Health inspection·May 17, 2022

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based on interview and record review, the facility staff failed to respond to call lights timely when five of 16 sampled residents had to wait up to one hour for staff to respond when residents pressed their call lights for assistance. This failure resulted in residents sitting in soiled briefs. Findings: During an interview on 5/9/22 at 12:33 p.m., Resident 52 stated she had had sores on her bottom for one year and they (the sores) would heal if all the staff caring for her provided her wound care right. Resident 52 stated the longest she had to wait for staff to respond to call lights was 45 minutes, and she stated she has had to wait while she was wet which interfered with the wound healing. Resident 52 stated PM shift (3 p.m. to 11 p.m.) was the worst with responding to call lights. During an interview on 5/9/22 at 3:09 p.m. and 4:11 p.m., Resident 63 stated she would have to wait for someone to answer her call light, especially on the PM shift. Resident 63 stated the CNAs (Certified Nursing Assistants) were great, but overworked, and frequently had to work a double shift because the facility was short staffed on the PM shift. Resident 63 stated because the CNAs were overworked, especially on the PM shift, it caused residents to have to wait for their call light to be answered. During an interview on 5/10/22 at 9:11 a.m., Resident 7 stated he had to wait over an hour when he pressed his call light for assistance. Resident 7 stated response-time depended on who was working, but mostly on second shift (3 p.m. to 11 p.m.) he had long waits for help. Resident 7 stated sometimes the staff would cut off the light and not ask him what he needed, or the staff would say they would tell his CNA (what he needed) and then no one came back. Resident 7 stated this had resulted in sitting in stool for long periods. During an interview on 5/10/22 at 9:16 a.m., Resident 56 stated the facility was understaffed with CNAs, especially on the PM shift. Resident 56 stated she waited up to two hours for her call light to be answered. Resident 56 stated the CNAs were over worked and the facility was understaffed. During an observation on 5/10/22 at 9:40 a.m., Resident 25 had his phone in his hand thinking it was his call light and attempted to call his CNA. Resident 25's call light was hanging at the side of his bed out of reach. When the nurse was notified about Resident 25's call light being out of reach, she stated she would let Resident 25's CNA know. It took eight minutes until Resident 25's CNA went into Resident 25's room to ensure he could reach his call light and helped him with moving the arm of his television (TV) near him, so he could see the TV screen. The CNA stated to Resident 25 she had been assisting another resident. Page 1 of 29 055093 055093 05/17/2022 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 5/10/22 at 9:53 a.m., when asked how long he had to wait for help when he pressed his call light, Resident 24 stated it can take a long time, sometimes hours. During an interview on 5/11/22 at 10:45 a.m., Unlicensed Staff D stated she worked the AM and PM shift. Unlicensed Staff D stated the facility was more often short staffed CNAs on the PM shift. Unlicensed Staff D stated when the facility was short staffed CNAs, she would answer the resident's call light as soon as she could. Unlicensed Staff D stated she tried to answer a resident's call light within five minutes. Unlicensed Staff D stated she has come on shift in the morning to residents' besd completely soaked. Unlicensed Staff D stated an incontinent resident should be checked every one to one and a half hours. During an interview on 5/11/22 at 10:53 a.m., Unlicensed Staff E stated the facility was short staffed CNAs all the time on the PM shift. Unlicensed Staff E stated he tried to answer a resident's call light right away, but when the facility was short staffed it was hard to get all his work done. During an interview on 5/17/22 at 10:55 a.m., Licensed Staff F stated she expected residents' call lights to be answered within five minutes. During an interview on 5/17/22 at 10:57 a.m., when queried, Unlicensed Staff E stated he tried to respond right away when a resident pressed their call light. Unlicensed Staff E stated the resident should not have to wait. Unlicensed Staff E stated 45 minutes was way too long to wait for assistance. When asked what could happen if a resident was in a soiled brief for an extended period, Unlicensed Staff E stated the resident could get a rash if they waited too long, they would not be comfortable, and it could mess up their bed. Unlicensed Staff E stated, I wouldn't want to sit in my own (waste). During an interview on 5/17/22 at 2:30 p.m., Director of Staff Development stated staff were expected to respond as soon as possible to call lights. DSD stated the policy was within five minutes, but someone should be in the room right away whenever anyone saw a call light. When asked what could happen if a resident was in a soiled brief for an extended period, DSD stated the resident could develop a urinary tract infection or skin breakdown, and sitting in urine or feces was a dignity issue, they should be nice and clean. Review of facility policy Quality of Life - Dignity, last revised 8/2009, revealed, Staff shall promote dignity and assist residents as needed by . b. Promptly responding to the residents' request for toileting assistance. Review of facility policy and procedure Call Light Answering, not dated, indicated, 1. Answer the light/bell within a reasonable time. 2. Turn off the call light/bell. 3. Listen to the resident's request/need. 4. Respond to the request. 5. Leave the resident comfortable. 055093 Page 2 of 29 055093 05/17/2022 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on observations, interview and record review, the facility failed to ensure residents were aware of the facility's Grievance Process for seven out of 16 residents. This failure had the potential risk of unresolved grievances or concerns. Findings: During the resident council meeting on 05/10/22 at 10:58 a.m., Anonymous 1 stated the facility has no formal grievance process and would like it if there is one. Anonymous 2 stated she thought grievances are to be reported to the nurses. Anonymous 3 stated to just report to the Ombudsman. Anonymous 3 stated that when he has grievance or concerns, he talks to the administrator. Anonymous 1 stated not a lot of residents knew the Administrator. During an interview on 5/12/22 at 9:02 a.m., Resident 33 stated he does not know the facility's grievance process. During an interview on 5/12/22 at 9:07 a.m., Licensed Staff G stated she's not sure about the facility's grievance process. During an interview on 5/12/22 at 9:09 a.m., Unlicensed Staff H stated they report grievance to the