility ran out of flu tests; LNs did not place Resident 1 on droplet precautions (measures implemented to prevent the spread of infection when a person who is infected with a pathogen [germs that cause disease] coughs, sneezes, or talks);These failures resulted in Resident 1's hospitalization from 4/27/25 up to 5/6/25 where she was diagnosed with Influenza A and Acute Hypoxemic Respiratory Failure (AHRF, a serious condition where the respiratory system can't maintain adequate oxygen levels in the blood, potentially leading to organ dysfunction), received a new order for supplemental oxygen (additional oxygen to a person who is not receiving enough oxygen from the air they breathe), and decreased the facility's potential to prevent the spread of flu among other residents, visitors, and staff.Findings:A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] at the age of [AGE] years old.A review of Resident 1's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 4/27/25, indicated the primary reason for Resident 1's admission was due to a medically complex condition (a broad category of illnesses, diseases, or impairments that require extensive and ongoing medical care, often involving multiple body systems and comorbidities [simultaneous presence of two or more medical conditions in a patient]) including a diagnoses of chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing),.A review of Resident 1's admission Summary progress note, dated 4/24/25, indicated Resident 1 presented to the facility with stable (within normal limits [WNL] or acceptable ranges) vital signs (measurements of the body's most basic functions) including pulse (number of times the heart beats within a minute) at 94 beats per minute (bpm), and oxygen saturation level (O2 sata measurement of how much oxygen the blood is carrying as a percentage) at 94% without the use of supplemental oxygen.A review of Resident 1's nurse health status note, dated 4/24/25 at 4:06 p.m., indicated Resident 1's daughter notified Licensed Nurse (LN) A that Resident 1 had been exposed to a family member who tested positive for flu. The note also indicated Resident 1 had complained of sore throat and earache earlier that day.A review of Resident 1's nurse health status notes, for dates 4/24/25 and 4/25/25 did not indicate Resident 1's physician was notified that Resident 1 had been exposed to flu, had a reported symptom consistent with flu, and had not been tested for flu due to the facility not having flu testing supplies.A review of Resident 1's health status note, dated 4/26/25 at 9:56 p.m., indicated, [Resident 1's] daughter expressed concern regarding her mother's respiratory status. She requested that MD be notified regarding her concern that [Resident 1] may have flu.[with] [temperature] 98.7 [Fahrenheit, a unit of measure] ([Resident 1's] daughter notes that this is a high temp [temperature] for her mother.A review of Resident 1's health status note, dated 4/27/25 at 2:59 p.m., indicated, .[Resident 1] with elevated temp noted 99.1 [Fahrenheit].with episode of cough noted.family requesting to see MD; MD will be in on 4-28.A review of Resident 1's incident note, dated 4/27/25 at 11:30 p.m. indicated, .[Resident 1's] daughter called [facility] at approximately [4:30 p.m.] to report her concern that [Resident 1] had loose stools x2 [two times]. next call from [Resident 1's daughter] came after approximately one hour.that [Resident 1] had another loose stool.that [Resident 1] needed to be transferred to ‘the hospital' because ‘you are not doing anything for her'. [Resident 1] left [facility] with EMS [emergency Residents Affected - Few (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 07/29/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medical services] staff at approximately [7 p.m.].[Resident 1] had resisted having vitals taken.A review of Resident 1's incident note, dated 5/11/25, indicated, late entry /addendum for 4/27/25: assessment of time.Timing of [Resident 1's] discharge from [facility] with EMS Paramedic staff is now estimated to be between [9:15 p.m.] and [9:30 p.m.] .A review of the emergency department (ED, provides unscheduled outpatient services to patients whose condition requires immediate care) provider note, signed 4/28/25, indicated on 4/27/25 Resident 1 was, .[brought in by ambulance] from [skilled nursing facility] for concerns of flu.HR [heart rate, the number of times the heart beats per minute] 140s, [O2 sat] 92% . placed on [supplemental oxygen].Triage vital signs Temp 99 [Fahrenheit], Heart rate 153, [Respiratory Rate] 35, [O2 sat] 97% [on supplemental oxygen].presenting with shortness of breath. wheezing [a high-pitched sound made when breathing is restricted/obstructed in the lungs] and rhonchi [low-pitched, continuous, snoring or gurgling sounds heard in the lungs, resulting from mucus or other secretions obstructing the larger airways] present. Sepsis [a life-threatening response to infection] was present on arrival, specifically at [9:45 p.m.].ED diagnosis:1. Acute hypoxemic respiratory failure. 2. Influenza A. A review of Resident 1's Hospital Discharge summary, dated [DATE], indicated, . Date of admission: [DATE] Date of discharge: [DATE].Hospital summary.[Resident 1] with complain [sic] of shortness breath, sore throat, cough.Acute respiratory failure with hypoxia [condition with low oxygen] and hypercapnia [condition with high levels of carbon dioxide].Influenza A.COPD with exacerbation [worsening of a disease or its signs and symptoms]. Per [oxygen] eval, [Resident 1] will benefit from PRN [as needed] [supplemental oxygen] to keep [O2 sat] above 92% .