Health inspection·August 19, 2025

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 8/05/25, 8/06/25, 8/07/25 & 8/08/25 completed neurological assessments were documented for Resident 1 for morning, evening, and night shift, but the timing of the assessments was not documented.During an interview and concurrent record review on 8/18/25 at 3:26 p.m., the Director of Staff Development (DSD) stated after an initial fall, neuro checks were to be completed and documented Q [every] 15 mins. (minutes) x4 (4 times), Q30 mins. x2, Q2 hrs. (hours) x2, Q4 hrs. x2 and, Q shift for 24 hrs. on the resident's neurological assessment flowsheet. The DSD reviewed Resident 1's document, Neurological Assessment Flowsheet, dated 8/04-8/08/25, and confirmed the neuro sheet reflected Resident 1's recent fall on 8/04/25. The DSD stated she would expect Resident 1's vital signs and assessment to start at 7:20 a.m., when Resident 1's fall occurred, and then per protocol. The DSD further stated, I should have seen more Q15 checks prior to her [Resident 1] going out. There was a note that she [Resident 1] transferred at 8:05 a.m. [on 8/04/25]. It should have been documented that she [Resident 1] transferred at that time on the neuro check sheet, and after that- I would expect that the documentation would start from the beginning of the neuro check protocol when she returned. The DSD verified no specific times were documented for each neurological assessment on the neuro assessment sheet and instead, the timing of the assessments was documented as AM (morning), PM (evening) and NOC (night shift). The DSD stated, My expectation is that the times are documented, not the shift. The DSD confirmed the neurological assessments for Resident 1 were not up to her expectation. The DSD stated all resident vital signs were expected to be completed in the morning and evening, and documented at the time they were taken in the resident's electronic medical record.During an interview and concurrent record review on 8/19/25 at 1:28 p.m., the DSD reviewed Resident 1's document, Weights and Vitals Summary, and verified, based on the documentation, on 8/04/25, no vital signs were taken the morning of Resident 1's fall. The DSD confirmed vital signs documented on 8/05/25 at 2:30 a.m. was not during normal morning hours. The DSD confirmed vital signs documented on 8/05/25 was not documented again until the evening. The DSD confirmed there were no vitals signs documented on 8/06/25, and no morning vital signs documented on 8/07/25 and 8/08/25. The DSD stated, I would expect to see documentation of vital signs for the morning and evening every day, for all residents. The DSD stated she did not audit vital sign documentation, and further stated, It's something we are working on. I expect more. It's important to have more oversight so that a change of condition can be noted, or if a resident may need a higher level of medical attention- then we know what is going on. It's very important to stay on top of it. Say for example, with a head trauma- it's important to follow up. Visually, we don't actually see everything that is going on following a head trauma. If there are unseen issues related to a fall, especially one with head trauma, it could be detrimental to the resident.A review of the facility's undated document, Neuro Check Frequency for Falls, indicated, When neuro sheet started at the time of the fall: The nurse initiating the sheet will fill in all dates/times to ensure all nurses know when to do the neuro checks. [Assessments/Documentation] Q15x4, Q30x2, Q1 hour x2, Q2 hours x 2, Q4 hours x2, and Q Shift for 24 hrs.A review of the facility's policy and procedure (P&P) titled, Medical Record Documentation, dated 2024, indicated, .to ensure that pertinent information regarding each resident's course of care in the community is documented in the individual's medical record in an accurate, timely, and professional manner.Medical record documentation is currently a combination of an electronic record, as well as, manual (i.e. on paper).In general, all documentation should be completed as soon as possible after the respective event.A review of the facility's P&P titled, Accident Prevention/Mitigation and Response, dated 2025, indicated, As part of the post fall response.Conducting neuro-checks on the resident for a period of five (5) days.A review of the facility's document titled, RN/LVN CHARGE NURSE dated 2023, indicated, Charting and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555826 If continuation sheet Page 2 of 3 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 08/19/2025 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 0658 Level of Harm - Minimal harm or potential for actual harm Documentation.Enter the (EMR [electronic medical record]) data for residents.assessments.and all other assessments as they are due.Complete the entry of Incident reports and associated paper work. Follow established procedures. A review of the facility's undated document titled, Certified Nursing Assistant, indicated, Performs the following tasks.vital signs. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555826 If continuation sheet Page 3 of 3