nurses. During an interview on 5/13/22 at 8:30 a.m., Director of Staff Development (DSD) stated the facility protocol was to have the grievance form filled out by staff and submit to Social Services Director (SSD). She stated this form can be found at nursing stations 1 and 2. DSD verified there were no available grievance form at Nursing station 2. During an interview on 5/13/22 at 8:32 a.m., Licensed Staff I stated grievances were reported directly to the Social Services Director (SSD). Licensed Staff I did not mention about a grievance form. During an interview on 5/13/22 at 8:46 a.m., Licensed Staff J stated if there was grievance reported by a resident, she would try to resolve it first. Licensed Staff J stated she would only give the grievance form to the resident after obtaining the Director of Nursing (DON) approval. During an interview on 5/13/22 at 8:54 a.m., Resident 26 stated he was not aware of the facility's grievance process. He stated it would be nice if someone from the facility talked to him about the process. During an interview on 5/13/22 at 10:57 a.m., Case Manager (CM) stated that grievances were reported to and addressed by the SSD. CM stated residents not knowing how to file a grievance was a concern as it could result in unresolved issues. She stated this may cause anxiety and frustration. CM stated it was expected for staff to fill out a grievance form so that SSD can follow up to resolve the issue. During an interview on 5/13/22 at 11:21 a.m., Resident 47 stated he was not aware of how to file a grievance. He stated no facility staff had come to him to explain about the Grievance Process and would like it if staff explainsed the process to him. 055093 Page 3 of 29 055093 05/17/2022 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 5/13/22 at 11:25 a.m., SSD stated the facility process on Grievance includes staff filling out a grievance form and handing it to her for follow up. She stated she had a grievance binder to keep track of grievances and to ensure there was a resolution for the reported grievance. She stated the Grievance Process was discussed with newly admitted residents during baseline care planning with the Interdisciplinary team (IDT), residents and or Responsible Party (RP). She stated there were no documentations or checklist to ensure this process was not missed during base line care planning. She stated if residents did not know how to file a grievance, the grievance or concerns may end up unresolved. She stated this could lead to resident's frustration and anger. She stated residents may also feel their issues were not heard. During an interview on 5/16/22 at 10:35 a.m., Minimum Data Set Coordinator (MDS) stated if residents did not know who the grievance officer was and how to report a grievance, the grievance may not be addressed. She stated this could lead to a resident's anxiety. During an interview on 5/16/22 at 11:08 a.m., Resident 48 stated she was not aware of who the Grievance Officer was nor was she aware on how to file a grievance. She stated that she did have concerns in the past but had not known to whom and how to report it. Resident 48 stated she would like to understand the facility's grievance process. Resident 48 stated she felt a little left out for not knowing there was a formal grievance process. During an interview on 5/16/22 11:18 a.m., Director of Nursing (DON) stated Administrator was the Grievance Officer and SSD was the designee. DON stated it was important for residents to know about the grievance process. She stated resident would feel frustrated and disappointed if grievance or concern was not addressed. The facility's policy and procedure titled Grievances/Complaints, Recording and Investigating revised April 2017, indicated it was the facility's policy to investigate and report grievances. It stated the report will include date/time of the alleged incident, circumstances, location surrounding the alleged incident. Report should also include names of witness if any, residents and employees account of the alleged incident and a recommendation for corrective action. 055093 Page 4 of 29 055093 05/17/2022 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Based on observations, interviews and record review, the facility failed to follow up on a Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure individuals are not inappropriately placed in nursing homes for long term care) level 2 referral (determines if mental illness needs of a the individual can be met in a nursing facility) for 1 out of 16 sampled residents (Resident 27) and five unsampled residents (Resident 64, Resident 7, Resident 16, Resident 65 and Resident 66). This failure had the potential risk of Resident 27 missing out on specialized services and obtaining additional resources. Findings: Resident 27 face sheet (demographics) indicates a diagnosis of Schizoaffective disorder, Bipolar type (a mental health condition with combined symptoms of both schizophrenia and mood disorder with dramatic highs, manic and depressive episodes.) During an observation in the dining room on 5/09/22 at 12:33 p.m. Resident 27 was verbal and interacting with visitor. Resident 27 was observed with inability to sit still (rocking motion) and involuntary facial movement (lip smacking). During a review on 5/10/22 at 10:37 a.m., of the PASRR form dated 12/14/20, indicated a level 2 screening was required. There was one progress note from the Psychiatrist dated 11/14/2021 which indicated Resident 27 had shown increased Extrapyramidal Syndrome, a drug induced movement disorder, a side effects caused by antipsychotic medication. During an interview and concurrent Resident 27's PASRR record review on 5/12/22 at 2:57 p.m., Case Manager (CM) verified the PASRR dated 12/14/21 indicated a level 2 mental health evaluation (to determine placement and specialized services) was required. CM stated there were no results for level 2 assessment since Resident 27 has not been evaluated yet. CM stated she do not know who follows up to ensure a PASRR level 2 assessment was performed. CM verified the last documentation for Psychologist visit was on November 14, 2021. During an interview on 5/16/22 at 10:02 a.m., SSD verified Resident 27 needed to have a PASRR level 2 assessment. SSD stated the Case Manager (CM) and or Medical Record Director (MRD) follows up on the result. If a level 2 assessment was not done, SSD stated Resident 27 was at risk for missing out on specialized treatments. SSD stated that this could be detrimental to Resident 27's well-being. SSD stated that Resident 27's behavior could also worsen. During an interview on 5/16/22 at 10:18 a.m., CM verified the facility did not follow up on Resident 27's PASRR level 2 referral. CM stated lack of follow up on the level 2 referral can result in resident 27's behavior escalating. She stated Resident 27 might miss out on specialized treatments. During an interview on 5/16/22 at 11:29 a.m., Director of Nursing (DON) verified Resident 27 required a PASRR level 2 evaluation. DON stated she expected staff to call the state to follow up on a PASRR level 2 referral. DON stated that it was important to follow up on the Level 2 evaluation referral. She stated not doing so placed Resident 27 at risk for missing out on specialized treatment and other pertinent recommendation. 