Other·August 7, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during a RECERTIFICATION SURVEY. Representing the California Department of Public Health were Health Facilities Evaluator Nurses #35842 and #39792. Census on the date of entry, 12/10/18, was 51. There were 13 sampled residents. Incorporated in the survey process was Facility Reported Incident: CA00609895 and CA00586915 - Substantiated with no deficiency. An IMMEDIATE JEOPARDY (IJ) was identified on 12/12/18 at 12:10 p.m. under Resident Rights: 483.10, F584. Administrative Staff A and Consultant H were notified in the Administrator's office of the IJ on 12/12/18 at 1:56 p.m. The IMMEDIATE JEOPARDY was abated on 12/13/18 at 1:49 p.m. Administrative Staff A was present in the Administrator's office when the IJ was abated. Substandard Quality of Care was identified under Resident Rights: 483.10, F 584. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 1 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F557 Respect, Dignity/Right to have Prsnl Property CFR(s): 483.10(e)(2)

F557 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 03/05/2019 §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure each resident was treated with dignity and respect when 1 of 13 sampled residents: 1. (Resident 6's) primary language of Chinese was not addressed and 2. Resident 6 was not provide a homelike environment when she was observed lying in bed in a hospital gown for three consecutive days with the overhead light shining on her face, and was not provided a radio and/or television, and no pictures and/or other personal effects. This had the potential to decrease Resident 6's quality of life by placing Resident 6 at risk of sensory deprivation, depression, social isolation, further cognitive decline, failure to thrive for a vulnerable resident, and compromise residents' physical and psychosocial well-being. Findings: A review of Resident 6's "Admission Record," dated 12/13/13, and "History and Physical," dated 11/23/14, indicated Resident 6 had diagnosis including Alzheimer's (progressive mental deterioration), cerebrovascular accident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 2 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (CVA) disease (stroke), contractors (deformity of limbs due to the result of stiffness or constriction in the connective tissues of your body causing loss of motion), dysphagia (difficulty in swallowing) following CVA, aphasia (loss of ability to understand or express speech) following CVA, muscle weakness, etc. and her primary language was Chinese. 1. During a review of Resident 6's Quarterly MDS (minimum data set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 9/12/18, indicated Resident 6's cognitive skills (core skills your brain uses to think, read, learn, remember, reason, and pay attention for daily decision making) were severely impaired (never/rarely made decisions). Review of Resident 6's care plan indicated she was "Care Planned" for: 1. "Impaired Cognitive Function/Dementia (describes a group of symptoms associated with a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) or Impaired Thought Process," initiated 8/31/15 and 2. "Communication Problem Related to Language Barrier, mostly Aphasia and seldom makes clear word, but may produce audible sounds," initiated 12/9/16, indicated interventions included: a. Anticipate routinely and meet needs, b. The resident need total assist with all decision making, and c. Be conscious of resident positioning when you greet her, speak directly in front of her with clear tone. Do not rush, she usually acknowledge with a smile. Resident 6's care plan did not address her primary language of Chinese and how the staff would assure communication, so Resident 6 understood while care was taking place. There was no mention of using cue cards. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 3 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview on 12/18/18 at 10:38 a.m., Administrative Staff D stated she did have cue cards in Chinese, which she used to communicate with Resident 6. Administrative Staff D stated Resident 6's son stated she has never talked much. Administrative Staff D stated there was still a person inside, even if Resident 6 was severely cognitively impaired. Administrative Staff D stated Resident 6 should have been care planned for her primary language being Chinese. Administrative Staff D stated the facility did not have any staff member who spoke Chinese and could communicate with Resident 6. During multiple observations from 12/10/1812/20/18, no staff member spoke Chinese to Resident 6 or used cue cards when caring for Resident 6. The facility policy/procedure titled, "Transactional and/or Interpretation of Facility Services," dated 1/18, indicated it is understood that in order to provide meaningful access to services provided by this facility, translation and/or interpretation must be provided in a way that is cultural/ relevant and appropriate to the limited English proficiency. 2. A review of Resident 6's care plan for "Cognitive Function/Dementia or Impaired Thought Processes," date initiated 8/31/15 and revised 8/1/17, indicated interventions included provide resident with a homelike environment During an observation on 12/10/18 at 12:51 p.m., Resident 6 was sound asleep, dressed in a hospital gown, and positioned on her left side. Resident 6's roommate stated Resident 6 had a stroke and never got up. The overhead light was shining on Resident 6's face. There FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 4 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE was no television, radio, or pictures or other personal belongs in Resident 6's room. During an observation on 12/10/18 at 4:21 p.m., Resident 6 was positioned on her left side with the overhead light shining on her face. During an interview on 12/11/18 at 10:01 a.m., Licensed Staff O stated Resident 6 did not get up very often, but she was repositioned every 2 hours and she received bolus PEG [(percutaneous endoscopic gastrostomy) a tube feed given like a meal in a short period of time via way of PEG: placement of a tube through the abdominal wall and into the stomach through which nutritional liquids can be infused] every 6 hours. During an observation on 12/11/18 at 1:00 p.m., Resident 6 was in bed, wearing a hospital gown, and positioned on her left side. There were no pictures in her room and/or other personal items, and no television in her room or radio for music. Resident 6's opened her eyes and moaned when spoken to. During a concurrent observation and interview on 12/12/18 at 9:33 a.m. Resident 6 was dressed in a hospital gown and positioned on her back in bed with the bright overhead light shining on her face. Resident 6's legs were very contracted and she had a hand towel in her left hand, which was very contracted. Licensed Staff P stated Resident 6 wore lower leg splints and a right arm splint; legs very contracted. Splints were not on. Licensed Staff P stated the RNA [Restorative Nursing Assistant: a program where RNA's provide specific treatments to residents to restore and maintain the strength, coordination and skills to ambulate (walk) and perform functional activities of daily living (ADLs)] will put them on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 5 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE during the day shift and the splints will be removed on the PM shift. Licensed Staff P stated Resident 6 was transferred to a wheelchair a few hours a day, but leaned forward in her wheelchair, so she was in bed most of the time. When Licensed Staff P was asked why Resident 6 did not have a television in her room, Licensed Staff P stated Resident 6 used to reside in another room, which had a television, but she did not respond to the television. During a concurrent observation and interview on 12/13/18 at 12:30 p.m., Resident 6 was dressed in a hospital gown and was wearing a splint to the right wrist and bilateral lamb's wool boots from lower legs to feet. Resident 6 had dried nasal mucus noticeable in her left nostril. Licensed Staff P stated Resident 6 was up yesterday afternoon in her wheelchair and resided in the hallway and the PM shift put her back to bed. Licensed Staff P stated the Activities Director did room checks on Resident 6. Resident 6's room did not look homelike: no television, radio for music, no pictures on the walls and/or other personal items/belongings. During an observation on 12/13/18 at 2:34 p.m., Resident 6 was positioned on her back in bed with her head elevated at a 20 degree angle. The bright overhead light was shining on her face. Surveyor had not seen Resident 6 out of bed in the past 3 days and Resident 6 did not have television, a radio for music, and there were no personal effects, such as pictures in Resident 6's room. During an observation on 12/14/18 at 9:51 a.m., Resident 6 was sound asleep in bed with the bright overhead light shining on her face. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 6 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 6 was wearing a sweat shirt, but she had been wearing a hospital gown for the past 3 days (12/10-12-13/18). During an interview on 12/14/18 at 11:00 a.m., Administrative Staff N stated, "No, Resident 6's room was not homelike: no television, no music, and no pictures. The staff gets her up twice a week due to she will scream if gotten up." Administrative Staff N stated, "Resident 6's roommate will not leave you alone when I go into talk to Resident 6. Resident 6 needs one on one for activities. There is also a language barrier - She speaks Chinese." During an observation on 12/19/18 at 10:08 a.m., Resident 6 was up in a wheelchair, which reclines, and in activities. Yesterday (12/18/18) she was observed up in a wheelchair watching the children's choir. Resident 6 has been calm and surveyor has not heard Resident 6 moan or become agitated while up. The facility admission agreement titled, "California Standard Agreement for Skilled Nursing Facilities and Intermediate Care Facilities," undated, indicated "A facility must care for its resident in a manner and in an environment that promotes, maintenance or enhancement of each resident's quality of life. (a) Dignity: The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality" (p. 76). The facility policy/procedure titled, "Quality of Life-Homelike Environment," 1/18, indicated: 1. Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible, 2. the facility staff and management shall maximize to the extent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 7 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Comfortable (minimum glare) yet adequate (suitable to the task) lighting, b. Personalized furniture and room arrangements, etc.