[supplemental oxygen] has been ordered and will be delivered to [home health agency]. [Resident 1] influenza positive.COPD made worse by influenza a. discharge disposition: home with home health.During an interview on 7/29/25 at 10:20 a.m., LN A stated when a facility received a report that a resident was exposed to flu, [AD1] the facility would test the resident for flu as a precautionary measure. LN A acknowledged Resident 1 had not been tested for the flu at the facility because there were no flu test kits available. LN A stated that since there was no confirmation Resident 1 was positive for flu, Resident 1 could only be suspected of having the flu virus. LN A stated testing for flu was important to protect the residents and provide Resident 1 with the appropriate treatment. LN 1 clarified, when a resident tested positive for flu, the resident should be put on transmission-based precaution (TBP, an infection control measures used in healthcare settings to prevent the spread of pathogens that can be transmitted through contact with an infected patient, their body fluids, or contaminated surfaces or objects). LN A added placing a resident who tested positive for flu on TBP was for everyone's safety and to prevent outbreaks (a sudden increase in the number of cases of a disease in a specific area or population over a short period). During a concurrent interview and record review on 7/29/25 at 10:26 a.m. with the facility's Infection Preventionist (IP, a healthcare professional who specializes in preventing and controlling infections in healthcare settings), Resident 1's nurse health status notes, dated 4/24/25 through 4/25/25, were reviewed. The IP verified Resident 1's daughter had reported that Resident 1 was exposed to flu. The IP stated that since the family member told the facility staff Resident 1 was exposed to flu, the facility staff should have tested Resident 1 for flu. The IP stated the flu test was not done on Resident 1 because the facility ran out of flu tests. The IP stated it was important to do the flu test to determine Resident 1 flu status and to provide appropriate treatment. The IP verified the nurse health status notes dated 4/24/25 through 4/25/25 did not indicate the MD was notified Resident 1 was exposed to flu, suspected of having flu since she reported a symptom consistent with flu, or that the facility was unable to test Resident 1 for flu virus due to facility's lack of flu test. The IP verified, Resident 1's electronic health (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 07/29/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete record did not indicate Resident 1 was placed on any TBP.During a concurrent interview and record review on 7/29/25 at 11:21 a.m., with the IP, the facility's policy and procedure (P&P) titled Infection Control PlanInfluenza, dated 02/2024 was reviewed. The IP verified that based on their flu plan, which the facility follows, Resident 1 was considered a suspect for flu and should have been tested for flu, placed on droplet precautions and immediately started on antiviral medication. The IP confirmed that none of those actions were done for Resident 1. The IP stated it was important to test Resident 1 for flu to know her flu status and to be able to treat her right away. The IP stated placing Resident 1 on droplet precaution ensures the safety of everyone and could help prevent outbreaks.During a concurrent interview and record review on 7/29/25 at 11:50 a.m. with the Director of Nursing (DON), Resident 1's nurse health status notes from 4/24/25 through 4/27/25 and Resident 1's electronic medication administration record (EMAR, a digital system used to track and document the administration of medications, ensuring accuracy and timeliness in medication delivery) for April 2025 was reviewed. The DON verified Resident 1 should have been tested for flu upon report she had been exposed to flu and was symptomatic but was not tested due to lack of a flu test kit. The DON verified that when Resident 1 was admitted on [DATE] and up to the time Resident 1 was sent out to the hospital on 4/27/25, Resident 1 was not tested for flu, did not receive any antiviral medications nor was placed on droplet TBP. The DON confirmed Resident 1 was sent to the ED due to concern from Resident 1's daughter that Resident 1's condition was worsening and the belief that the facility was not taking care of Resident 1. The DON verified the facility's flu policy and procedure (P&P) was not followed, since Resident 1 was suspected of flu, Resident 1 should had been tested for flu, should have been placed on droplet TBP and should have been started on antiviral medication.A review of the facility's P&P titled Infection Control Plan-Influenza (Residents/Patients), last reviewed on 2/2024, the P&P indicated, .Healthcare clinic infection control lead and clinical staff will evaluate, observed or report residents with symptoms and implement daily surveillance and/or testing and symptoms screening.LTC [long term care] residents who have confirmed or suspected influenza should receive antiviral treatment immediately as antiviral treatment works best when started within the first 2 days of symptoms.communications/notifications to residents physicians.A review of the Center for Disease Control and Prevention (the national public health agency for the United States) document titled, Treating Flu with Antiviral Drugs, dated 9/11/24, indicated, .Treatment of flu with flu antiviral medications works best when started within 1-2 days after flu symptoms begin. Flu antiviral drugs can lessen symptoms and shorten the time you are sick. It's very important that flu antiviral drugs are started as soon as possible to treat patients who are. at increased risk of serious flu complications based on their age or underling health conditions, if they develop flu symptoms. For example, people with asthma and chronic lung disease. Event ID: Facility ID: 555826 If continuation sheet Page 5 of 5