055093 Page 5 of 29 055093 05/17/2022 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0644 Level of Harm - Minimal harm or potential for actual harm During an interview and concurrent review of the PASRR dashboard on 5/17/22 at 12:10 p.m., CM verified there were five more residents (Resident 64, Resident 7, Resident 16, Resident 65 and Resident 66) in their facility that had pending PASRR level 2 evaluations. CM stated she had not followed up on these level 2 referrals. CM stated level 2 evaluations were important as this determines appropriate placement, and specialized treatments for residents. Residents Affected - Some The facility's policy and procedure Aspen Skilled Health Policy- PAS/PASSARR revised 12/2017, indicated that any residents identified with Mental illness (MI) must be referred for a level 2 evaluation and it was the DON's responsibility to make certain a system was in place to check the timeliness and ensure facility's compliance with the PASRR process. 055093 Page 6 of 29 055093 05/17/2022 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive person-centered care plan with interventions to meet the needs of one of 16 sampled residents (Resident 267) when Resident 267 was assessed to be immobile and at high risk for pressure ulcers and the facility did not include in her care plan the intervention of turning and repositioning Resident 267 every two hours. This failure had the potential for Resident 267 to develop pressure ulcers. Findings: A review of Resident 267's Facesheet indicated she was admitted to the facility on [DATE] and had diagnosis including Alzheimer's disease, vascular dementia, history of falling and failure to thrive. A review of Resident 267's admission Braden Scale (a standardized tool that indicates the risk of a resident developing pressure ulcers), dated 4/5/22, indicated Resident 267 was bedfast: confined to bed and was completely immobile: does not make even slight changes in body or extremity position without assistance. The Braden Scale indicated Resident 267 was at HIGH RISK for developing pressure ulcers. A review of Resident 267's care plans (documents indicating the care to be provided to residents) indicated a care plan for the prevention of pressure ulcers titled: HIGH RISK for skin breakdown R/T [related to] fragile skin and impaired mobility. A review of this care plan indicated interventions to prevent pressure ulcers included Turn and reposition during care and as needed. The care plan, however, did not include the intervention to turn and reposition Resident 267 every two hours. During interviews on 5/10/22, at 8:30 a.m., and on 5/13/22, at 9:55 a.m., the Director of Nursing (DON) confirmed Resident 267 was totally dependent on staff for repositioning in bed, was at high risk for pressure ulcers, and needed to be turned and repositioned every two hours. The DON reviewed Resident 267's care plans and confirmed it did not contain the intervention of turning and repositioning Resident 267 every two hours. A review of facility policy titled Prevention of Pressure Ulcers/Injuries, dated July 2017, indicated: Prevention .Mobility/Repositioning . At least every two hours, reposition residents who are chair-bound or bed-bound with the head of the bed elevated 30 degrees or more. A review of facility policy and procedure titled Care Plans, Comprehensive Person-Centered, dated December 2016, indicated: The comprehensive, person-centered care plan will . describe the services that are to be furnished to attain or maintain the resident's highest practical physical, mental, and psychological well-being. 055093 Page 7 of 29 055093 05/17/2022 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, facility staff failed to follow medication safety measures when licensed staff administered twice the ordered dose of a medication to a resident, Resident 57. This failure could potentially lead to further medication errors and cause harm to vulnerable residents. Residents Affected - Few Findings: During a medication pass observation on 5/12/22 at 8:28 a.m., Licensed Staff G removed two tablets of Buspirone (anti-anxiety drug) 30 mg (milligrams, a unit of measure) from a bubble pack and administered them to Resident 57. Review of Resident 57's physician orders revealed, Buspirone HCl (hydrochloride, an additive for shelf life) Tablet 15 MG Give 2 tablets by mouth two times a day for anxiety. During an interview on 5/12/22 at 3:11 p.m., Licensed Staff G verified the bubble pack's instructions to give one tablet of Buspirone 30 mg did not match the physician's order to give two tablets of buspirone 15 mg. During an interview on 5/17/22 at 11:16 a.m., Director of Nursing (DON) stated that every Friday she went through all the medication bubble packs and checked them against the physician's orders to make sure there were no discrepencies. DON stated she had missed performing this check for a week and did not catch the discrepency on Resident 57's bubble pack of Buspirone. Review of facility policy Administering Medications, revised 12/2012, indicated, The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication. 055093 Page 8 of 29 055093 05/17/2022 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide two of three sampled residents (Resident 8 and Resident 18) scheduled weekly showers, who depended on staff to assist. This failure to provide the necessary care resulted in residents looking unkempt and had the potential for residents having body odors, dry/broken skin not being assessed, and/or an infection, further negatively impacting the resident's physical and psychosocial wellbeing. Residents Affected - Some Findings: 1. A review of Resident 18's admission Record, indicated Resident 18 was admitted on [DATE] with diagnoses including degenerative disease of the nervous system (Your body's command center. Originating from your brain, it controls your movements, thoughts and automatic responses to the world around), dementia (mental processes caused by brain disease and marked by memory disorders, personality changes, and impaired reasoning), dysphagia (difficulty swallowing), fracture of the left femur (broken thighbone), aftercare following joint replacement surgery of the left hip, pain in left hip, need for assistance with personal care, abnormalities with gait (walking) and mobility , repeated falls, unsteadiness on feet, muscle weakness, amongst others. A review of Resident 18's admission