F584 SS=L Safe/Clean/Comfortable/Homelike Environment F584 CFR(s): 483.10(i)(1)-(7) 03/05/2019 §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 8 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.10(i)(3) Clean bed and bath linens that are in good condition; §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2) (iv); §483.10(i)(5) Adequate and comfortable lighting levels in all areas; §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and §483.10(i)(7) For the maintenance of comfortable sound levels. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure a comfortable and sanitary environment when: 1. Multiple residents (Resident 1, 2, 9, 10, 11, 12, 16, 23, 27, 29, 34, 37, 39, and 50) out of 51 residents complained of being cold inside the facility for weeks, and the facility did not maintain comfortable facility temperatures ranging from 71 to 81 degrees Fahrenheit (°F). On 12/12/18 at 1:56 p.m., due to the facilities failure to provide comfortable facility temperature, Administrative Staff A and Consultant H were verbally notified of the Immediate Jeopardy. The Health Facilities Evaluator Nurses informed Administrative Staff A and Consultant H of the interviews with residents complaining of being cold and facility thermometer indicating the temperatures in three of three hallways were 75 °F. Multiple temperature readings were obtained by FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 9 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Administrative Staff A, and three of out three hallways did not indicate 75 °F. "Immediate Jeopardy is a situation in which a provider's noncompliance with one or more requirements of participation has caused or is like to cause serious injury, harm impairment or death to a resident" (Standard Operation Manual, Appendix Q). On 12/13/18, at 11:02 a.m. the facility presented a corrective plan of action, including but not limited to: 1) servicing heating system, 2) relocating the three thermostats to the approximate middle point of each hallway, 3) installing thermometers in each resident room and increasing the outflow of heat for entire facility. On 12/13/18 at 11:05 a.m., the abatement (lifted) of Immediate Jeopardy occurred in the presence of Administrative Staff A after interviews and observations confirmed the facility implemented the corrective plan of actions. Administrative Staff A understood the facility would continue to complete plan of action to replace the heating and airconditioning system. On 12/13/18 at 11:35 a.m. Administrative Staff A, Consultant H and Consultant L were notified of substandard quality of care identified and the facility was on extended survey. "Substandard quality of care means one or more deficiencies related to participation requirements under 42 CFR 486.10 resident rights that constitute to immediate jeopardy to resident health or safety (level J, K or L)" (Standard Operation Manual, Appendix P) These failures had the potential to cause: a) Resident's susceptibility to loss of body heat FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 10 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and risk of hypothermia (medical emergency that occurs when your body loses heat faster than it can produce, causing dangerous low body temperature) or susceptibility to respiratory ailments and colds, b) immobility issues related to not wanting to get out of bed due to the cold, c) Cross-contamination and spread an infection among residents, and d) negatively impact residents comfort and homelike environment 2. Multiple resident toilets were clogged with feces on a routine basis as indicated in the maintenance logs for the previous six months. This resulted in discomfort with room environment due to the smell, loss of dignity due to reaction of staff regarding fixing the issue and potential infection control related to feces in a standing toilet for a time period. 3. Two resident room's (Room 11 & 26) privacy curtains where soiled. This failure had the potential to cause cross-contamination and spread the infection if touched by a resident and/or staff member. 4. Multiple residents were effected by soiled and/ or sticky floors (Room 1, 6, 8, 9, 10, 11, 17, 23, 24, & 25). This failure had the potential to create an infection control issue due to soiled floors, potential safety issue with ambulating on sticky and/or soiled floors, and loss of a comfortable homelike environment. 5. Two resident's (Resident 13 & 29) had dirty wheelchairs, which had the potential to cause cross-contamination and spread the infection related to touching a dirty wheelchair, and loss of comfortable homelike environment. 6. Two resident rooms (Room 9 & 11) wall's had missing plaster and paint, and the walls were dirty. This failure had the potential to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 11 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE negatively impact residents' comfort and homelike environment. Findings: 1. During a concurrent observation and interview on 12/10/18 at 12:52 p.m., Room 11 felt very cold. Resident 34 stated she was very cold. Resident 34 stated. "Do you see, I have 7 blankets on me. Administrative Staff A controls heat located in his office." During a concurrent observation, and record review on 12/10/18 at 12:52 p.m., Room 11 felt very cold. Resident 6 was asleep, wearing a hospital gown, and was covered with a sheet and a light weight blanket. A review of the clinical record for Resident 6, the "Admission Record," dated 12/13/13, and Resident 6's "History and Physical", dated 11/23/14, indicated Resident 6 had a diagnosis including Alzheimer's (progressive mental deterioration), cerebrovascular accident (CVA) disease (stroke), contractors (deformity of limbs due to the result of stiffness or constriction in the connective tissues of your body causing loss of motion), dysphagia (difficulty in swallowing) following CVA, aphasia (loss of ability to understand or express speech) following CVA, muscle weakness, etc. and her primary language was Chinese. During a concurrent observation and interview on 12/10/18 at 12:54 p.m., Room 12 felt very cold. Resident 10 stated she had no complaints except being cold. Resident 10 was wearing pajamas and had multiple blankets on her bed. During a concurrent observation and interview on 12/11/18 at 1:54 p.m., Room 11 felt very cold. Resident 34 was in bed and had multiple layers of clothing and had 7 blankets on the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 12 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE bed. Resident 34 stated the room was extremely cold and she felt very cold. During concurrent interviews and observations at Resident Council on 12/11/18 at 9:25 a.m., Residents stated the rooms were cold and uncomfortable. Resident 9 stated it was "freezing" and indicated it was always freezing. Resident 9 was observed wearing two T-shirts, thick sweatpants and a thick pull over sweatshirt. Residents 39, 2 and 50 agreed with the rooms being uncomfortably cold. Resident 39 was observed dressed in thick sweatpants, a hooded sweatshirt and jacket. Resident 2 was dressed in pants, shirt, sweater and two blankets draped over her wheelchair. Resident 50 was observed wearing jeans, a t-shirt, sweatshirt and jacket. Resident 27 and 29 were asked if it felt cold, stating it's "darn cold" in this place. Resident 27 was observed wearing sweatpants, with a sweatshirt and jacket. Resident 29 was observed wearing jeans, Tshirt, sweatshirt and jacket. Resident 11 stated she always felt cold and was observed wearing pajamas, sweatshirt and thick bathrobe. During a concurrent interview and observation on 12/12/18 at 9:02 a.m., Administrative Staff K observed to measure temperatures in the "East Wing" of the facility, by using a laser thermometer. Room 11 was 65.5 °F and Resident 34 stated she was very cold and observed to have multiple blankets on her bed. During concurrent interviews and observations, on 12/12/18 at 9:07 a.m., Administrative Staff A indicated he wanted to measure the temperatures in each "Resident Room" rather than Administrative Staff I. Administrative Staff A held the laser thermometer and measured multiple points of each room. *Room 12 measured between 58 to 65 °F. *Room 9 measured 65 °F. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 13 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE *Room 8 measured 68 °F. *Room 6 measured 67.5 °F. *Room 5 measured between 62 -67.5°F. *Room 3 measured 69°F. Resident 11, who was observed to be in bed, stated she always felt cold. *Room 4 measured between 66.5 and 70 °F. *Room 1 measured 66 to 69°F. Resident 2 stated she was cold. During concurrent interviews and observations on 12/12/18 at 9:20 a.m., Administrative Staff A measured room temperatures in the "South Wing" of the facility: *Activity Room measured 66 to 67°F. Resident 9 was observed sitting at a table, and stated he was cold. *Room 27 measured 59 to 63°F. Resident 37 stated he was cold, and was wearing a sweatshirt, knit cap and flannel pajama pants. Resident 29 stated he was cold, and was wearing blue jean pants, multiple T-shirts and a coat. During concurrent interviews and observations on 12/12/18 at 9:25 a.m., Administrative Staff A measured resident rooms in the "West Wing" of the facility: *Room 23 measured 61.5 to 67°F. Resident 12 was in bed, wearing a knit cap, pajamas and sweatshirt. Resident 12 stated she was very cold. Resident 23 was observed in bed with multiple blankets, and stated she was very cold. Resident 23 became anxious during the encounter when she thought she might have to get out of bed complaining of the cold. * Room 24 measured 64 to 67°F. Resident 1 was observed to be in bed wearing jeans, Tshirt, sweatshirt and jacket. Resident 1 stated he was cold. *Room 20 measured 63°F to 68°F. Resident 16 stated, "It can get cold here." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 14 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview on 12/12/18 at 9:55 a.m., Administrative Staff A was asked for a policy addressing the temperature ranges for resident rooms. Administrator A indicated he was not aware of the existence of such a policy. During a concurrent observation and interview on 12/12/18 at 10:30 a.m., Room 12 felt cold. Resident 10 stated the room was very cold. Resident 10 was wearing pajamas and had multiple blankets on her bed. During an interview on 12/12/18 at 10:36 a.m., Administrative Staff I stated each hallway had its own thermostat and the surveyor was escorted to the Director of Nursing's (DON) office where three thermostats were located next to each other on the wall labeled, East Hallway, South Hallway and West Hallway. The East Hallway thermostat indicated the temperature was 75°F and if the temperature dropped below 71°F, the heater would turn on. Administrative Staff I escorted the surveyor to the main desk area, (proximal to the intersection of all three hallways) just outside of the DON office and measured 69.8°F. Administrative Staff I measured the East Hallway, 70.9°F at the beginning, 68.5°F middle and at the end under the Exit sign, measured 64.5°F. Administrative Staff I, in the South Hallway measured 69.6°F at the beginning, 69.2°F in the middle and the end of the hallway under the Exit sign 65.5°F. Administrative Staff I measured the beginning of West Hallway 69.8°F, the middle 69.9°F and the end of the hallway under the Exit sign 67.4°F. During a concurrent observation and interview on 12/12/18 at 10:47 a.m., Administrative Staff I and surveyor were in the East Hallway. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 15 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE hallway felt very cold and Administrative Staff I stated, "The temperature was dropping the closer we traveled toward Room 11 and 12," which were located across the hall from one another, and right and left of the Exit door. During an interview on 12/12/18 at 10:52 a.m., Licensed Staff P stated the East Hallway was always cold. Licensed Staff P stated she was running around and always needed to wear a sweater. During an interview on 12/12/18 at 11:56 a.m., Unlicensed Staff K stated the East Hallway felt cold to her. Unlicensed Staff K stated, "I feel real cold right now." During interview on 12/12/18 at 1:56 p.m., Administrative Staff A and Consultant H met with surveyors. Consultant H stated when their company acquired the facility, the previous owners were supposed to fix the heating/air conditioning unit, but it did not happen. Consultant H stated the facility had applied to OSHPD (Office of Statewide Health Planning and Development: improves access to quality healthcare for Californians. They ensure hospital buildings are safe, etc.) for a permit to have a new system installed back on 8/31/18. During observations on 12/14/18 at 3:38 p.m., Surveyors checked on where the thermostats were relocated from the DON's office to the three hallways and how the thermostats were mounted to the wall. *Thermostat relocated to West Hallway was anchored by drywall screws, *Thermostat relocated to East Hallway was anchored by drywall screws, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 16 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE *Thermostat relocated to South Hallway was anchored by dry wall screws. During an interview on 12/14/18 at 3:52 p.m. Administrative A was asked with the presence of Consultant L, if he called OSHPD for an "Emergency Permit" before drilling into the drywall in order to relocate the three thermostats in the varies hallways. Administrative A stated, "No I did not." During an interview on 12/14/18 at 4:17 p.m., Surveyors met with Administrative Staff A and Consultant L regarding the OSHPD Project # S181202-21-00 (General Repairs Project), not meeting the HVAC (Heating, Ventilation, and Air Conditioning) requirements, no mention of HVAC for OSHPD Project # S181202-21-00. Administrative Staff A stated he would research further to find out a project number consistent with the HVAC scope of changing a whole new system over. Consultant L stated, "I do not know if corporate has a copy of the project number." Administrative Staff A stated, "This was all above my pay grade, but I will call and get a number that includes the HVAC project." During an interview on 12/14/18 at 5:02 p.m., conference call with Administrative Staff A, Consultant L, and surveyors on the phone with Consultant Y. Consultant Y stated OSHPD Project # S181202-21-00 (General Repairs Project) related to General Maintenance, but was comprised of two phases. The Phase I was described as removal of the duct work and Phase II would be re-install all new duct work and the new cooler and heater. At 17:04 p.m. Consultant Y transferred phone over to Consultant Z. Consultant Z stated there was a non-compliance of the HVAC system and the "General Repair" consisted of lighting, generator annunciator panel (group of lights used as a central indicator of status of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 17 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE equipment or systems in an industrial process, building, etc.) and duct work. Consultant Z was asked if there was another project number since the project number did not state HVAC work was being done. Consultant Z stated there was no other "number" (project number) to reference the HVAC work. Three times Consultant Y and Consultant Z were asked if there was a "project number" containing HVAC work, and both stated there was not an additional project number and both kept insisting the number being discussed contained the HVAC information. At 5:45 p.m. Consultant L presented a document with the project number, OSHPD "Project # S181202-21-00," indicating the Project Description: 1. Demo (3) condensing units and ductwork (previously installed), 2. Install generator annunciator at nurse station (previously installed), and 3. Replace (14) light fixtures in corridor (previously installed). During a concurrent observation and interview on 12/18/18 at 11:38 a.m. Room 12's wall thermometer read 68 degrees Fahrenheit. Resident 10 stated she felt cold. Resident 10 had just woken up and was sitting on the side of the bed. She was wearing pajamas, had a hospital gown over the pajamas, and socks. The facility Policy/Procedure (P/P) titled, "Quality of Life-Homelike Environment,"1/18, indicated, "The facility staff and management shall maximize...clean, sanitary and orderly environment,...comfortable and safe temperatures." The facility P/P titled, "Ambient Temperature," 1/18, indicated, "Ambient temperature (71 °F -81 °F) will be maintained at comfortable and safe temperature level." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 18 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 2. During an observation on 12/10/18 at 5:20 p.m., Administrative Staff I stated the toilet in Room 24 was clogged and could not explain the large amount of feces located in toilet bowl. Administrative Staff I stated the size of the resident did not coincide with amount of feces in the toilet bowl and the conversation continued with Administrative Staff A. Resident 27 stated he hoped with future toilet issues he would not be made to feel badly regarding the back up and amount of feces. There was no acknowledgement or response to Resident 27's comment from Administrative Staff A or Administrative Staff I. The maintenance logs available from 5/27/18 to 11/26/18 indicated the following: Date Description of issue 7/11/18 Room 14: toilet not working 7/21/18 Room 18: bathroom leaking gasket 9/29/18 Room 17 to 15: toilet is broken 10/15/18 Room 17-19: toilet does not flush 10/28/18 Room 2: toilet bowl will not flush Administrative Staff I stated the toilet issues were related to paper towels and other objects being flushed inappropriately down, causing the back up. Administrative Staff I could not state a plan to communicate these issues to the staff and residents in order to further prevent toilet clogging. Administrative Staff I stated he did not routinely enter resident rooms, since he had a maintenance person on site to handle most issues. Administrative Staff I stated when he was hired there was training on how to deal with resident population of the facility and agreed the conversation between himself and Administrative Staff A on 12/10/18 was not respectful to residents who lived in the facility. The facility P/P titled, "Quality of Life-Homelike Environment," dated 1/18, indicated "The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 19 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility staff and management shall maximize,..Clean, sanitary and orderly environment...." During a review of the job description titled, "Maintenance Director", dated 10/19/15, Maintenance Director was to, "Maintains the building...free of hazards such as those caused by ...plumbing...systems etc." and "Puts Customer Service First: Ensures that customers and families receive the highest quality of service in a caring and compassionate atmosphere...". 3. During a concurrent observation and interview on 12/11/18 at 1:54 p.m., Room 11's privacy curtain between A and B bed had a brown smear and the walls were dirty. Resident 34 stated the room has never been deep cleaned. During a concurrent observation and interview on 12/18/18, Room 26's privacy curtain between A and B bed had a red/brownish smudge. Resident 37 stated he thought it was from his bloody nose. Resident 37 indicated the smudge was approximately a week old. The facility P/P titled, "Quality of Life-Homelike Environment," dated 1/18, indicated "The facility staff and management shall maximize,..Clean, sanitary and orderly environment...." 4. During a concurrent observation and interview on 12/10/18 at 10:34 a.m., Room 1's linoleum floor was audibly sticky. Resident 2 stated she felt the staff needed to clean the room better for her health. During an observation on 12/10/18 at 10:56 a.m., Room 6's linoleum floor was audibly sticky. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 20 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During a concurrent observation and interview on 12/10/18 at 12:27 p.m., Room 10's linoleum floor was peeling, dirty and was audibly sticky. Resident 41 stated there was lack of cleaning in her room. During an observation on 12/11/18 at 10:18 a.m., Room 8's linoleum floor looked dirty, multiple spots throughout flooring. During a concurrent observation and interview on 12/11/18 at 1:54 p.m., Room 11's linoleum floor around the baseboards had a build-up of dust/dirt. During a concurrent observation and interview on 2/12/18 at 11:56 a.m., Room 9's linoleum floor was audibly sticky. When Unlicensed Staff K was asked if the floor felt sticky, Unlicensed Staff K stated, "Yes, a lot of the resident floors are sticky. She thinks it has something to do with the housekeepers mop head." During a concurrent observation and interview on 12/13/18 at 1:28 p.m., Room 6's linoleum floor was audibly sticky, dirty, and the linoleum was cracked and tiles were pulling apart at the seams. Resident 17 stated she asked the housekeeper to mop the floor, but she only stocked gloves; housekeeper had not cleaned the room yet. Resident 17 stated the Certified Nursing Assistants will give her a sponge bath and place the dirty towels and bagged briefs on the floor, so the floor needed to be mopped. During multiple observations on 12/13/18, 12/14/18 and 12/18/18, Room 25's floor next to Bed B was audibly sticky. When Resident 32 was asked if he could hear the shoe sticking to the floor, he nodded, "Yes," but could not tell surveyor how long the floor had been sticky since he did not get out of bed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 21 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During multiple observations on 12/13/18, 12/18/18 and 12/19/18, Room 17's floor, near Bed A, was audibly sticky. When Resident 24 was asked if she could hear the shoe sticking to the floor, resident 24 could not indicate how long the floor had been sticky since she did not get out of bed unless it was "Bingo day". During multiple observations on 12/13/18, 12/14/18 and 12/15/18, Room 23's floor near Bed A was audibly sticky when walking past the bed. During multiple observations on 12/11/18, 12/13 and 12/15/18, Room 24's floor was audibly sticky when walking into and around the room. The facility P/P titled, "Quality of Life-Homelike Environment, dated 1/18, indicated, "The facility staff and management shall maximize,..Clean, sanitary and orderly environment...." During an interview on 12/14/18 at 10:00 a.m., Housekeeper Q with interpreter (Unlicensed Staff R) stated she had a Deep Cleaning schedule. Housekeeper Q stated she cleaned every room daily and deep cleaned one room per day per cleaning schedule. Housekeeper Q stated she was going to deep clean Room 9, but she was not able to because the resident in 9 A did not want to leave her room, so she would do the daily cleaning of Room 9. Housekeeper Q stated when she deep cleaned a room, she cleaned the following: *Cleaned mattresses using Air Fresh spray *Removed privacy curtains and had them cleaned *Windows were cleaned *Tables FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 22 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE *Baseboards *Dusted entire room *If she had to clean a room under isolation precautions, she would disinfect the entire room. *Solutions used: One-Step Disinfectant, which had Ammonia Chloride in it Air Fresh for mattresses and furniture Window Cleaner/multi-surface non-ammonia cleaner Review of the facility's "Deep Cleaning Schedule." indicated Room 9 was to be cleaned on Thurs (12/13/18), not Fri (12/14/18). When asked why the rooms felt so sticky, Unlicensed Staff R stated it was because the wax was coming off the linoleum and the linoleum was peeling in the rooms. The residents' floors were very old, wax was worn and linoleum was chipping/peeling. 5. During an observation on 12/11/18 at 3:07 p.m., Resident 13 was up in her wheelchair located in the dining room. Resident 13's wheelchair was very dirty; food particles were all over the cushion part of the armrests. During multiple observations on 12/11/18, 12/12/18 and 12/13/18, Resident 29's wheelchair was dirty with food crumbs, general dirt and grime. Resident 29 was not aware how to get his wheelchair cleaned since it was an electric one and he just received it. During an interview on 12/11/18 at 9:30 a.m., Administrative Staff D stated that there had been a new maintenance person who was reasonable to clean the wheelchairs. The schedule was to clean the wheelchairs once a week but the Administrative Staff D person FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 23 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicated employment had stared in November 2018 and trying to become more familiar in the role. 6. During an observation on 2/11/18 at 1:00 p.m., Room 9's wall, right of window and wall next to 9 A's bed had missing plaster and paint. During an observation on 12/11/18 at 1:54 p.m., Room 11's vent screen right of the bathroom door was dirty with missing paint and walls were dirty. The facility P/P titled, "Quality of Life-Homelike Environment, dated 1/18, indicated, "The facility staff and management shall maximize,..Clean, sanitary and orderly environment...." During an interview on 12/14/18 at 12:08 p.m., Administrative Staff A stated there was no policy for cleaning rooms and/or deep cleaning rooms. Administrative Staff A stated if a privacy curtain became soiled it was up to any person (Administrator, nursing staff, residents, etc.) who saw the soiled privacy curtain to notify housekeeping, so the privacy curtain could be changed. Administrative Staff A stated wheelchairs had not been cleaned for the past two months; the person who used to clean the wheelchairs quit a few months ago. Administrative Staff A stated there was a cleaning schedule for resident wheelchairs, and the wheelchairs were scheduled to be cleaned weekly. During an interview on 12//20/18 at 10:20 a.m., when Administrative Staff A was asked who oversaw housekeeping, he stated, "Right now I oversee housekeeping." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 24 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F623 Notice Requirements Before Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8)

F623 SS=E PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State LongTerm Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 25 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 26 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to send a copy of " Notice of Discharge" to the representative of the Office of the State Long-Term Care (LTC) Ombudsman [a public advocate (official) is an official who is charged with representing the interests of the public by investigating and addressing complaints of maladministration or a violation of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 27 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE rights] for ten unsampled residents (Resident 49, 51, 53, 54, 55, 56, 57, 58, and 59), who were discharged to home and Resident 52, who was discharged to a skilled nursing facility. This failure had the potential for Resident 49, 51, 52, 53, 54, 55, 56, 57, 58, and 59 being inappropriately discharged and not being provided an advocate who could inform them of their rights and options if they were not ready to be discharged home or did not want to be transferred to another skilled nursing facility. Findings: During an interview on 12/04/18 at 3:37 p.m., Ombudsman W stated often the facility would not send the Ombudsman's office a "Notice of Resident Discharge or Transfer." The facility did not have any standard notification form and if the facility did notify the Ombudsman's office about a resident being discharged or transferred, the facility would fax them the information. A record review of Resident 49's "Notice of Transfer/Discharge - V 4," dated 11/27/18 and "Progress Notes," dated 11/27/18, indicated Resident 49 was discharged on 11/27/18, but there was no indication a "Notice of Discharge" was sent to the Ombudsman's office prior to Resident 49's discharge. During a concurrent record review and interview on 12/14/18 at 5:40 p.m., when Administrative Staff D was asked if the Ombudsman's office was notified about Resident 49's discharge to home prior to her being discharge; she could not find paperwork indicating the Ombudsman's office was notified. Administrative Staff D stated prior to the resident being discharged, she would have the resident sign their "Notice of Transfer/Discharge - V4" document and then FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 28 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE she would fax the document to the Ombudsman's office, which indicated the date the resident was going to be discharged. The Ombudsman's office would call her to confirm the Ombudsman's office received the Transfer/Discharge notice. Administrative Staff D stated she would have proof the "Notice of Transfer/Discharge - V 4" document was sent by the "Transmission Verification Report" indicating the date and time on the "Cover Letter." Administrative Staff D had the "Discharge" binder, but no record of notifying the Ombudsman. A review of Resident 51's "Notice of Transfer/Discharge - V 4," dated 10/26/18, and "Progress Notes," dated 10/26/18, indicated Resident 51 was discharged to home on 10/26/18. A review of Resident 53's "Notice of Transfer/Discharge - V 4," dated 10/1/18, and "Progress Notes," dated 10/2/18, indicated Resident 53 was discharged to home on 10/2/18. Resident 52's "Notice of Transfer/Discharge - V 4," dated 10/17/18, and "Progress Notes," dated 10/17/18, indicated Resident 52 was discharged to a skilled nursing facility on 10/17/18. There was no record found indicating the Ombudsman's office was notified about Resident 51's, 53's, and 52's discharge. A review of Resident 54's "Notice of Transfer/Discharge - V 4," dated 9/13/18, and "Progress Notes," dated 9/13/18, indicated Resident 54 was discharged to home on 9/13/18. The faxed cover sheet for Resident 54's notice to the Ombudsman's office was dated 9/14/18, but she was discharged on 9/13/18. A review of Resident 56's "Notice of Transfer/Discharge - V 4," dated 6/28/18, and "Progress Notes," dated 6/28/18, indicated Resident 56 was discharged to home on 6/28/18. The faxed cover sheet for Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 29 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 56's notice to the Ombudsman's office was dated 7/6/18, but he was discharged on 6/28/18. Review of Resident 57's "Notice of Transfer/Discharge - V 4," dated 6/13/18, and "Progress Notes," dated 6/13/18, indicated Resident 57 was discharged to home on 6/13/18. Review of Resident 58's "Notice of Transfer/Discharge - V 4," dated 6/19/18, and "Progress Notes," dated 6/19/18, indicated Resident 58 was discharged to home on 6/19/18. The faxed cover sheet for Resident 58's notice to the Ombudsman's office was dated 7/6/18, but she was discharged on 6/19/18. Review of Resident 59's "Notice of Transfer/Discharge - V 4," dated 6/17/18, and "Progress Notes," dated 6/17/18, indicated Resident 59 was discharged to home on 6/17/18. The faxed cover sheet for Resident 59's notice to the Ombudsman's office was dated 7/6/18, but he was discharged on 6/17/18. Residents 54, 56, 58, and 59's Notice of Transfer/Discharge were all sent after the residents were discharged. There was no proof the "Notice of Transfer/Discharge - V 4" document was sent to the Ombudsman's office for Resident 54, 56, 57, 58, and 59 because there was no "Transmission Verification Report" indicating the date and time on the "Cover Letter." During a review of Resident 55's "Notice of Transfer/Discharge - V 4," dated 6/28/18, and "Progress Notes," dated 6/28/18, indicated Resident 55 was discharged to home on 6/28/18. The faxed cover sheet for Resident 55's "Notice of Transfer/Discharge" to the Ombudsman's office was dated 7/6/18 and the "Transmission Verification Report" located on the faxed cover sheet, indicated the "Notice of Transfer/Discharge" was sent to the Ombudsman's office on 7/5/18 at 1:57 p.m. Resident 55 was discharged from the facility on 6/28/18. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 30 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview on 12/18/18 at 9:31 a.m., Administrative Staff D stated the "Notice of Transfer/Discharge" needed to be sent to the Ombudsman's office prior to the resident being discharged from the facility. Administrative Staff D stated Resident 51's, 52's, 53's, 54's, 55's 56's, 57's, 58's, and 59's "Notice of Transfer/Discharge" should have been sent to the Ombudsman's office prior to the residents' charge. During an interview on 12/19/18 at 8:35 a.m., Administrative Staff D stated the reason why the Ombudsman's office was notified about a resident being discharged prior to the resident's discharge was so the Ombudsman could be an advocate for the resident, which included: 1. checking to see if the discharge was a safe discharge, 2. making sure the family was aware of the discharge, 3. the resident was not being discharged to the street or back to the hospital just to get rid of the resident, 4. the discharge was a planned discharge with discharge orders in place, etc. A document titled "All Facility Letter (17-27) Summary," dated 12/27/17, based on Health and Safety Code (HSC) section 1439.6, which indicated Long Term Care (LTC) facilities were to notify the local LTC Ombudsman at the same time notice is provided to the resident or resident's representatives when a facilityinitiated transfer or discharge occurred. The facility must send a notice to the local Ombudsman for any transfer or discharge that is initiated by the facility, whether or not the resident agrees with the facility's decision. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 31 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F641 Accuracy of Assessments CFR(s): 483.20(g)

F641 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 02/22/2019 §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to accurately reassess and update a care plan for 1 sampled resident (Resident 6) for: 1. Activities of Daily Living Assistance [(ADL): daily self-care activities. ... Common ADLs include feeding ourselves, bathing, dressing, grooming, transfer, etc.) and 2. activities. This failure had the potential to cause: 1. inadequate care to prevent Resident 6 from being transferred (how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position) safely, which could lead to resident falling and being severely injured and 2. decrease Resident 6's quality of life by placing her at risk of sensory deprivation, social isolation, further cognitive decline, or failure to thrive for a vulnerable resident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 32 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: A review of Resident 6's "Admission Record," dated 12/13/13, and "History and Physical," dated 11/23/14, indicated Resident 6 had a diagnosis including Alzheimer's (progressive mental deterioration), cerebrovascular accident (CVA) disease (stroke), contractors (deformity of limbs due to the result of stiffness or constriction in the connective tissues of your body causing loss of motion), dysphagia (difficulty in swallowing) following CVA, aphasia (loss of ability to understand or express speech) following CVA, muscle weakness, etc. and her primary language was Chinese. 1. Resident 6's Quarterly MDSs (minimum data set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems) dated 3/12/18 and 6/12/18, both indicated Resident 6 needed a one person physical assist with transfer (how a resident moves between surfaces including to or from bed, chair, and wheelchair. Resident 6 was a total dependent on bathing and needed one person physical assist. Resident 6's Care Plan for ADLs, initiated 8/31/15, indicated Resident 6 was totally dependent on two staff for transferring and one person assist with showering. During an interview on 12/14/18 at 12:45 p.m., Unlicensed Staff J stated staff did not use a Hoyer Lift (a device used for transfers when a person requires 90-100% assistance to get into and out of bed) to transfer Resident 6. Unlicensed Staff J stated Resident 6 was a two person transfer to the wheelchair and shower chair. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 33 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview on 12/14/18 at 12:50 p.m. and 1:30 p.m., Unlicensed Staff K stated Resident 6 was very stiff and took two people to transfer to and from her wheelchair and to give a shower. Unlicensed Staff K stated she would not risk transferring Resident 6 or giving her a shower without another staff member assisting her for the safety of Resident 6. Unlicensed Staff K stated Resident 6 was very contracted and was non-weight bearing. During an interview on 12/14/18 at 1:20 p.m., Administrative Staff F stated Resident 6 was a one person assist, but she was a total dependent; she could not stand. Administrative Staff F stated a male CNA (Certified Nursing Assistant) could transfer Resident 6 by them self, but Administrative Staff F stated she could not. Administrative Staff F stated, "I guess that was assessed inaccurately." Administrative Staff F stated it would be safer if Resident 6 was transferred with a two person assist. Administrative Staff F stated the information she gathered to complete the resident's MDS assessment included looking at the CNAs' task assessment, nurses' and physician progress notes, talking to the CNAs and nurses, observing the resident's care and doing a physical assessment on the resident. 2. A review of Resident 6's Quarterly MDS, dated 9/12/18, indicated Resident 6's cognitive skills (core skills your brain uses to think, read, learn, remember, reason, and pay attention for daily decision making) were severely impaired (never/rarely made decisions). A review of Resident 6's "Activity Assessment - V 1," dated 11/7/18, indicated Resident 6 was able to let the activities director know the following activities were very important to her: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 34 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1. use a phone in private, 2. take care of her personal belongings and a place to lock and to keep her things safe, 3. have books, newspapers, and magazines to read, 4. listen to music, 5. be around animals, 6. keep up with the news, 7. to do things with groups of people, 8. to do her favorite activities, 9. get outside in the fresh air, 10. participate in religious activities, 11. choose her own clothes, 12. have a tub bath, shower, bed bath, or sponge bath, choose her own bed time, and 13. snacks available between meals (Resident 6 received her nutrition via way of a gastrostomy tube [(also called a G-tube) is a tube inserted through the abdomen that delivers nutrition directly to the stomach]. A review of Resident 6's Annual MDS, dated 11/11/18, indicated Resident 6 was not able to let the activities director know "Daily and Activity Preferences." The Staff Assessment of Daily and Activity Preferences was done by the activities director, which included: 1. receiving shower, 2. receiving bed bath, 3. staying up past 8:00 p.m., and 4. reading books, newspapers, or magazines. Resident 6's Quarterly MDS, dated 6/12/18, indicated Resident 6's vision was severely impaired (no vision or sees only light colors or shapes, eyes do not appear to follow objects) and her Quarterly MDS, dated 9/12/18, indicated Resident 6 rarely/never understood others. Resident 6's primary language was Chinese, but there was nowhere on her care plan addressing Chinese as her primary language. During an interview on 12/18/18 at 10:38 a.m., Administrative Staff E stated she did not know why the "Activity Assessment V 1," dated 11/7/18, was filled out indicating Resident 6 was able to be interviewed about her "Daily and Activity Preferences," because she was severely cognitively impaired and her primary FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 35 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE language was Chinese. Administrative Staff E stated although Resident 6 was severely cognitively impaired, she was still a person and should be care planned accordingly. Administrative Staff E stated she did not fill out the "Activity Assessment V 1," which was filled out wrong. Administrative Staff E stated no staff member spoke Chinese, but she used cue cards to communicate with Resident 6, which all staff should have been using. Administrative Staff E stated Resident 6 should have been care planned for her primary language being Chinese. The facility policy/procedure titled, "Comprehensive Plan of Care," dated 4/05, indicated care plan evaluation must occur in response to changes in the resident's physical, emotional, functional psychosocial, or communicative status as they occur, etc. The facility document titled, "HR Manual: Job Description - RN Assessment/MDS Coordinator, revised 10/19/15, indicated 1. The Position Summary included the coordination of appropriate participating health professionals (interdisciplinary team: a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the patient) for the purpose of conducting initial and periodical comprehensive, accurate assessments of each resident to plan care that allows the resident to reach his/her highest practicable level of physical and mental and psychosocial functioning. 2. Responsibilities/Accountabilities: Develops and maintains a flow of communication that enhances the expected positive resident outcome, includes but is not limited to: Ensuring exchange of essential information necessary for the accurate completion of resident assessments, etc. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 36 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F655 Baseline Care Plan CFR(s): 483.21(a)(1)-(3)