MDS (Minimum Data Set, a clinical assessment process which provides a comprehensive assessment of the resident's functional capabilities and helps staff identify health problems), dated 2/11/22, indicated Resident 18 needed physical help in part of bathing activity and one person physical assist, had left lower extremity impairment, and needed one person physical assist with personal hygiene, including combing hair, brushing teeth, shaving, and washing/drying face/hands. A review of Resident 18's Self Care Deficit: Activities of Daily (ADLs- fundamental skills required to independently care for oneself, such as eating, bathing, and mobility) care plan, initiated 2/9/22, indicated Resident 18's ADLs self-performance and support fluctuated on a daily basis due to impaired mobility status [after] left hip arthroplasty (surgical procedure to restore the function of a joint). Interventions included, assist as needed with showers, toileting and locomotion, and assist with maintaining good personal hygiene every shift and as needed. A review of the document titled, Shower Schedule indicated Resident 18 was supposed to get a shower based on his room number during 2/10/2022 through 5/12/22, either Tuesday, Thursday, and Saturday, PM shift or Monday, Wednesday, and Friday, PM shift. Resident 18 was to have a shower or bed bath nine times in 2/2022, 14 times in 3/2022, 13 times in 4/2022 and six times in 5/1/22-5/13/22. A review of Resident 18's documents titled, Shower/Bed Bath Task and Skin Check Sheet, completed by the CNA (Certified Nursing Assistant) after giving the resident their shower or bed bath or documented refusal on the Skin Check Sheet, indicated in 2/2022, Resident 18 had four showers or bed baths, refused three, and two were not documented. In 3/2022, Resident 18 had ten showers or bed baths, refused three and one was not documented. In 4/2022, Resident 18 had seven showers or bed baths, refused two, and four were not documented. From 5/2/22 through 5/12/22, Resident 18 had three showers or bed baths and two where not documented. Out of the 44 showers or bed baths Resident 18 was to have during this time period, nine showers or bed baths (2/15/22, 2/22/22, 3/1/22, 4/16/22, 4/20/22, 4/22/22, 4/29/22, 5/2/22, and 5/6/22) had no documentation and he refused eight showers or bed baths. 055093 Page 9 of 29 055093 05/17/2022 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0677 Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and record review on 5/9/22 at 4:34 p.m., Resident 18 was sitting up in his wheelchair resting, his oxygen was on, he sounded congested and looked unkept. Resident 18 needed a clean shave and his hair washed. Reisident 18 had a scruffy gray patch beard growing, and his hair looked greasy. Resident 18's Shower/Bed Bath Task and Skin Check Sheet, indicated he had not had a shower or bed bath for five days. Residents Affected - Some During an interview on 5/12/22 at 8:40 a.m., Unlicensed Staff B stated residents should have a shower or bed bath every other day. During a concurrent interview and Skin Check Sheet record review on 5/16/22 at 10:29 a.m., the DON stated the licensed nurse's relied on the CNA to check the resident's skin when the resident had a shower. The DON stated if a resident refused a shower or bed bath it should be documented on the shower sheets. Resident 18's Skin Check Sheet indicated Resident 18 had a bed bath on 2/12/22 and 4/5/22, but his Skin Check was not completed. Resident 18 Skin Check Sheet indicated he refused a shower or bed bath on 2/19/22, 2/24/22, 2/26/22, 3/5/22, 3/22/22, 4/2/22, and 4/9/22, and there was no Skin Check completed. Resident 18's electronic document titled, Shower/Bed Bath Task indicated Resident 18 refused a shower/bed bath on 3/3/22, but no Skin Check Sheet was completed. Resident 18 did not receive nine showers or bed baths and there was no refusal documented on his Shower/Bed Bath Task and the Skin Check Sheet was not completed. There was a total of 17 times CNAs did not check Resident 18's skin from head to toe because Resident 18 did not have a shower or bed bath. During an interview on 5/16/22 at 12:05 p.m., Unlicensed Staff C stated a resident's refusal of a shower would be documented after offering the resident their shower or bed bath four times during the resident's shower day. Unlicensed Staff C stated the CNA would then notify the resident's nurse regarding the resident refusing their shower or bed bath. Unlicensed Staff C stated a Shower sheet (Skin Check Sheet) should be filled out after giving the resident their shower or bed bath and when the resident refused their shower or bed bath. 2. During an interview on 5/10/22 at 10:45 a.m., Resident 8 stated he should be receiving 3 showers in a week. He stated that one time, he did not receive a shower for a week. Resident 8 stated he feels frustrated when this occurs. Anonymous 4 stated sometimes residents even had to remind staff of their showers. During an interview and concurrent care plan review on 5/13/22 at 10:12 a.m., MDS confirmed that there was no specific shower schedule on Resident's 8 Care plan. MDS stated she expected the staff to follow his shower schedule. During an interview on 5/13/22 10:19 a.m., CM stated that residents get a minimum of three showers in a week per facility policy. During an interview and concurrent shower schedule review, regarding Resident 8, on 5/13/22 at 10:21 a.m., Licensed Staff K stated that Resident 8 should be receiving three showers in a week unless there were refusals. Licensed Staff K stated the risk for resident missing his showers would be low self-esteem, loss of confidence, infection, not feeling recharged/rejuvenated. During an interview and concurrent shower schedule review, regarding Resident 8, on 5/13/22 at 10:35 a.m., Director of Staff Development (DSD) confirmed Resident 8 should be receiving three showers in a week. She stated that risk for Resident 8 not receiving his shower were discomfort and infection. She stated skin issue might be missed and may worsen. DSD stated residents may lose confidence and 055093 Page 10 of 29 055093 05/17/2022 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some may show decreased self esteem. DSD stated Resident 8 should be receiving a minimum of 12 showers in a month. DSD verified Resident 8 received eight showers for February 2022, eight showers for March 2022 and eight showers for April 2022. DSD stated there was no facility policy for showers. The facility policy/procedure titled, Activities of Daily Living (ADLs), Supporting, revised 3/2018, indicated: Policy Statement: Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who are unable to carry out ADL independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Policy Interpretation and Implementation: 1. Residents will be provided with care, treatment and services to ensure that their ADL do not diminish unless the circumstances of their clinical condition(s) demonstrate that diminishing ADLs are unavoidable . 