F655 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 02/22/2019 §483.21 Comprehensive Person-Centered Care Planning §483.21(a) Baseline Care Plans §483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must(i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to(A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 37 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan(i) Is developed within 48 hours of the resident's admission. (ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section). §483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure staff initiated an accurate Baseline Care Plan for Bowel and Bladder for one of 13 sampled residents (Resident 17), when Resident 17 was assessed upon admission as being continent of bowel and bladder, but was admitted to the facility with an indwelling Foley catheter (a flexible tube that is inserted through the urethral and into the bladder to drain urine) and an ileostomy (a surgical operation in which a piece of the ileum (third portion of the small intestine) is diverted to an artificial opening into the abdominal wall). This failure had the potential for Resident 17's ileostomy and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 38 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indwelling Foley catheter to not be cleaned and cared for appropriately, which could result in a UTI (Urinary Tract Infection) and/or skin breakdown. Findings: A review of Resident 17's "Admission Record," dated 9/27/18, indicated Resident 17's diagnosis included multiple sclerosis (disabling disease of the central nervous system that disrupts the flow of information within the brain, spinal cord, and optic nerves in your eyes. It can cause problems with vision, balance, muscle control, etc.), paraplegia ( loss of muscle function in the lower half of the body), encounter for attention to ileostomy , encounter to colostomy (surgical procedure that brings one end of the large intestine out through the abdominal wall), retention of urine, etc. A review of "Physician Progress Notes," dated 9/28/17, indicated Resident 17 was admitted with a Foley catheter and ileostomy. A review of "Nursing Progress Notes," dated 9/27/18, indicated Resident 17 was admitted to the facility with a Foley catheter and a colostomy. During a concurrent observation and interview on 12/10/18 at 10:58 a.m., Resident 17 had a Foley catheter bag hanging on the side of the bed covered. Resident 17 stated she has had a colostomy for 2 years due she had a bad infection and a Foley catheter for 1 1/2 years due to retention of urine. Review of Resident 17's "Baseline Care Plan V-2," dated 9/28/18, indicated Resident 17 was continent of urine and stool. There was no assessment of Resident 17 being admitted to the facility with a Foley catheter and an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 39 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ileostomy. During a concurrent interview and record review on 12/19/18 at 12:10 p.m., Consultant T stated Resident 17's Baseline Care Plan was inaccurate for bowel and bladder. The care plan should have indicated Resident 17 was admitted to the facility with a Foley catheter and a colostomy. The facility document titled, "HR Manual: Job Description - RN Assessment/MDS Coordinator, revised 10/19/15, indicated Responsibilities/Accountabilities: Administrative: Develops and maintains a flow of communication that enhances the expected positive resident outcome, includes but is not limited to: Ensuring exchange of essential information necessary for the accurate completion of resident assessments, and Supervision: Conducting record reviews and staff meetings as delegated by the Director of Nursing, as it relates to resident assessment in order to provide input and feedback on facility provision of quality of care.

F656 SS=E Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 03/05/2019 Facility ID: CA220000075 If continuation sheet 40 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 41 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE by: Based on interview and record review, the facility failed to have an individualized care plan for 4 of 13 sampled residents (Resident 6, 9, 22, and 32) when: 1. Resident 32 was not care planned for the RNA (Restorative Nursing Assistant: a program where RNA's provide specific treatments to residents to restore and maintain the strength, coordination and skills to ambulate (walk) and perform functional activities of daily living (ADLs) 2. Resident 6 and Resident 22 were not care planned for: a. her primary language of Chinese and b. for one on one room visit by Activities to meet the needs of a resident whose diagnosis included severely cognitively impaired(never/rarely made decisions) following a CVA (cerebrovascular accident (stroke: when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or ruptures)), 3. Resident 9 was not care planned for weight loss, and 4. Resident 32 was not care planned for weight gain. The lack of care plans had the potential to: 1. Decrease Resident 6's and Resident 22 quality of life by placing her at risk of sensory deprivation, depression, social isolation, further cognitive decline, failure to thrive for a vulnerable resident, and compromise residents' physical and psychosocial well-being. 2. Decreased Resident 9's quality of life by not being able to consume appropriate amount of calories for weight gain, loss of enjoyment around meal times related to distaste of food, loss of strength for mobility and loss of dignity related to not providing an individualized plan of care related to offering palatable food choices for example, likes and dislikes. 3. Decreased Resident 32's quality of life as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 42 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE evidenced by excessive weight, lack of activity options, increased blood sugar levels and lack of nutritional monitoring plan to manage weight loss with healthy appetizing menu options reducing the desire to order take-out food. Findings: 1. A review of Resident 6's "Admission Record," dated 12/13/18, and "History and Physical," dated 11/23/14, indicated Resident 6 had a diagnosis including Alzheimer's (progressive mental deterioration), cerebrovascular accident (CVA) disease (stroke: occurs when blood flow to an area of brain is cut off. When this happens, brain cells are deprived of oxygen and begin to die. When brain cells die during a stroke, abilities controlled by that area of the brain such as memory and muscle control are lost). How a person is affected by their stroke depends on where the stroke occurs in the brain and how much the brain is damaged), contractors (deformity of limbs due to the result of stiffness or constriction in the connective tissues of your body causing loss of motion), dysphagia (difficulty in swallowing) following CVA, aphasia (loss of ability to understand or express speech) following CVA, muscle weakness, etc. and her primary language was Chinese. a. A review of Resident 6's Quarterly MDS (minimum data set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 9/12/18, indicated Resident 6's cognitive skills (core skills your brain uses to think, read, learn, remember, reason, and pay attention for daily decision making) were severely impaired (never/rarely made decisions). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 43 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of Resident 6's "Care Planned" for: 1. "Impaired Cognitive Function/Dementia (describes a group of symptoms associated with a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities) or Impaired Thought Process," initiated 8/31/15 and 2. "Communication Problem Related to Language Barrier, mostly Aphasia and seldom makes clear word, but may produce audible sounds," initiated 12/9/16, indicated interventions included: a. Anticipate routinely and meet needs, b. The resident needed total assist with all decision making, and c. Be conscious of resident positioning when you greet her, speak directly in front of her with clear tone. Do not rush, she usually acknowledge with a smile. Resident 6's care plan did not specify her primary language of Chinese and how staff would assure communication, so Resident 6 understood while care was taking place. There was no mention of using cue cards. During multiple observations from 12/10/1812/20/18, no staff member spoke Chinese to Resident 6 or used cue cards when caring for Resident 6. During a clinical record , Resident 22, "Admission Record," dated 9/28/18, indicated she was a native Chinese speaker and was admitted for physical rehabilitation after undergoing surgical repair for a broken hip. The medical record indicated Resident 22 was living with her brother but her brother had become sick and could no longer take care of her. The plan of care changed from short term rehabilitation to long term care. During an interview on 12/11/18 at 12:17 p.m., Resident 22 indicated she was a non-native English speaker and difficult to understand due FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 44 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to her thick accent. Resident 22 would speak English and then insert words from another language making it difficult to track her train of thought. Resident 22's "Plan of care," dated 9/30/18, did not incorporate her native Chinese language nor the interventions for Resident 22 to participate in activities and make her needs known to staff. The facility policy/procedure titled, "Transactional and/or Interpretation of Facility Services," dated 1/18, indicated it is understood that in order to provide meaningful access to services provided by this facility, translation and/or interpretation must be provided in a way that is cultural/ relevant and appropriate to the limited English proficiency. b. During a review of Resident 6's Annual MDS (minimum data set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 12/11/18, indicated Staff Assessment of Daily and Activity Preferences were: 1. receiving showers, 2. receiving bed bath, 3. receiving sponge baths, 4. staying up past 8 p.m., and reading books, newspapers, or magazine. Review of Resident 6's "Care Plan" for "Activities," initiated 10/11/18, focus indicated Resident 6 had no activity involvement relate to immobility: Physical limitations and cognitive impairment. Activity interventions, initiated 12/9/16 and revised 8/1/17, included Resident 6 was to be up in wheelchair daily as tolerated and place her in hallway for sensory stimulation, then back in bed. The care plan did not specify "One on One Room Visits" by Activities for sensory stimulation, including FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 45 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE music, touch therapy, etc. Resident 6 was not observed out of bed 12/10-12-13/18. During an observation on 12/10/18 at 12:51 p.m., Resident 6 was sound asleep, dressed in a hospital gown, and positioned on her left side. Resident 6's roommate stated Resident 6 had a stroke and never got up. The overhead light was shining on Resident 6's face. There was no television, radio, or other sensory stimulation in Resident 6's room. During an observation on 12/10/18 at 4:21 p.m., Resident 6 was positioned on her left side with the overhead light shining on her face. During an interview on 12/11/18 at 10:01 a.m., Licensed Staff O stated Resident 6 did not get up very often, but she was repositioned every 2 hours and she received bolus PEG (a tube feed given like a meal in a short period of time via way of percutaneous endoscopic gastrostomy: placement of a tube through the abdominal wall and into the stomach through which nutritional liquids can be infused) every 6 hours. During an observation on 12/11/18 at 1:00 p.m., Resident 6 was in bed, wearing a hospital gown, and positioned on her left side. There were no pictures in her room and/or other personal items, and no television or radio for music. Resident 6 opened her eyes and moaned when spoken to. During a concurrent observation and interview on 12/12/18 at 9:33 a.m. Resident 6 was dressed in a hospital gown and positioned on her back in bed with the bright overhead light shining on her face. Resident 6's legs were very contracted and she had a hand towel in her left hand, which was very contracted. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 46 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Licensed Staff P stated Resident 6 wore lower leg splints and a right arm splint; legs very contracted. Splints were not on. Licensed Staff P stated the RNA [Restorative Nursing Assistant: a program where RNA's provide specific treatments to residents to restore and maintain the strength, coordination and skills to ambulate (walk) and perform functional activities of daily living (ADLs)] will put them on during the day shift and the splints will be removed on the PM shift. Licensed Staff P stated Resident 6 was transferred to a wheelchair a few hours a day, but leaned forward in her wheelchair, so she was in bed most of the time. When Licensed Staff P was asked why Resident 6 did not have a television in her room, Licensed Staff P stated Resident 6 used to reside in another room, which had a television, but she did not respond to the television. During a concurrent observation and interview on 12/13/18 at 12:30 p.m., Resident 6 was dressed in a hospital gown and was wearing a splint to the right wrist and bilateral lamb's wool boots from lower legs to feet. Resident 6 had dried nasal mucus noticeable in her left nostril. Licensed Staff P stated Resident 6 was up yesterday afternoon in her wheelchair and resided in the hallway and the PM shift put her back to bed. Licensed Staff P stated the Activities Director did room checks on Resident 6. Resident 6's room did not have any sensory stimulation (no television, radio, personal effects, etc.) and no "One on One Room Visits" by Activities was observed. During an observation on 12/13/18 at 2:34 p.m., Resident 6 was positioned on her back in bed with her head elevated at a 20 degree angle. The bright overhead light was shining on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 47 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE her face. Surveyor had not seen Resident 6 out of bed in the past 3 days and Resident 6 did not have television, a radio for music, and there were no personal effects, such as pictures in Resident 6's room. During an observation on 12/14/18 at 9:51 a.m., Resident 6 was sound asleep in bed with the bright overhead light shining on her face. Resident 6 was wearing a sweat shirt, but she had been wearing a hospital gown for the past 3 days (12/10-12-13/18). During an interview on 12/14/18 at 11:00 a.m., Administrative Staff N stated, "No, Resident 6's room was not homelike: no television, no music, and no pictures. The staff gets her up twice a week due to she will scream if gotten up." Administrative Staff N stated, "Resident 6's roommate will not leave you alone when I go into talk to Resident 6. Resident 6 needs one on one for activities. There is also a language barrier - She speaks Chinese." During an interview on 12/18/18 at 10:38 a.m., Administrative Staff D stated Resident 6 should be "Care Planned" for one on one room visits by "Activities," who should be doing hand messages for sensory stimulation and making rounds daily. Administrative Staff D stated she did have cue cards in Chinese, which she used to communicate with Resident 6. Administrative Staff D stated Resident 6's son stated she has never talked much. Administrative Staff D stated there was still a person inside, even if Resident 6 was severely cognitively impaired. Administrative Staff D stated Resident 6 should have been cared planned for her primary language being Chinese. Administrative Staff D stated the facility did not have any staff FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 48 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE member who could communicate with Resident 6 in Chinese. The facility policy/procedure titled, "Individual Activities and Room Visit Program," dated 1/18, indicated: 1. Individual activities are provided for individuals who have conditions or situations that prevent them from participating in group activities, or who do not wish to do so, 2. It is recommended that residents on a full room visit program receive, at a minimum, three room visits per week. Typically a room visit is ten to fifteen minutes in length, etc. The facility policy/procedure titled, "Comprehensive Plan of Care," dated 4/05, indicated: 1. care plan evaluation must occur in response to changes in the resident's physical, emotional, functional psychosocial, or communicative status as they occur, as well as following the RAI (Resident Assessment Instrument), 2. Address the resident's individual needs, strengths, and preferences, 3. Include interventions to prevent avoidable decline in functions or functional level, 4. Re-evaluate and modify care plans: as necessary to reflect changes in care, service and treatment, quarterly and with significant change in status assessment, 5. Care plan evaluation menus occur in response to changes in the resident's physical, emotional, functional, psychosocial, or communication status as they occur, etc. The facility document titled, "HR Manual: Job Description - RN Assessment/MDS Coordinator, revised 10/19/15, indicated 1. The Position Summary included the coordination of appropriate participating health professionals (interdisciplinary team: a group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the patient) for the purpose of conducting initial FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 49 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and periodical comprehensive, accurate assessments of each resident to plan care that allows the resident to reach his/her highest practicable level of physical and mental and psychosocial functioning. 2. Responsibilities/Accountabilities: Develops and maintains a flow of communication that enhances the expected positive resident outcome, includes but is not limited to: Ensuring exchange of essential information necessary for the accurate completion of resident assessments, etc 2. During a review of Resident 9's "Admission" record, dated 5/11/16, indicated he was a 66 year old male with a diagnosis of congestive heart failure (heart does not pump blood as well as it should), atrial fibrillation (often symptoms of rapid heart rate causing poor blood flow) and implanted defibrillator which maintains a consistent heart. During an interview on 12/11/18 at 1:34 p.m., Resident 9 stated that he was aware of his weight loss but does not like to food so it's difficult maintain or gain weight. Resident 9 stated when a meal is presented he does enjoy then he tries to eat a lot of it. During a review of Resident 9's "Nutrition/Dietary" note, dated 3/28/18, indicated food preferences including dislikes for spinach, carrots and yogurt. During a review of Resident 9's "Nutrition/Dietary" noted, dated 10/31/18, indicated an insidious weight loss as follows: *5/1/18 137.8 lbs. (pounds) *6/1/18 136 lbs. *7/2/18 136.3lbs *8/1/18 136 lbs. *9/1/18 134 lbs. *10/30/18 128 lbs. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 50 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During a review of Resident 9's dietary note, dated 3/28/18, indicated he did not like spinach, carrots or yogurt. This information was indicated as accommodation for dietary food preferences. During a review of Resident 9's dietary note, dated 10/31/18, indicated he had been given yogurt for snacks and would prefer deli sandwiches as a snack in-between meals. Snacks to be given three times a day and to discontinue the bedtime snack was ordered by Registered Dietician (RD). During a review of Resident 9's dietary note, dated 11/7/18, indicated further weight loss as evidenced by 11/1/18-127.8 lbs. and 11/7/18127.6 lbs.. RD indicated in the progress note to continue with the previous diet, snacks as previously ordered and add a health shake two times a day between meals to "prevent further weight loss." During a review of Resident 9's dietary note, dated 12/4/18, indicated the Resident's current weight as 123.8 lbs. RD indicated in the progress note to add a fortified diet, to increase the health shake to three times a day between meals and add a magic cup (consistency indicated to like ice cream and or pudding at room temperature) to be served with lunch and dinner. RD indicated an Interdisciplinary Department Team (IDT: care plan meeting with set items to discuss) meeting to discuss goals and "level of care given Physician Order for Life Sustaining Treatment stated no artificial means of nutrition" and recent weight loss. During a review of Resident 9's plan of care, dated 12/1/18, indicated the Resident had unplanned/unexpected weight loss related to poor food intake. The Resident's plan of care was updated on 12/10/18 to include the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 51 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE following interventions: 1) encourage resident to eat 75% or more every meal and offer substitutes as requested or indicated, 2) continue to monitor weight, 3) if weight decline persists, contact physician and dietician immediately and monitor and evaluate any weight loss. During an interview on 12/18/18 at 2:16 p.m., RD stated she had started working as the facilities registered dietician since 10/18 and was not aware of the previous plan of care regarding Resident 9's weight loss since 6/18. RD stated she has been working with Resident 9's weight loss and aside from adding a health shake and or magic cup, a meeting to address the Resident's wishes for no artificial means of nutrition would have to be discussed since a feeding tube would be the next step to increase weight gain. RD stated due to Resident's 9 advanced age, health history and current weight loss that a feeding tube would have to be addressed but given the request for no artificial means of nutrition a decision would need to be made. RD stated she did not update the interventions portion of the plan of care and could not explain a definition of "if weight decline persists" or how the staff would "monitor and evaluate any weight loss or how to interpret "continue to monitor weight". RD stated she did not speak directly with the physician regarding her recommendations and the communication of recommendations would go through nursing who would speak with the physician. RD could not explain how the follow up would occur if the nursing staff did not communicate her recommendations or if the physician did not agree with her recommendations. RD indicated she did not attend IDT meeting since she was at the facility one day a week and other facilities to visit. An additional intervention stated by RD was to request Resident 9 be prescribed a medication FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 52 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to increase appetite. 3. During a review of Resident 32's "Admission" record, dated 4/18/17, indicated he was admitted to the facility with a diagnosis disease of the spinal cord (condition effecting the back resulting in loss of function to the legs and fine motor of hands), diabetes (body's inability to control blood sugar levels) and chronic pain. During a review of Resident 32's "Occupational" therapy discharge note, dated 5/10/17, indicated the Resident had been discharged due to physical capabilities being inconsistent and progress was minimal. During a review of Resident 32's "Physical" therapy discharge note, dated 6/28/17, indicated the Resident had been discharged due to functional abilities had progressed to maximum level. During a review of Resident 32's "Plan of Care," updated on 7/27/18, indicating he was interested in preventing further weight gain and diet education was provided. During a review of Resident 32's "Nutritional/Dietary," note dated 8/8/18, indicated he wanted to lose weight, but did not want to reduce portion size of meal. During a review of Resident 32's "Weight" summary report measured the following: 1/5/18 310 lbs. (pounds) wheelchair/standing scale 2/5/18 311 lbs. wheelchair/standing scale 3/1/18 313 lbs. wheelchair/standing scale 4/8/18 314 lbs. 5/2/18 347 lbs. wheelchair/standing scale 5/28/18 347.6 lbs. wheelchair/standing scale. 5/13/18 317 lbs. Hoyer lift. 6/1/18 319 lbs. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 53 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 6/14/18 320 lbs. wheelchair/standing scale 7/13/18 320 lbs. 8/3/18 321 lbs. wheelchair/standing scale 9/6/18 320 lbs. wheelchair/standing scale 10/1/18 322 lbs. wheelchair/standing scale 11/3/18 319 lbs. wheelchair/standing scale 12/1/18 320 lbs. During a review of Resident 32's "Blood Sugar" summary report, dated 12/1/18 to 12/14/18, indicated the following: Resident 32's blood sugar was measured 54 times between 12/1/18 and 12/14/18 and in 39 instances, Resident 32's blood sugar level was greater than 200 mg/dl. During an interview on 12/11/18 at 3:29 p.m., Resident 32 stated the food was terrible and he would ask his sister for money to order out food. Resident 32 stated for instance if they are serving fish and I don't like fish then they will give me a grilled cheese sandwich and I don't want a grilled cheese sandwich. Resident 32 stated he does not meet with the dietary supervisor or complain to his aide because nothing changes and there is no point and additionally the staff are always changing. Resident 32 stated that he has the use of one hand and finds it difficult to eat certain foods like soup and spaghetti. Resident 32 stated he was not given assistive devices to use with eating so again he indicated another reason why he was ordering take out. During an interview on 12/18/18 at 3:21, RD stated she was not aware of Resident 32's weight status changes throughout the year and was not aware of his blood sugar levels for the month of December. RD indicated she would have to honor Resident 32's request to not reduce portions, leaving not many other options to lose weight other than increase activity and exercise. RD indicated she had not met with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 54 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 32 and did not know that he ordered out food because of the taste and substitute options available to him. RD indicted if Resident 32 had problems with the regular utensils he could have a consult with occupational therapy to evaluate the need for special utensils. RD could not explain the correlation with the elevated blood sugar levels measured in December and the Resident's regular diet order. RD indicated she did not attend "Interdisciplinary Team Meetings" and does not speak with the physician directly regarding Resident dietary recommendations.

F677 SS=E ADL Care Provided for Dependent Residents CFR(s): 483.24(a)(2)

F677 02/22/2019 §483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 55 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE by: Based on interview and record review, the facility failed to provide 4 of 13 sampled residents (Resident 1, 6, 9, and 29) and for unsampled residents (Resident 26, 27, 37, and 50) scheduled weekly showers. This resulted in residents looking unkempt, feeling neglected and unclean, and had the potential to negatively impact the resident's physical and psychosocial wellbeing. Findings: 1. During an interview on 12/10/18 at 11:00 a.m. Resident 1 indicated that he has a shower "whenever", stating he was not really sure of the date or day of the week for his last shower. During a Review of Resident 1's "Admission Record," indicated he was admitted to the facility on 5/18/18 During a review of Resident 1's "Shower" report dated 11/15/18 to 12/14/18, indicated Resident 1 received a shower during the month of: *November - 3 showers (11/15/18, 11/19/18, and 11/29/18) out of 9 scheduled shower opportunities *December - 3 showers (12/1/18, 12/4/18 and 12/12/18) out of 4 scheduled shower opportunities Resident 1 received a total of 6 showers out of 13 scheduled shower opportunities. 2. A review of Resident 6's "Admission Record," dated 12/13/13, and "History and Physical," dated 11/23/14, indicated Resident 6 had diagnosis including Alzheimer's (progressive mental deterioration), cerebrovascular accident (CVA) disease FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 56 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (stroke: occurs when blood flow to an area of brain is cut off. When this happens, brain cells are deprived of oxygen and begin to die. When brain cells die during a stroke, abilities controlled by that area of the brain such as memory and muscle control are lost), contractors (deformity of limbs due to the result of stiffness or constriction in the connective tissues of your body causing loss of motion), dysphagia (difficulty in swallowing) following CVA, aphasia (loss of ability to understand or express speech) following CVA, muscle weakness, etc. and her primary language was Chinese. Resident 6's Quarterly MDSs (minimum data set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems) dated 3/12/18, 6/12/18, and 9/12/18, indicated Resident 6 cognitive skills (core skills your brain uses to think, read, learn, remember, reason, and pay attention for daily decision making) were severely impaired (never/rarely made decisions), and she needed a one person physical assist with transfer (how a resident moves between surfaces including to or from bed, chair, and wheelchair. Resident 6 was a total dependent on bathing and needed one person physical assist. Resident 6's Care Plan for ADLs [(Activities of Daily Living): daily self-care activities. ... Common ADLs include feeding ourselves, bathing, dressing, grooming, transfer, etc.) , initiated 8/31/15 and revised 8/1/17, indicated Resident 6 was a one person assist with showering and totally dependent on two staff for transferring. During an interview on 12/12/18 at 10:33 a.m., Unlicensed Staff S stated Resident 6 was to get a shower twice a week and her next shower FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 57 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE was due on Friday, 12/14/18. Unlicensed Staff S stated Resident 6 should have a full body bed bath every day. Review of the document titled, "Shower Schedules," indicated Resident 6 should have received a shower on Tuesday and Friday during the AM shift. Review of Resident 6's "Shower" report, dated 1/1/18 through 12/16/18 indicated Resident 6 received a shower during the month of: *January - no shower and one total bed bath *February - no shower and two total bed baths *March - 1 shower on 3/27/18 and three total bed baths *April - no shower and 1 total bed bath *May - no shower and 9 total bed baths *June - 1 shower on 6/15/18 and total 15 bed baths *July - no shower and 18 bed baths *August - 1 shower on 8/31 and 15 total bed baths *September - 1 shower on 9/28 and 18 total bed baths *October - no shower and 17 total bed baths *November - 3 showers (11/8, 11/16, & 11/29) and 6 total bed baths *December - 1 shower on 12/5 and 1 total bed bath. Resident 6 did not receive a shower as Unlicensed Staff S stated Resident 6 was scheduled to receive on Friday, 12/14/18. Resident 6 received a total of 8 showers from 1/1/18 through 12/16/18. 3. During an interview on 12/10/18 at 2:20 p.m. Resident 9 indicated that he was getting two showers a week and would have requested two showers a week if he knew that was an option. During a review of "Admission Record", indicated he was admitted to the facility on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 58 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 5/11/16. During a review of Resident 1's "Shower" report dated 11/15/18 to 12/14/18, indicated Resident 9 received a shower during the month of: *November - 3 showers (11/15/18, 11/19/18, and 11/29/18) out of 9 scheduled shower opportunities *December - 3 showers (12/1/18, 12/4/18 and 12/12/18) out of 4 scheduled shower opportunities Resident 9 received a total of 6 showers out of 13 scheduled shower opportunities. 4. During an interview on 12/12/18 at 10:00 a.m. at Resident Council meeting, Resident 29 stated he did not get a shower twice a week and would like to have a shower more than once a week. A review of Resident 29's "Admission Record" indicated he was admitted to the facility on 6/16/18 with a diagnosis of COPD, PVD and dementia. Review of the document titled, "Shower Schedules," indicated Resident 29 should have received a shower on Tuesday and Friday during the AM shift. Review of Resident 29's "Shower" report, dated 11/15/18 to 12/13/18 indicated Resident 29 received a shower during the month of: *November - 1 shower (11/19/18) out of 9 scheduled shower opportunities. *December - 1 shower on (12/4/18) out of 5 scheduled shower opportunities. Resident 29 received a total of 2 showers out of 14 scheduled shower opportunities FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 59 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 5. During an interview on 12/10/18 at 10:57 a.m., Resident 26 stated she had resided at the facility for 2 months and had only received two showers. Resident 26 stated she would like one shower per week. Review of Resident 26's "Admission Record," indicated she was admitted to the facility on 10/1/18. Review of Resident 26's admission MDS (minimum data set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 10/8/18, indicated Resident 26's BIM (Brief Interview of Mental Status) of 15 (resident's mental understanding was cognitively intact) and needed two plus person physical assistance with transfer. Resident 26 was a total dependent on bathing and needed one person physical assist. Review of the document titled, "Shower Schedules," indicated Resident 26 should have received a shower on Tuesday and Friday during the PM shift. Review of Resident 26's "Shower" report, dated 10/1/18 through 12/10/18, indicated Resident 26 had been provided a shower during the AM shift on 10/16, 11/6, 11/10, and 11/15/18. 6. During an interview on 12/11/18 at 10:00 a.m., Resident 27 indicated that he was not having two showers a week and was not aware of a schedule assigned to him regarding his days to shower. During a review of Resident 27's "Admission Record" indicated he was admitted to the facility on 7/5/18 with a diagnosis of left leg FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 60 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE below the knee amputation, high blood pressure and diabetes (condition that affects the way the body's ability to processes sugar). During a review of Resident 27's "Shower" report dated 11/19/18 to 12/13/18, indicated Resident 27 received a shower during the month of: *November - 2 showers (11/19/18 and 11/22/18 ) out of 9 scheduled shower opportunities *December - 3 showers (12/5/18, 12/6/18 and 12/13/18) out of 4 scheduled shower opportunities Resident 27 received a total of 5 showers out of 13 scheduled shower opportunities. During an interview on 12/18/18 at 3:45 p.m., Resident 27 indicated that he did not receive a shower two days in a row and the shower documented in the medical record on 12/6/18 was not correct. 7. A review of Resident 37's "Admission Record, dated 9/15/16, indicated Resident 37 had a diagnosis including chronic obstructive pulmonary disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe), high blood pressure, peripheral vascular disease (PVD, a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs) and frontotemporal dementia (a disorder of the brain caused by loss of nerve cell connections located behind the forehead. Resident 37's Quarterly MDSs (minimum data set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems) dated 11/5/18 indicated Resident 37's cognitive skills (core skills your brain uses to think, read, learn, remember, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 61 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE reason and pay attention to daily decision making) were minimally impaired and he needed extensive one person assistance for bathing. Resident 37 required assistance to a wheelchair for ambulation purposes. Resident 37's Care Plan for ADLs (Activities of Daily Living): daily self-care activities. ... Common ADLs include feeding ourselves, bathing, dressing, grooming, transfer, etc.) , initiated 9/15/16 and updated 11/5/18, indicated Resident 37 was a one person assist with showering and dependent on one staff for transferring. Review of the document titled, "Shower Schedules," indicated Resident 37 should have received a shower on Wednesday and Saturday during the a.m. shift. Review of Resident 37's "Shower" report, dated 9/1/18 through 12/16/18 indicated Resident 37 received a shower during the month of: *September - 4 showers (9/6/18, 9/12/18, 9/19/18 and 9/29/18) out of 9 scheduled shower opportunities *October - 3 showers (10/17/18, 10/24/18 and 10/29/18) out of 9 scheduled shower opportunities *November - 4 showers (11/8/18, 11/16/18, 11/17/18 and 11/28/18) out of 9 scheduled shower opportunities *December - 4 showers (12/1/18, 12/4/18, 12/5/18 and 12/12/18) out of 8 scheduled shower opportunities Resident 37 received a total of 15 showers out of 35 scheduled shower opportunities. During an interview on 12/14/18 at 4:50 p.m. Resident 37 joined the conversation with his roommate regarding how many showers are FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 62 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE given during a week and if either Resident was aware of their own shower schedule. Resident 37 stated that he did know there was a shower schedule, "I get a shower when they tell me I can have a shower." Resident 37 stated that he has had a shower once a week or so and would love to have two showers a week but no one has offered me that opportunity. Resident 37 was asked regarding the documentation in the medical record indicating he had a shower on 12/4/18 and 12/5/18 and he stated that he would not want a shower two days in a row, "I didn't have a shower on both of those days, that's wrong. Resident 37 was asked regarding the medical record documentation indicating he had a shower on 11/16 and 11/17 and he stated, "Nope that sure wasn't me." 8. During an interview on 12/11/18 at 10:00 a.m. Resident 50 stated he did not get two showers a week and was not aware that he was scheduled to have two showers a week. During a review of Resident 50's "Shower" report dated 11/15/18 to 12/13/18 indicated Resident 50 received a shower during the month of: *November - 2 showers (11/19/18 and 11/26/18 ) out of 9 scheduled shower opportunities. *December - 1 shower on 12/12/18 out of 4 scheduled shower opportunities. Resident 50 received a total of 2 showers out of 13 scheduled shower opportunities. The facility policy/procedure titled. "Shower," dated 1/18, indicated the purpose of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The facility document titled, "Job Description: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 63 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Certified Nursing Assistant,"revised 10/19/15, indicated: 1. Provides patient care in a manner conductive to safety and comfort. 2. Patient care includes, but is not limited to: a. Assists patient with or performs ADLs, etc.