2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care) . 4. If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching the resident in a different way or at a different time, or having another staff member speak with the resident may be appropriate . The facility job description titled, CNA, dated 2003, indicated: Purpose of Your Job Position: The primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan, and as may be directed by your supervisors . Duties and Responsibilities: Administrative Functions: Record all entries on flow sheets, notes, charts, etc., in an informative and descriptive manner . Personnel Functions: Perform all assigned tasks in accordance with our established policies and procedures, and as instructed by your supervisors. Follow work assignments, and/or work schedules in completing and performing your assigned tasks . Personal Nursing Care Functions: . Assist residents with bath functions (i.e., bed bath, tub or shower bath, etc.) as directed . The facility job description titled, Charge Nurse, dated 2003, indicated: Purpose of Your Job Position: The primary purpose of your job position is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants .Administrative Functions: Direct the day-to-day functions of the nursing assistants in accordance with current rules, regulations, and guidelines that govern the long-term care facility . Personnel Functions: . Make daily rounds of your unit/shift to ensure that nursing service personnel are performing their work assignments in accordance with acceptable nursing standards . Meet with your shift's nursing personnel, on a regularly scheduled basis, to assist in identifying and correcting problem areas, and/or to improve services . 055093 Page 11 of 29 055093 05/17/2022 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents with or at risk for developing pressure ulcers (PUs - injury to skin and underlying tissue resulting from prolonged pressure on the skin caused by staying in one position too long) for two of three sampled residents (Resident 18 and Resident 267) were provided treatment consistent with professional standards to promote healing of a pressure ulcer when Resident 18 and Resident 267 were not being turned and repositioned per the facility's policy/procedure, nursing staff did not document turning and repositioning, inconsistent skin documentation and Resident 18's heels were not being floated (offloading by using pillow(s) under resident's calves) per physician order. This deficient practice had the potential for Resident 18 and Resident 267 to acquire new pressure ulcers and/or worsen current pressure ulcers. Residents Affected - Some Findings: Resident 18 A review of Resident 18's admission Record, indicated Resident 18 was admitted on [DATE] with diagnoses including degenerative disease of the nervous system (Your body's command center. Originating from your brain, it controls your movements, thoughts and automatic responses to the world around), dementia (mental processes caused by brain disease and marked by memory disorders, personality changes, and impaired reasoning), dysphagia (difficulty swallowing), fracture of the left femur (broken thighbone), aftercare following joint replacement surgery of the left hip, pain in left hip, need for assistance with personal care, abnormalities with gait (walking) and mobility , repeated falls, unsteadiness on feet, muscle weakness, amongst others. A review of Resident 18's Baseline Admission/readmission Screen v.4, dated 2/9/22, indicated Resident 18 required assistants with Activities of Daily (ADLs- fundamental skills required to independently care for oneself, such as eating, bathing, and mobility). Resident 18 was dependent on bed mobility, transfer, personal hygiene, and bathing, incontinent of bladder and bowel function, and skin issues: scattered bruising on right and left wrist, red rash on his buttocks, and an abrasion (an area damaged by scraping or wearing away of the skin) with redness measuring 2 cm (centimeters) x 1 cm on left inner thigh. A review of Resident 18's Braden Scale, (a scale for predicting Pressure Sore Risk) dated 2/9/22 and 2/16/22, indicated Resident 18 was at high risk for developing a PU. A review of Resident 18'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 2/11/22, indicated Resident 18 needed two plus person(s) physical assistance with bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed) and toilet use. Resident 18 needed one-person physical assistance in transfers (how a resident moves between surfaces including to or from bed, chair, wheelchair and standing position), dressing, eating, personal hygiene and bed bath or shower. A review of Resident 18's High Risk for Skin Breakdown Related to Fragile Skin and Impaired Mobility care plan, date initiated 2/9/22, interventions included, Observe for presence of skin breakdown during care, provide good skin care, gentle handling of resident during care and when turning and repositioning, and turn and reposition during care and as needed. 055093 Page 12 of 29 055093 05/17/2022 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of Resident 18's Baseline Care Plan Summary Progress Notes, dated 2/22/22, indicated, . 5. We will monitor your left hip surgical incision for signs and symptoms of infection such as redness or excessive swelling, pus or watery discharge, foul odor from wound, generalized chills or fever . A review of Resident 18's daily Skilled Service Documentation, from 3/1/22 through 3/6/22 and 3/8/22 through 3/12/22 and 3/14/22 through 3/15/22, and 3/17/22, indicated under the Skin section, there was no PU or skin related issues, on 3/7/22 and 3/13/22, indicated Resident 18 had a surgical wound, which was being treated, on 3/16/22, indicated Resident 18 had a PU, and Skilled Service Documentation, dated 3/18/22, was not completed. Skin documentation was not consistent and there was no indication that Resident 18, who was at High Risk for developing a PU, was being turned every one to two hours. A review of Resident 18's Change of Condition Evaluation V5, dated 3/15/22, indicated Resident 18 had developed a PU, Deep Tissue Injury (DTI - skin may look purple or dark red, or there may be a blood-filled blister), on his left heel, which measured 3 cm x 3 cm. A review of Resident 18's Surgical Note, dated 3/21/22, indicated Resident 18 had an unstageable pressure injury located on the left posterior heel. Resident 18 had a subcutaneous tissue (inner most layer of skin) debridement (doctor removes dead tissue from the wound) performed. The PU measured 2.3 cm x 2.7 cm. A review of Resident 18's, Altered Skin Integrity Related to PU: Unstageable Deep Tissue Injury care plan, initiated 3/15/22, additional interventions included a Low