F679 SS=D Activities Meet Interest/Needs Each Resident CFR(s): 483.24(c)(1) FORM CMS-2567(02-99) Previous Versions Obsolete

F679 Event ID: Z25911 03/05/2019 Facility ID: CA220000075 If continuation sheet 64 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.24(c) Activities. §483.24(c)(1) The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure one of 13 sampled residents (Resident 6) was provided One on One Room Visits per the facility's policy/procedure to meet the needs of a resident whose diagnosis included severely cognitively impaired (never/rarely made decisions) following a CVA (cerebrovascular accident (stroke: when a blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or ruptures). This failure had the potential to decrease Resident 6's quality of life by placing her at risk of sensory deprivation, social isolation, depression, further cognitive decline, and/or failure to thrive for a vulnerable resident. Findings: A review of Resident 6's "Admission Record," dated 12/13/18, and "History and Physical," dated 11/23/14, indicated Resident 6 had a diagnosis including Alzheimer's (progressive mental deterioration), cerebrovascular accident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 65 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (CVA) disease (stroke: occurs when blood flow to an area of brain is cut off. When this happens, brain cells are deprived of oxygen and begin to die. When brain cells die during a stroke, abilities controlled by that area of the brain such as memory and muscle control are lost), contractors (deformity of limbs due to the result of stiffness or constriction in the connective tissues of your body causing loss of motion), dysphagia (difficulty in swallowing) following CVA, aphasia (loss of ability to understand or express speech) following CVA, muscle weakness, etc. and her primary language was Chinese. A review of Resident 6's Quarterly MDS (minimum data set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 9/12/18, indicated Resident 6's cognitive skills (core skills your brain uses to think, read, learn, remember, reason, and pay attention for daily decision making) were severely impaired (never/rarely made decisions). During a review of Resident 6's Annual MDS (minimum data set, a clinical assessment process provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 12/11/18, indicated Staff Assessment of Daily and Activity Preferences were: 1. receiving showers, 2. receiving bed bath, 3. receiving sponge baths, 4. staying up past 8 p.m., and reading books, newspapers, or magazine. Review of Resident 6's "Care Plan" for "Activities," initiated 10/11/18, focus indicated Resident 6 had no activity involvement relate to immobility: Physical limitations and cognitive FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 66 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE impairment. Activity interventions, initiated 12/9/16 and revised 8/1/17, included Resident 6 was to be up in wheelchair daily as tolerated and place her in hallway for sensory stimulation, then back in bed. The care plan did not specify "One on One Room Visits" by Activities for sensory stimulation, including music, touch therapy, etc. Resident 6 was not observed out of bed 12/10-12-13/18. During an observation on 12/10/18 at 12:51 p.m., Resident 6 was sound asleep, dressed in a hospital gown, and positioned on her left side. Resident 6's roommate stated Resident 6 had a stroke and never got up. The overhead light was shining on Resident 6's face. There was no television, radio, or other sensory stimulation in Resident 6's room. During an observation on 12/10/18 at 4:21 p.m., Resident 6 was positioned on her left side with the overhead light shining on her face. During an interview on 12/11/18 at 10:01 a.m., Licensed Staff O stated Resident 6 did not get up very often, but she was repositioned every 2 hours and she received bolus PEG (a tube feed given like a meal in a short period of time via way of percutaneous endoscopic gastrostomy: placement of a tube through the abdominal wall and into the stomach through which nutritional liquids can be infused) every 6 hours. During an observation on 12/11/18 at 1:00 p.m., Resident 6 was in bed, wearing a hospital gown, and positioned on her left side. There were no pictures in her room and/or other personal items, and no television or radio for music. Resident 6 opened her eyes and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 67 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE moaned when spoken to. During a concurrent observation and interview on 12/12/18 at 9:33 a.m. Resident 6 was dressed in a hospital gown and positioned on her back in bed with the bright overhead light shining on her face. Resident 6's legs were very contracted and she had a hand towel in her left hand, which was very contracted. Licensed Staff P stated Resident 6 wore lower leg splints and a right arm splint; legs very contracted. Splints were not on. Licensed Staff P stated the RNA [Restorative Nursing Assistant: a program where RNA's provide specific treatments to residents to restore and maintain the strength, coordination and skills to ambulate (walk) and perform functional activities of daily living (ADLs)] will put them on during the day shift and the splints will be removed on the PM shift. Licensed Staff P stated Resident 6 was transferred to a wheelchair a few hours a day, but leaned forward in her wheelchair, so she was in bed most of the time. When Licensed Staff P was asked why Resident 6 did not have a television in her room, Licensed Staff P stated Resident 6 used to reside in another room, which had a television, but she did not respond to the television. During a concurrent observation and interview on 12/13/18 at 12:30 p.m., Resident 6 was dressed in a hospital gown and was wearing a splint to the right wrist and bilateral lamb's wool boots from lower legs to feet. Resident 6 had dried nasal mucus noticeable in her left nostril. Licensed Staff P stated Resident 6 was up yesterday afternoon in her wheelchair and resided in the hallway and the PM shift put her back to bed. Licensed Staff P stated the Activities Director did room checks on Resident 6. Resident 6's room did not have any sensory FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 68 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE stimulation (no television, radio, personal effects, etc.) and no "One on One Room Visits" by Activities was observed. During an observation on 12/13/18 at 2:34 p.m., Resident 6 was positioned on her back in bed with her head elevated at a 20 degree angle. The bright overhead light was shining on her face. Surveyor had not seen Resident 6 out of bed in the past 3 days and Resident 6 did not have television, a radio for music, and there were no personal effects, such as pictures in Resident 6's room. During an observation on 12/14/18 at 9:51 a.m., Resident 6 was sound asleep in bed with the bright overhead light shining on her face. Resident 6 was wearing a sweet shirt, but she had been wearing a hospital gown for the past 3 days (12/10-12-13/18). Review of Resident 6's "Activity Attendance Record" indicated she was provided "Room Visits" as follows: *January 2018: 1 to 2 times per week *February 1-28/18: 1 to 2 times per week, and was not seen for 9 days (2/14-2/22/28) during one span and 13 days during another span (2/24-3/8/18). *March 2018: 5 Times in 31 day span *April 2018: 2 visits per week *May 2018: 1 to 2 visits per week *June 2018: 1 visit per week *July 2018: 3 visits per week *August 2018: 2 to 3 visits per week *September to December 2018 no "Activities Attendance Record was kept indicating Room Visit Activity. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 69 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview on 12/14/18 at 11:00 a.m., Administrative Staff N stated, "No, Resident 6's room was not homelike: no television, no music, no pictures. The staff gets her up twice a week due to she will scream if gotten up." Administrative Staff N stated, "Resident 6's roommate will not leave you alone when I go into talk to Resident 6. Resident 6 needs one on one for activities. There is also a language barrier - She speaks Chinese." During an interview on 12/18/18 at 10:38 a.m., Administrative Staff D stated Resident 6 should be "Care Planned" for one on one room visits by "Activities," who should be doing hand messages for sensory stimulation and making rounds daily. Administrative Staff D stated she did have cue cards in Chinese, which she used to communicate with Resident 6. Administrative Staff D stated Resident 6's son stated she has never talked much. Administrative Staff D stated there was still a person inside, even if Resident 6 was severely cognitively impaired. Administrative Staff D stated Resident 6 should have been cared planned for her primary language being Chinese. Administrative Staff D stated the facility did not have any staff member who could communicate with Resident 6 in Chinese. The facility policy/procedure titled, "Individual Activities and Room Visit Program," dated 1/18, indicated: 1. Individual activities are provided for individuals who have conditions or situations that prevent them from participating in group activities, or who do not wish to do so, 2. It is recommended that residents on a full room visit program receive, at a minimum, three room visits per week. Typically a room FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 70 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE visit is ten to fifteen minutes in length, etc. The facility document titled, "Job Description: Director of Recreation Services," revised 10/19/15, indicated the Director of Recreation Services is responsible for the development, implementation, and supervision of the full scope of recreation services in the nursing center. Responsibilities/Accountabilities included: 1. Puts Customer Service First: Ensures that customers and families receive the highest quality of services in a caring and compassionate atmosphere, which recognizes the individuals' needs and rights, 2. Contributes to the development of an interdisciplinary plan of care, etc. The facility policy/procedure titled, "Comprehensive Plan of Care," dated 4/05, indicated: 1. care plan evaluation must occur in response to changes in the resident's physical, emotional, functional psychosocial, or communicative status as they occur, 2. Address the resident's individual needs, strengths, and preferences, 3. include interventions to prevent avoidable decline in functions or functional level, 4. Re-evaluate and modify care plans: as necessary to reflect changes in care, service and treatment, quarterly and with significant change in status assessment, 5. Care plan evaluation menus occur in response to changes in the resident's physical, emotional, functional, psychosocial, or communication status as they occur, etc. The facility document titled, "HR Manual: Job Description - RN Assessment/MDS Coordinator, revised 10/19/15, indicated 1. The Position Summary included the coordination of appropriate participating health professionals (interdisciplinary team: a group of health care professionals from diverse fields who work in a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 71 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE coordinated fashion toward a common goal for the patient) for the purpose of conducting initial and periodical comprehensive, accurate assessments of each resident to plan care that allows the resident to reach his/her highest practicable level of physical and mental and psychosocial functioning. 2. Responsibilities/Accountabilities: Develops and maintains a flow of communication that enhances the expected positive resident outcome, includes but is not limited to: Ensuring exchange of essential information necessary for the accurate completion of resident assessments, etc.

F726 SS=E Competent Nursing Staff CFR(s): 483.35(a)(3)(4)(c)

F726 03/05/2019 §483.35 Nursing Services The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.35(a)(3) The facility must ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 72 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.35(a)(4) Providing care includes but is not limited to assessing, evaluating, planning and implementing resident care plans and responding to resident's needs. §483.35(c) Proficiency of nurse aides. The facility must ensure that nurse aides are able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. This REQUIREMENT is not met as evidenced by: Based on observations, interviews and record review, the facility failed to develop and implement new employee competency and ongoing competency assessment training program for Certified Nursing Assistants (CNA), which had the potential of inappropriate conduct related to Resident safety and potential unqualified and incompetent staff providing inadequate or unsafe resident care. During concurrent observation and interviews on 12/11/18 at 3:52 p.m., Unlicensed Staff CC, DD and EE were observed in room 17 behind the resident privacy curtain. Unlicensed Staff CC was observed to be eating food at the beside of Room 17 A behind the privacy curtain as evidenced by a mouthful of food observed. Unlicensed Staff CC stated he was not eating the resident's food and was dressed in a Tshirt. Unlicensed Staff DD was located behind the privacy curtain at the foot of the bed (17 A), stating he was "watching the resident". The resident was observed to be sleeping and remained asleep during the encounter. Unlicensed Staff DD was asked if he was watching the Resident sleep, did not answer FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 73 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE any further questions and exited the room. Unlicensed Staff CC was located at the bedside nightstand (17 A) shuffling contents on the top of the nightstand but the view was obscured since her back remained facing the surveyor. Unlicensed Staff CC stated she was cleaning up, did not answer any further questions and left the room. During an interview on 12/11/18 at 4:09 p.m., Administrative Staff B stated CNA's were "expected" to look professional by wearing a nursing type top and dark colored pants. Administrative Staff B stated-shirts were unacceptable and not considered appropriate attire. Administrative Staff B could not explain why the behavior might have occurred as was observed in Room 17 A. Administrative Staff B stated he expected the staff to "carry themselves" professionally, choose respectful words when speaking to residents and treat the resident environment as a private room since, it is considered their home. During an interview on 12/11/18 at 5:08 p.m., Administrative Staff A requested information regarding the interview with Administrative Staff B. Administrative A stated he was concerned regarding the possibility of neglect or abuse had occurred during the encounter in Room 17 A. Administrative Staff A stated the behavior described was unacceptable and there would be disciplinary action with the unlicensed staff involved. During an interview on 12/19/18 at 12:16 p.m., Administrative Staff B stated the, "(Facility Name) PostAcute Care, Inc. Certified Nursing Assistant Skill Evaluation-Self Assessment" was the tool used to assess competency and train staff for new employees and annually for those staff not newly hired. Administrative Staff B stated he used the tool as his assessment of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 74 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE employee qualifications in performing resident care tasks competently. Administrative Staff B stated he was aware of the "Self Assessment" tool and could not explain the check marks located in boxes labeled "A = never performed" and where the documentation was to indicate the employee had been appropriately trained having never performed the task listed. Administrative Staff B could not explain why an employee would sign the document and there was not an administrator signature to attest to the authenticity of the document. Administrative Staff B could not explain how the skills were measured to ensure the staff member was competent to perform the skill on residents. Administrative Staff B could not explain the administrative oversight of new employees or regular employees and could not produce any other document to define competency in performing resident care. Administrative Staff B stated, form titled, "(Facility Name) PostAcute Care Inc. Evaluation of Employee" was used to document areas of employee performance such as quality of work, relationship with patients or appearance but could not explain the measuring tool used to determine how an employee would meet the criteria "Above Average" category as an example. Administrative Staff B stated all CNA employee have these forms located in their personnel files and or training records. Administrative Staff B could not explain the education and training plan for 2019, he stated he would include hand hygiene because it has always been very important for the staff to work on. Administrative Staff B could not indicate areas of identified areas of improvement for the staff as part of the educational plan. Administrative Staff B stated there was no plan for 2019 and he was going to incorporate elements of last years in-service training like hand washing and flu vaccine because they are always important and the staff are never 100% in those areas. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 75 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Administrative Staff B could not produce documentation that showed the level of compliance for the staff with regard to handwashing or any other area included in last years training. Administrative Staff BB stated he did not know exactly how the staff were compliant in handwashing as he would walk around and observe staff washing their hands; giving real time feedback but did not document the number of occurrences hand hygiene was not practiced appropriately during observations. The facility did not produce a policy and procedure addressing competency assessment and resident care requirements.

F791 SS=D Routine/Emergency Dental Srvcs in NFs CFR(s): 483.55(b)(1)-(5)

F791 03/05/2019 §483.55 Dental Services The facility must assist residents in obtaining routine and 24-hour emergency dental care. §483.55(b) Nursing Facilities. The facility§483.55(b)(1) Must provide or obtain from an outside resource, in accordance with §483.70(g) of this part, the following dental services to meet the needs of each resident: (i) Routine dental services (to the extent covered under the State plan); and (ii) Emergency dental services; §483.55(b)(2) Must, if necessary or if FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 76 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE requested, assist the resident(i) In making appointments; and (ii) By arranging for transportation to and from the dental services locations; §483.55(b)(3) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay; §483.55(b)(4) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility; and §483.55(b)(5) Must assist residents who are eligible and wish to participate to apply for reimbursement of dental services as an incurred medical expense under the State plan. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to follow the Policy and Procedure with assisting Resident 22 obtaining dental services. This had the potential for problems with eating, speaking and infections of the mouth. Findings: During a review of the admission record for Resident 22, she was admitted to the facility on 9/28/18 with a history of recent hip surgery and low thyroid (gland within the body that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 77 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE produces thyroid hormone that assists with metabolism). During an observation and concurrent interview on 12/11/18 at 11:36 a.m., Resident 22 was observed sitting up in bed, awake and alert. Resident 22 stated she liked being here and smiled, showing gaps of missing teeth. Resident 22 was difficult to understand since she was not a native English speaker and could not explain if she had seen a dentist while in the facility. During a review of the plan of care record on dated 10/3/18., indicated Resident 22 had broken/missing teeth and difficulty in chewing. The plan of care indicated a Dental consult as needed. During an interview on 12/12/18 at 9:10 a.m., Administrative Staff D stated a dentist visits the facility every three to six months, depending on the need of the Residents. Administrative Staff D stated the process was to fax a copy with a list of Residents to be seen on the next visit to Oral Healthcare company, including newly admitted Residents if indicated. Administrative Staff D showed the surveyor a binder with the list of names of the Residents and the month of when the visit took place. Oral Healthcare company indicated progress notes on the care of each Resident and Administrative Staff D stated the progress notes would be either kept in the binder and/or scanned into the electronic medical record for each resident. Administrative Staff D could not explain why Resident 22 had not been evaluated by the dentist since her 9/28/18 admission. The facility policy and procedure titled, "Dental Services" dated 1/18, indicated "Social services representatives will assist residents with appointments..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 78 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

F804 Nutritive Value/Appear, Palatable/Prefer Temp F804 CFR(s): 483.60(d)(1)(2) SS=E ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 03/05/2019 §483.60(d) Food and drink Each resident receives and the facility provides§483.60(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance; §483.60(d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide a palatable meal to Residents. This failure had the potential to cause a negative dining experience, loss of appetite, decrease in caloric intake and unintential weight loss. Findings: During multiple interviews on 12/11/18 at 10:00 a.m., Residents (39, 9, 27, 2 and 50) stated the food did not taste good and each resident stated their food choices were not being honored. Resident 39 stated she did not know there were other food choices if she did not like what was being offered on the menu. Resident 9 stated he has tried to eat as much as he could when he liked an entree, but too many times he just could not eat the food due to the taste. Resident 27 stated he had not asked for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 79 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE substitutions anymore because even the substitutions did not taste very good. Resident 2 indicated she has had food brought in from outside of the facility because she could not eat the food served. Resident 50 stated he did not like the taste of the food. During an interview on 12/11/18 at 3:29 p.m., Resident 32 stated he hated the food and would order pizza for delivery to the facility. Resident 32 stated he thought the food was of low quality, no taste and not enough options. Resident 32 stated when he had complained of an entree, he would receive a grilled cheese sandwich and stated, "I don't like grilled cheese sandwiches". During a review of the test tray on 12/13/18 at 1:00 p.m., the turkey served had the texture of gelatin with little to no taste. The green beans and red bell peppers had a soggy texture with little to no taste. During an interview of the lunch tray on 12/13/18 at 1 p.m., Administrative Staff C stated she did not find any problems with the lunch served after sampling the food. Administrative Staff C indicated she could not do anything about the texture of the turkey since it was "loaf" (turkey compiled together without the bones, cartilage or skin) and she could only purchase foods from an approved vendor. The facility policy and procedure titled, " Menu Planning" dated 2018, indicated ... "Menus are planned to consider: ...texture and color of all foods." During an interview on 12/10/18 at 12:27 p.m., Resident 41 stated food was bad, often cold, a lot of same things with gravy. She finds the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 80 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE food very cheap and she was sure the eggs were powdered eggs. During a concurrent observation and interview on 12/10/18 at 12:29 p.m., when Resident 33 was asked about the food she received, she stated, "Last of what they have in the kitchen is what we get. Once a week food good." Resident 33 stated if you ask for ice cream or crackers, the staff will say "No." Resident 33 had a lettuce salad on her lunch tray. The lettuce looked wilted and brown with a couple of tiny chopped tomatoes and shredded carrots. Resident 33 stated, "Look at this salad, It only fills the bottom of the bowl and a couple of tiny chopped tomatoes, can hardly find. Lettuce wilted and brown today." During an interview on 12/10/18 at 12:52 p.m., when Resident 34 was asked how she like the food, she stated, "The food is horrible! Look what I am having baked beans. Salad always that small. Small glass of orange juice and I cannot get more orange juice." During a concurrent observation and interview on 12/10/18 01:15 PM, Resident 34 had asked for another bowl of chili. Unlicensed Staff X came into Resident X's room and stated to Resident 34, "The kitchen said no more chili left." Unlicensed Staff X did not offer to get Resident 34 anything in the place of another bowl of chili. Resident 34 stated, the chili was "Soup bowl portion." Three Bean Chili was the meal for lunch, which was served in a small soup bowl. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 81 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F812 Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 03/05/2019 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to discard expired lettuce from the kitchen refrigerator, did not store juice on the medication cart at the appropriate temperature range, did not appropriately label a container of graham cracker crumbs and one cook could not explain the cool down method. These failures had the potential to cause foodborne illness and spread of infections to the resident population. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 82 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: During an initial kitchen tour and concurrent interviews, on 12/10/18 at 9:51 a.m., Administrative Staff C observed several heads of lettuce appeared brown and wilted and had a "received date of 11/27/18". Administrative Staff C could not state the expiration date of the heads of lettuce and referred to the information being contained in a policy. During an interview on 12/14/18 at 4:36 p.m., Administrative Staff C stated the remaining heads of lettuce observed on 12/10/18 had been used in resident food consumption. During an interview on 12/18/18 at 9:20 a.m., Administrative Staff C stated she had thrown out all of the heads of lettuce dated 11/27/18 after the observation on 12/10/18 since they were observed to have been brown around the edges and appeared wilted. During a kitchen tour and concurrent interviews on 12/10/18 at 9:51 a.m., a plastic container of graham cracker crumbs was observed to not have a date associated with the container. Administrative Staff C could not explain the missing date on the container of graham cracker crumbs and did state a date should have been placed on the container. During an observation and concurrent interview on 12/13/18 at 2:40 p.m., with Administrator Staff C and Licensed Staff U, a pitcher of red juice was observed on the medication cart located in the "West Hallway". A cup of juice was poured from the pitcher and observed to measure 65 degrees by the facility kitchen thermometer. Administrator Staff C stated the temperature was too warm and stated it was not good. Licensed Staff U was present at the medication cart during the temperature FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 83 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE measurement and could not state the appropriate temperature range for the pitcher of juice. During an interview on 12/13/18 at 2:55 p.m., Administrative Staff BB could not explain the steps in cooling down hot foods prior to placing them in the refrigerator. Administrative Staff BB stated the food item would need to be cooled to a temperature of 41 degrees but could not state time frames of when the food item would need reach an appropriate temperature. Administrative Staff BB stated she would check the temperature of the food item every hour but could not state if there was a limit to how many hours the food item would be left out of the refrigerator until the temperature of 41 degrees was achieved. The facility policy and procedure titled, "Storing Produce" dated 2018, indicated "lettuce...had a date to use between seven to ten days." The facility policy and procedure titled, "Storage of Food and Supplies" dated 2017 indicated, "Bins/containers are to be labeled, covered and dated." The facility policy and procedure titled, "Procedure for Refrigerated Storage" dated 2018, indicated "Refrigerator temperature to be 41 degrees or lower"... The facility policy and procedure titled, "Cooling and Reheating Potentially Hazardous Foods" dated 2018, indicated "Two Stage Method, cool cooked food from 140 degrees to 70 degrees within two hours...". FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 84 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F842 Resident Records - Identifiable Information CFR(s): 483.20(f)(5), 483.70(i)(1)-(5)

F842 SS=E PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 02/22/2019 §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 85 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for(i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 86 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Based on interview and record review, the facility failed to maintain complete and accurate records for 3 of 13 sampled residents (Residents 1, 29, and 41) and two unsampled residents (Resident 11 and 30 ) when: 1. a. Resident 1's "Order Summary Report for August, September, October, November, December, b. Resident 29's "Order Summary Report" for September and November, c. Resident 11's "Order Summary Report" for September, October, and December were not signed and dated by the attending physician , and d. Resident 30's "Order Summary Report" for August, September, October and December, and 2. Resident 41's "Inventory of Personal Effects" document was not signed or dated by a facility representative verifying all belongings were accounted for upon Resident 41's admission. This had the potential for: 1. Resident 1, 11, 29, and 30 to receive incorrect orders, which could have led to harm or even death, and 2. Resident 41's belongings to get lost and/or not returned to her. Findings: 1a. During a clinical record review, Resident 1's "Order Summary Reports," dated 8/1/18 for August, 8/31/18 for September, 10/1/18 for October, and 11/1/18 for November were not signed and dated by the attending physician approving Resident 1's orders for these months b. During a clinical record review, Resident 29's, "Order Summary Reports," dated 10/1/18 for October and 11/1/18 for November were not signed and dated by the attending physician approving Resident 1's orders for these months. c. During a clinical record review, Resident 11's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 87 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE "Order Summary Reports," dated 8/31/18 for September, 10/1/18 for October, and 11/30/18 for December were not signed and dated by the attending physician approving Resident 11's orders for these months. d. During a clinical record review, Resident 30's "Order Summary Reports," dated 8/1/18 for August, 8/31/18 for September, 10/1/18 for October, and 11/30/18 for December were not signed and dated by the attending physician approving Resident 30's orders for these months. During a concurrent interview and clinical record review on 12/13/18 at 12:21 p.m. and 12:55 p.m., the "Order Summary Reports" for Resident 1, 29, 11, and 30 were not signed and dated by their attending physician. Administrative Staff G stated the facility was aware of issues with the attending physician not signing the resident's "Order Summary Report" in a timely manner. Administrative Staff G stated Resident 1, 29, 11, and 30's attending physician was on vacation, but he did have 2 nurse practitioners (advanced practice registered nurse classified as a mid-level practitioner. A nurse practitioner is trained to assess patient needs, order and interpret diagnostic and laboratory tests, diagnose illness and disease, etc.), who could have signed the "Order Summary Reports." Administrative Staff G stated she was responsible for making sure orders were signed by physician in a timely manner. Administrative Staff G stated she reminded the attending physician every time he came to the facility to visit his residents. Administrative Staff G stated she even installed a mobile app so he could electronically sign the "Order Summary Report," but the physician still forgot to sign the orders. Administrative Staff G stated she also placed the "Summary Order Reports" for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 88 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE physicians to sign and date in the order binder; the order binder was placed on the wall rack, which the physician was aware to check when they came to the facility to visit their residents. The facility policy/procedure titled, "Recapping of Physician Orders - EMR - Guidelines," dated 1/15, indicated the recapitulated physician orders shall be printed by the Health Information Staff on a monthly basis for physician review and approve, until which time, the physician is able to review and electronically sign in the Electronic Medical Record (EMR) System. 2. During a clinical review, Resident 41's "Inventory of Personal Effects" document was not signed or dated by a facility representative verifying all belongings were accounted for upon Resident 41's admission on 11/16/18. During an interview on 12/19/18 at 11:12 a.m., when Licensed Staff U was asked who was responsible for completing the resident's "Inventory of Personal Effects" document upon the resident's admission and discharge, she stated it was both the Certified Nursing Assistant and the nurse attending to the resident, responsibility in making sure the resident's personal belongings were all accounted for upon the resident's admission and discharge. The facility policy/procedure titled, "Theft and Loss of Resident Personal Property," undated, indicated a written resident personal property inventory will be made at the time of admission by the nursing staff and retained during the resident's stay. A copy of this inventory will be given to the resident and/or residents' representative. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 89 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F867 QAPI/QAA Improvement Activities CFR(s): 483.75(g)(2)(ii)