Air Loss (LAL) mattress (distributes the resident's body weight over a broad surface area and help prevent skin breakdown), off-load boots as ordered, and turn and reposition every two hours. A review of Resident 18's Nurses Weekly Progress Notes v.3, dated 3/2/22, 3/9/22, and 3/23/22, indicated Resident 18's skin was clear and intact. Resident 18's Nurses Weekly Progress Notes v.3, dated 3/16/22, indicated Resident 18 had a suspected DTI, and skin interventions and management included pressure reducing mattress, off-loading (Place pillow under resident's calves. If one's hand slides easily under the heel, the heel is offloaded), and turning and reposition. Skin documentation was not consistent and there was no indication of Resident 18, who developed a PU, was being turned every one to two hours. A review of Resident 18's Order Summary Report, dated 5/2022, indicated Resident 18 had an order to Float Heels While in Bed, every shift, start date 3/15/22, and Off-Loading Boots to Left Heel, every shift for skin management, start date 3/16/22. During multiple observations on 5/10/22 between 8-12:30 p.m., Resident 18 had a LAL mattress and was positioned on his back. Again, at 2:48 p.m., Resident 18 was observed positioned on his back. Resident 18's heels were ordered to be floated while in bed. Resident 18's heels were not floated, but his left foot did have a boot on. During an observation on 5/11/22 at 11:08 a.m., Resident 18 was asleep on his back for half-an-hour with his head elevated 65 degrees and his neck leaning to his right side. Resident 18's left boot was on but his feet were not floated. During an interview on 5/12/22 at 8:20 a.m., Unlicensed Staff A stated floating heels meant putting a pillow under a resident's feet so the heels were not touching anything. 055093 Page 13 of 29 055093 05/17/2022 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 5/12/22 at 8:28 a.m., Resident 18 was in a hospital gown, on his back, with his head elevated at 45 degrees, but his heels were not being floated. During a concurrent observation and interview on 5/12/22 at 8:40 a.m., Unlicensed Staff B, who was taking care of Resident 18, was asked what was wrong with Resident 18's position in the bed. Unlicensed Staff B lifted his covers and stated his heels should have been floated by way of pillows placed under his calves. Resident 18 did have a boot on his left foot, the foot whereby there was a PU on the left heel. During an interview on 5/12/22 at 10:10 a.m., the DSD stated turning a resident, who was at risk for skin breakdown/PUs, was a standard nursing practice, so the CNAs would only document when they turned/repositioned residents who had a PU issue. The CNAs would document under the electronic charting task, Turn Every Two Hours. There was no record/documentation of how often the CNAs turned/repositioned Resident 18, who developed a PU on the left heel, dated 3/15/22. During an interview on 5/16/22 at 10:29 a.m., the DON stated Resident 18's Skilled Nursing Documentation was completed by the AM shift nurses. The DON stated the nurse should document about Resident 18's skin. The nurses relied on the CNAs to report any skin changes, because the CNAs were supposed to check the resident's skin when the resident had a shower and when the CNAs turned the residents. The DON stated turning is a standard nursing practice, which should be performed every two hours on residents who were at high risk for developing a PU. The DON stated CNAs would not usually document when a resident was turned. The DON stated, Yes, if not documented not done. Resident 267 A review of Resident 267's Facesheet indicated she was admitted to the facility on [DATE] and had diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), vascular dementia (brain damage typically caused by multiple strokes), history of falling and failure to thrive. A review of Resident 267's admission Braden Scale (a standardized tool that indicates the risk of a resident developing pressure ulcers), dated 4/5/22, indicated Resident 267 was bedfast: confined to bed and was completely immobile: does not make even slight changes in body or extremity position without assistance. The Braden Scale indicated Resident 267 was at HIGH RISK for developing pressure ulcers. A review of Resident 267's care plans (documents indicating the care to be provided to residents) indicated a care plan for the prevention of pressure ulcers titled: HIGH RISK for skin breakdown R/T [related to] fragile skin and impaired mobility. A review of this care plan indicated interventions to prevent pressure ulcers, including Turn and reposition during care and as needed. The care plan, however, did not include the intervention to turn and reposition Resident 267 every two hours. During interviews on 5/10/22, at 8:30 a.m., and on 5/13/22, at 9:55 a.m., the Director of Nursing (DON) confirmed Resident 267 was totally dependent on staff for repositioning in bed, was at high risk for pressure ulcers, and needed to be turned and repositioned every two hours. The DON reviewed Resident 267's care plans and confirmed it did not contain the intervention of turning and repositioning Resident 267 every two hours. The DON was asked if there was documentation in Resident 267's clinical record indicating she was turned and repositioned every two hours and the DON stated there was not any. 055093 Page 14 of 29 055093 05/17/2022 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0686 During an observation on 5/10/22, at 10 a.m., Resident 267 was lying on her side in bed. Level of Harm - Minimal harm or potential for actual harm During an observation on 5/10/22, at 12 p.m., Resident 267 was lying on her side in bed. Residents Affected - Some The facility policy/procedure titled, Prevention of Pressure Ulcers/Injuries, revised 7/2017, indicated: . Prevention: . Mobility/Reposition . 2. At least every hour, reposition residents who are chair-bound or bed-bound with the head of the bed elevated 30 degrees or more. 3. At least every two hours, reposition residents who are reclining and dependent on staff for repositioning. 4. Reposition more frequently as needed, based on the condition of the skin and the resident's comfort . Monitoring: 1. Evaluate, report and document potential changes in the skin. 2. Review the interventions and strategies for effectiveness on an ongoing basis. The facility policy/procedure titled, Repositioning, revised 5/2013, indicated: Purpose: The purpose of this procedure is to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed - or chair-bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents . General Guidelines: 1. Repositioning is a common effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief . 3. Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning . The facility job description titled, CNA, dated 2003, indicated: Purpose of Your Job Position: The primary purpose of your job position is to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan, and as may be directed by your supervisors . Duties and Responsibilities: Administrative Functions: Record all entries on flow sheets, notes, charts, etc., in an informative and descriptive manner . Personnel Functions: Perform all assigned tasks in accordance with our established policies and procedures, and as instructed by your supervisors. Follow work assignments, and/or work schedules in completing and performing your assigned tasks . Personal Nursing Care Functions: . Position bedfast residents in correct and comfortable position . Special Nursing Care Functions: . Turn bedfast residents at least every two hours . The facility job description titled, Charge Nurse, dated 2003, indicated: Purpose of Your Job Position: The primary purpose of your job position is to provide direct nursing care to the residents, and to supervise the day-to-day nursing activities performed by nursing assistants .Administrative Functions: Direct the day-to-day functions of the nursing assistants in accordance with current rules, regulations, and guidelines that govern the long-term care facility . Charting and Documentation: . Chart nurses' notes in an informative and descriptive manner that reflects the care provided to the resident, as well as the resident's response to the care. Personnel Functions: . Make daily rounds of your unit/shift to ensure that nursing service personnel are performing their work assignments in accordance with acceptable nursing standards . Meet with your shift's nursing personnel, on a regularly scheduled basis, to assist in identifying and correcting problem areas, and/or to improve services . Care Plan and Assessment Functions: . Ensure that your assigned CNAs are aware of the resident care plans. Ensure that the CNAs refer to the resident's care plan prior to administering daily care to the resident . 055093 Page 15 of 29 055093 05/17/2022 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews and record review, the facility failed to change the nasal cannula (NC) weekly for one out of 16 sampled residents (Resident 48 ). Staff did not change Resident 48's NC tubing (device used to deliver supplemental oxygen or increased airflow to a patient in need of respiratory help) per the facility's policy policy. This failure had the potential risk of Resident 48 acquiring an infection and or not receiving the correct amount of prescribed oxygen. Residents Affected - Few Findings: During an observation on 5/09/22 at 11:56 a.m., Resident 48 was on oxygen at 2 liters per minute (lpm) via NC with a label that indicated a date of 4/18/22 (the date the NC was changed out). During an observation on 5/10/22 9:12 a.m., Resident 48's NC label was still dated 4/18/22 During an observation and interview on 5/11/22 at 11:50 a.m., Licensed Staff L verified Resident 48's nasal cannula, which was now on the floor, was dated 4/18/22. During an observation on 5/11/22 at 12:42 p.m., Resident 48 was in bed, with oxygen on at 2 lpm via NC with no date label. During an observation and interview on 5/12/22 at 10:04 a.m., Resident 48 was in bed. Licensed Staff G verified Resident 48's NC was not dated. Licensed Staff G stated that not changing the NC was unsanitary and an infection control issue. Licensed Staff G stated Resident 8 may get an infection. Licensed Staff G stated oxygen flow may also be compromised. Licensed Staff G stated the NC should be dated to alert staff of when the NC need to be changed out. During an interview on 5/12/22 at 3:33 p.m., Licensed Staff stated Resident 48's NC should have been changed every Sunday on night shift (NOC) per facility policy. Licensed Staff M stated Resident 48 was at risk for infection, inadequate flow of oxygen and SOB (shortness of breath) if the NC was not changed on a weekly basis. During an interview on 5/12/22 at 4:30 p.m., DSD stated nasal cannula was supposed to be changed weekly by night shift per facility policy. She stated Resident 48 could be at risk for infection. She stated there was a risk of impeded oxygen flow if an occlusion (blockage) occurred. During an interview on 5/13/22 at 9:06 a.m., Licensed Staff K stated the NC should be changed weekly by NOC shift nurses. Licensed Staff K stated Resident 48 was at risk for infection if the nasal cannula was not changed weekly. She stated if NC was not changed weekly, dirty particles might be inhaled by Resident 48. Licensed Staff K stated there might be an occlusion on the NC and Resident 48 would not receive the appropriate amount of oxygen that she needs. During an interview and concurrent Oxygen Therapy policy review on 5/16/22 at 11:24 a.m., Director of Nursing (DON) verified Resident 48's NC should be changed once a week. DON expects the nurses to follow the Oxygen Therapy policy. DON stated that if the NC was not changed weekly, Resident 48 may end up with an infection. DON stated if NC was not changed on a weekly basis, there's a risk of oxygen flow impediment due to sediment build up and Resident 48 may not get the full therapeutic effect of the oxygen therapy. 055093 Page 16 of 29 055093 05/17/2022 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0695 The facility's policy and procedure titled Oxygen Therapy, revised November 2017, indicated oxygen tubing should be changed no more than every 7 days and labeled with the date of change. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055093 Page 17 of 29 055093 05/17/2022 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Based on interview and record review, the facility's consultant licensed pharmacist failed to detect and report 62 medication errors involving the administration of insulin (a hormone which regulates the amount of glucose in the blood) at bedtime to one of 16 sampled residents (Resident 53). Over a four-month period, from January to April 2022, Resident 53 was administered the wrong dose of bedtime insulin 62 out of 118 nights. The wrong doses were documented in Resident 53's medication administration record. The facility's consultant licensed pharmacist reviewed Resident 53's medication administration record monthly during January and April 2022 but did not detect or report these drug errors. This failure prevented the facility from being alerted that Resident 53 was receiving the wrong bedtime doses of insulin which placed Resident 53 at risk of a potentially dangerous drop in blood sugar/hypoglycemia (low blood sugar). Findings: During an interview and record review on 5/12/22, at 10:50 a.m., the Director of Nursing (DON) stated the facility contracted with a consultant licensed pharmacist who conducted monthly drug regimen reviews of all residents. The DON stated that as part of the drug regimen review, the consultant licensed pharmacist reviewed the medication administration record of each resident. The DON provided the consultant licensed pharmacist's monthly drug regimen review reports for Resident 53 from January to April 2022. A review of these reports indicated the consultant licensed pharmacist reviewed Resident 53's medication record during the period of 1/1/22 to 4/29/22 and did not report any irregularities concerning the administration of insulin to Resident 53. The DON confirmed no irregularities were reported by the consultant licensed pharmacist during their monthly drug regimen review for Resident 53 concerning the administration of insulin. A review of Resident 53's Physician Orders indicated an order dated 1/2/22 for insulin four times a day (with meals: at breakfast, lunch and dinner; and at bedtime) as follows: Humalog (a fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) Solution - Inject as per sliding scale . 