F867 SS=F PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 03/05/2019 §483.75(g) Quality assessment and assurance. §483.75(g)(2) The quality assessment and assurance committee must: (ii) Develop and implement appropriate plans of action to correct identified quality deficiencies; This REQUIREMENT is not met as evidenced by: Based on interview and administrative document review, the facility failed to implement an effective facility wide Quality Assurance Performance Improvement (QAPI) program responsible for identifying significant resident safety issues and failed to ensure that performance improvement activities fully evaluated the depth and scope of the issues. 1. Lack of Infection prevention input and data to monitor Hand Hygiene and Antibiotic Stewardship. 2. Lack of monitoring Resident's to ensure Activities of Daily Living (ADL), for instance, if Resident's were receiving two showers a week, and was the documentation appropriate and accurate. 3. Lack of monitoring the competency level for Certified Nursing Assistants upon hire, annually and yearly education and training programs based on identified needs. This failure to identify and prioritize care areas resulted in facilities' lack of identification of resident safety issues, developing a plan to correct identified issues, implementing the plan and monitoring the results. This failure had the potential for decreased quality of care, potential FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 90 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE for harm and even death. Findings: 1. During concurrent interview and document review on 12/20/18 at 10:26 a.m. Administrative Staff A stated there was a monthly informal quality meeting to discuss issues identified within the facility, started 5/18 by a previous administrator. Administrative Staff A explained the quality meeting took place monthly but could not explain for example how the dietary reports presented to the monthly meetings were incorporated into the quality plan. Administrative Staff A stated, "I'm taking these meetings off the table for discussion since there was not a regulatory requirement to have these meetings monthly". Administrative Staff A stated the quality meetings were routinely held every quarter, but could not identify for example how elements of hand hygiene could be improved upon or the plan to improve the quality of hand hygiene compliance within the facility. Administrative Staff A could not explain how the infection control information collected each month was incorporated into the quality meetings held every quarter. Administrative Staff A stated the information regarding antibiotics usage was included in the 5/18 quality meeting as evidenced by a laboratory report of the infectious organisms grown and the antibiotics used to treat those organisms. Administrative Staff A could not explain how the information from the report was monitored and analyzed to determine if the goal of antibiotic stewardship had been achieved. The laboratory report was included once during the year of quality meetings held for 2018. Administrative Staff A could not produce audit tools or other elements to capture identified needs within the facility, no specific programs were put in place and no evaluations were established to measure the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 91 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE results of a program or plan of actions. 2) During concurrent interview and document review on 12/20/18 at 10:26 a.m., Administrative Staff A stated he was unaware of resident's not receiving their showers twice a week and stated it was probably by resident choice or preference. Administrative Staff A stated that every day there are stand up meetings with the department heads to discuss issues effecting the facility and when an issue has been identified it is taken care by the department head. Administrative Staff A stated he was not aware of residents not getting their showers and CNA (Certified Nurse Assistant) staff were not documenting appropriately in the medical record as observed by multiple instances of a resident having had a shower two days in a row. 3) During concurrent interview and document review on 12/20/18 at 10:26 a.m., Administrative Staff A stated he was not aware of issues with staff not being competent to perform their jobs and was not aware of the training and competency program in place at the facility. Administrative Staff A did not agree regarding the behavior of three CNA's behind a curtain not performing resident care was a direct result of lack of competency training. Administrative Staff A stated, "No staff observed what was observed the other day." 4) Administrative Staff A stated no issues brought up in the QA (Quality Assessment) meeting, such as resident falls, use of antibiotics, Urinary Tract Infections, housekeeping concerns, not reporting transfers/discharges to the Ombudsman's office prior to the resident's transfer or discharge, etc. had been tracked since 2017. Administrative Staff A stated issues were discussed in various departments, such as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 92 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Social Services, Nursing, Housekeeping, etc., but not brought to QAPI. Administrative Staff A could not recall addressing falls or the Heating/Air condition project; maintenance does not attend the QA meeting. 5) Administrative Staff A stated falls are audited by way of an "Incident Log," which indicated: a. Location of Fall, b. How the fall occurred, c. Unwitnessed/Witnessed, etc.; "Falls" were reported Quarterly at QAPI, not at the monthly. 6) When Administrative Staff A was asked what were the action plans for the various issues the surveyors presented to him pertaining to the facility, Administrative Staff A could not explain. The facilities policy and procedure titled, "Draft QAPI Plan"..."Effective Date 28-Nov-2017".. indicated "...ensuring data collection tools and monitoring systems are in place and are consistent for proactive analysis, system failures..."

F868 SS=D QAA Committee CFR(s): 483.75(g)(1)(i)-(iii)(2)(i) FORM CMS-2567(02-99) Previous Versions Obsolete

F868 Event ID: Z25911 02/22/2019 Facility ID: CA220000075 If continuation sheet 93 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.75(g) Quality assessment and assurance. §483.75(g)(1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of: (i) The director of nursing services; (ii) The Medical Director or his/her designee; (iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; §483.75(g)(2) The quality assessment and assurance committee must: (i) Meet at least quarterly and as needed to identifying issues with respect to which quality assessment and assurance activities are necessary. This REQUIREMENT is not met as evidenced by: Based on interview, and administrative document review, the facility failed to ensure there was an effective facility wide Quality Assurance Performance Improvement (QAPI) program as evidenced by: 1. The Medical Director did not consistently attend meetings. This failure to have required committee members consistently attend meetings had the potential to result in lack of facility identification of significant resident safety issues, developing a plan to correct identified issues, implementing the plan and monitoring the results which had the potential to affect the outcomes, dignity and safety of facility residents. Findings: A review of a facility document titled, "QA & A Committee Information," indicated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 94 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE committee met quarterly (January, April, July, & October) and the committee included the Medical Director, Registered Dietician (RD), Administrator, Pharmacist, Director of Nursing (DON), Minimum Data Set (MDS) Coordinator, Medical Records, Social Service Director, Activities Director, etc. During a concurrent interview and record review on 12//20/18 at 10:20 a.m., the "Quarterly Quality Assurance (QA) Meeting" sign in sheets were reviewed and the Medical Director was absent for 1 out of 4 Quarterly meetings; he did not attend the 7/20/18 meeting. The Medical Director was not available to interview because he was on vacation. Administrative Staff A stated the facility had monthly QA meetings, but for the Quarterly Meetings, the Medical Director should have attended the meetings.

F880 SS=E Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 02/22/2019 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 95 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 96 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and document review, the facility failed to: 1) prevent cross contamination when staff did not follow the facility Policy & Procedure (P&P) for Hand Hygiene / Hand Washing when a staff member did not use gloves while bagging a resident's soiled splint. This failure placed the residents, staff, and visitors at risk for cross contamination and spread of infectious diseases, and had the potential for harm and potential for death from the development and transmission of diseases and epidemic infections for residents who possessed a range of functional disabilities and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 97 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE were weakened by other co-morbidities, and 2) collect data from monthly infection control/prevention meetings, to provide analysis and to implement corrective action plans to measure the achievement of facility infection prevention/goals. This failure to implement an inclusive infection control program had the potential for poor resident outcomes, related to increased infections and potential inappropriate antibiotic stewardship. Findings: 1) During a concurrent observation and interview on 12/12/18 at 11:56 a.m., Unlicensed Staff K was asked what the soiled blue thing was located on Resident 19's bed. Unlicensed Staff K stated the blue thing was Resident 19's knee brace." Resident 19 stated she pulled the brace off because the brace was hurting her. Resident 19's knee brace was soiled with dried brown smeared substance. Unlicensed Staff K stated Resident 19's knee brace should not have been placed on her because the knee brace was very soiled. Unlicensed Staff K stated the knee brace needed to be sent to the laundry. When Unlicensed Staff K was asked who placed the knee brace on Resident 19, she stated Unlicensed Staff V. When surveyor stated to Unlicensed Staff K she wanted Unlicensed Staff V to see the soiled knee brace before the brace was sent to the laundry, Unlicensed Staff K did not bag the soiled knee brace before she placed the brace on top of Resident 19's closet. During a concurrent observation and interview on 12/12/18 at 1:10 p.m., when Unlicensed Staff V was asked about Resident 19's knee brace located on top of her closet, Unlicensed Staff V grabbed the soiled knee brace down from on top of Resident 19's closet without wearing gloves. Unlicensed Staff V stated he FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 98 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE had not noticed the knee brace being soiled. Unlicensed Staff V stated, "It looked like dried feces." Unlicensed Staff V stated the knee brace needed to be washed, but he had never seen a knee brace washed before. He continued to touch the knee brace with his hands while he placed the brace in a bag. Unlicensed Staff V then walked out of the Resident 19's room, went down the hallway to a door, keyed in an entrance code, so he could open the door, which led to basement where the laundry room was located. He never wore gloves and/or washed his hands prior to going to the laundry and when he returned. When Unlicensed Staff V was asked what he should have done prior to touching Resident 19's soiled knee brace, he stated he should have put on gloves. Unlicensed Staff V could not explain to the surveyor the P/P for gloving and washing hands prior to, and after touching the soiled knee brace. The facility policy/procedure titled, "Handwashing Hand Hygiene,"1/18/18, indicate: 1. All personal shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections, 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, resident, and visitors, 3. Hand hygiene is the final step after removing and disposing of personal protective equipment, and the use of gloves does not replace washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. 2) During concurrent interview and document review on 12/19/18 at 10:42 a.m., Administrative Staff B stated he collects FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 99 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE information on types of infections, antibiotics used to treat the infection, identifies the resident effected and room locations of each resident that had an infection. Administrative Staff B showed the surveyor a binder with the same information described and could not indicate how the data collected was analyzed with identifying areas of opportunity to decrease infections. Administrative Staff B could not explain how many urinary tract infection (infections of the bladder) had occurred over the year and if there were more or less urinary tract infections during a certain part of the year. Administrative Staff B could not explain identified needs for the Infection Control/Prevention plan in the next year since the information collected had not been analyzed or a monitoring systems put in place to assist in identifying needs in the facility. Administrative Staff B could not determine the urinary tract infection rate for the facility and how education and training for CNA's would have a favorably impact to reduce the amount of urinary tract infections or if the urinary tract infections were clustered to an area of the facility and how that information analysis could be incorporated into the infection control plan. The facility policy and procedure titled, "Scope of Infection Control Program",dated 8/16 " ..."prevention, detection, management and control the spread of infection"..."identify baseline data in order to evaluate new control measures: and educate employees on infection control."

F881 SS=F Antibiotic Stewardship Program CFR(s): 483.80(a)(3)

F881 02/22/2019 §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 100 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE must include, at a minimum, the following elements: §483.80(a)(3) An antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure an effective Antibiotic Stewardship program was present and functioning, including promoting the appropriate use of antibiotics and consistent monitoring of antibiotic use to improve resident outcomes and reduction of antibiotic resistance, according to facility policy and procedure (P&P). This failure had the potential for inappropriate use of antibiotics resulting in adverse events associated with antibiotic use and subsequent antibiotic resistance (drugs designed to kill bacteria are no longer effective and bacteria are able to multiply). Findings: During an interview and concurrent document review on 12/19/18 at 10:42 a.m., Administrative Staff B stated there was no written"Antibiotic Stewardship" program or policies. Administrative Staff B stated he put information on each resident, identifying the infection and the antibiotic being prescribed in a binder every month and presents the information every quarter at the quality meeting. Administraive Staff B stated he coordinated with the pharmacist who would visit the facility every month and then communicated the physician through a form. Administrative Staff B showed a report generated by the pharmacist and the last page contained a typed out communication regarding FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 101 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the pharmacist recommendations regarding a medication and at the bottom of the form, the physician would fill out an acknowledgement and sign and date the form. The pharmacist to physician communication form was not signed by the physician during multiple document reviews. Administrative Staff B stated he would contact the physician by phone and relay the information from the form to the physician and he would sign the form with a "telephone order, date and signature." Administrative Staff B stated he would also write "noted with a date," which was to mean the "action had been completed." During a review of "Note To Attending Physician/Prescriber," dated 11/27/18, indicated a recommendation from the pharmacist to the physician to either reorder an as needed (PRN) medication with a rationale for risks/associated benefits or to discontinue the medication. At the bottom of the form, Administrative Staff B marked the box "Agree" and signed the form, "T.O." (provider name) with date and his signature. Administrative Staff B could not indicate what the provider had agreed to: to discontinue the medication or continue the order with benefit/risk statement. Administrative Staff B indicated he would speak to the provider by telephone and indicate agree or disagree by marking a box but in reviewing the medical record, but there was no change in the medication order, meaning the order had not been renewed or discontinued as evidenced in the Medication Administration Record. Administrative Staff B could not explain his role when completing the form as to who would update the Medication Administration Record. During document review of "Pharmacy Consultant" reports, dated from 7/18 to 11/18, indicated no antibiotic recommendations were communicated from the pharmacist to the physician. Administrative FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 102 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Staff B could not explain a process, system or workflow that would address how antibiotic use would be reviewed. The medical director was unavailable to be interviewed during this survey as he was on vacation and not available by phone. Administrative Staff B presented the Centers for Disease Control, "Core Elements of Antibiotic Stewardship for Nursing Homes" dated (document not dated) as a facility guide. Administrative Staff B could not explain how the elements described were being incorporated into the faculties' use of antibiotics. A document review of the CDC Summary of Core Elements of Hospital and Long Term Care Antibiotic Stewardship Programs, undated, indicated the necessary components for successful antibiotic stewardship to include: · Leadership Commitment: Dedicating necessary human, financial and information technology resources · Tracking: Monitoring antibiotic prescribing and resistance patterns · Reporting: Regular reporting information on antibiotic use and resistance to doctors, nurses and relevant staff · Education: Educating clinicians about FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 103 of 104 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056430 (X3) DATE SURVEY COMPLETED 12/20/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE NORTHGATE POSTACUTE CARE 40 Professional Center Pkwy San Rafael, CA 94903 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resistance and optimal prescribing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Z25911 Facility ID: CA220000075 If continuation sheet 104 of 104