70-150 (blood glucose measurement) = 0 units; 151-200 = 2 units; 201-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units; 351-400 = 10 units; 401+ call prescriber, subcutaneously (injected just under the skin) with meals for DM2 [diabetes mellitus type 2] AND Inject 8 units subcutaneously with meals for DM2, AND Inject as per sliding scale: if . 201-250 = 1 unit; 251-300 = 2 units; 301-350 = 3 units; 351+ = 10 units, subcutaneously at bedtime for DM2. A review of Resident 53's Medication Administration Record (MAR) for the period of January 2 to April 29, 2022 indicated the facility failed to administer bedtime insulin to Resident 53 according to the above order on 62 out of 118 nights, as follows: JANUARY 2022 (BS = Bedtime Blood Sugar) 1/26 - BS 207 - 4 units given (1 unit ordered) 1/27 - BS 190 - 2 units given (0 units ordered) 1/29 - BS 204 - 4 units given (1 unit ordered) 055093 Page 18 of 29 055093 05/17/2022 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0756 1/30 - BS 202 - 4 units given (1 unit ordered) Level of Harm - Minimal harm or potential for actual harm FEBRUARY 2022 2/1 - BS 211 - 4 units given (1 unit ordered) Residents Affected - Some 2/2 - BS 201 - 4 units given (1 unit ordered) 2/3 - BS 295 - 6 units given (2 units ordered) 2/5 - BS 202 - 4 units given (1 unit ordered) 2/6 - BS 164 - 2 units given (0 units ordered) 2/7 - BS 152 - 2 units given (0 units ordered) 2/8 - BS 163 - 2 units given (0 units ordered) 2/9 - BS 271 - 6 units given (2 units ordered) 2/10 - BS 181 - 2 units given (0 units ordered) 2/11 - BS 202 - 4 units given (1 unit ordered) 2/12 - BS 155 - 2 units given (0 units ordered) 2/13 - BS 202 - 4 units given (1 unit ordered) 2/14 - BS 195 - 2 units given (0 units ordered) 2/15 - BS 219 - 4 units given (1 unit ordered) 2/16 - BS 281 - 6 units given (2 units ordered) 2/17 - BS 192 - 2 units given (0 units ordered) 2/18 - BS 187 - 2 units given (0 units ordered) 2/19 - BS 271 - 6 units given (2 units ordered) 2/20 - BS 158 - 2 units given (0 units ordered) 2/21 - BS 191 - 2 units given (0 units ordered) 2/22 - BS 186 - 2 units given (0 units ordered) 2/23 - BS 194 - 2 units given (0 units ordered) 2/26 - BS 168 - 2 units given (0 units ordered) 055093 Page 19 of 29 055093 05/17/2022 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0756 2/27 - BS 235 - 4 units given (1 unit ordered) Level of Harm - Minimal harm or potential for actual harm MARCH 2022 3/1 - BS 202 - 4 units given (1 unit ordered) Residents Affected - Some 3/3 - BS 225 - 4 units given (1 unit ordered) 3/4 - BS 163 - 2 units given (0 units ordered) 3/5 - BS 198 - 2 units given (0 units ordered) 3/6 - BS 263 - 6 units given (2 units ordered) 3/9 - BS 165 - 2 units given (0 units ordered) 3/10 - BS 180 - 2 units given (0 units ordered) 3/11 - BS 239 - 4 units given (1 unit ordered) 3/12 - BS 221 - 4 units given (1 unit ordered) 3/13 - BS 153 - 2 units given (0 units ordered) 3/16 - BS 258 - 6 units given (2 units ordered) 3/17 - BS 221 - 4 units given (1 unit ordered) 3/18 - BS 192 - 2 units given (0 units ordered) 3/19 - BS 151 - 2 units given (0 units ordered) 3/20 - BS 235 - 4 units given (1 unit ordered) 3/21 - BS 201 - 4 units given (1 unit ordered) 3/22 - BS 233 - 4 units given (1 units ordered) 3/23 - BS 205 - 4 units given (1 unit ordered) 3/24 - BS 256 - 6 units given (2 units ordered) 3/25 - BS 166 - 2 units given (0 units ordered) APRIL 2022 4/13 - BS 178 - 2 units given (0 units ordered) 4/14 - BS 184 - 2 units given (0 units ordered) 055093 Page 20 of 29 055093 05/17/2022 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0756 4/16 - BS 219 - 4 units given (1 unit ordered) Level of Harm - Minimal harm or potential for actual harm 4/17 - BS 160 - 2 units given (0 units ordered) 4/18 - BS 203 - 4 units given (1 unit ordered) Residents Affected - Some 4/19 - BS 214 - 4 units given (1 unit ordered) 4/22 - BS 197 - 2 units given (0 units ordered) 4/23 - BS 193 - 2 units given (0 units ordered) 4/24 - BS 184 - 2 units given (0 units ordered) 4/25 - BS 289 - 6 units given (2 units ordered) 4/26 - BS 156 - 2 units given (0 units ordered) 4/27 - BS 220 - 4 units given (1 unit ordered) 4/28 - BS 288 - 6 units given (2 units ordered) 4/29 - BS 313 - 8 units given (3 units ordered) During interviews on 5/12/22 at 10:50 a.m. and 3 p.m. the Director of Nursing (DON) confirmed the above medication errors concerning the bedtime insulin administration for Resident 53. A review of the facility's policy and procedure titled Consultant Pharmacist Reports, dated December 2016, indicated: The consultant pharmacist performs a comprehensive medication regimen review (MRR) at least monthly Resident-specific irregularities and/or clinically significant risks resulting from or associated with medications are documented and reported to the Director of Nursing, and/or prescriber as appropriate. 055093 Page 21 of 29 055093 05/17/2022 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of 16 sampled residents (Resident 53) was free of significant medication errors when Resident 53 received the wrong dose of insulin (a hormone produced in the pancreas which regulates the amount of glucose in the blood) at bedtime 70 times over a period of 130 days from January 2 to May 11, 2022. These failures resulted in Resident 53 receiving up to four times the ordered bedtime dose of insulin during that period, placing Resident 53 at risk of a potentially dangerous drop in blood sugar/hypoglycemia (low blood sugar). Residents Affected - Some Findings: A review of Resident 53's Facesheet indicated he was admitted to the facility on [DATE] with diagnoses which included diabetes mellitus type 2 (Type 2 diabetes is an impairment in the way the body regulates and uses sugar (glucose) as a fuel). A review of Resident 53's Physician Orders indicated order dated 1/2/22 for insulin four times a day (with meals: at breakfast, lunch and dinner; and at bedtime) as follows: Humalog (a fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) Solution - Inject as per sliding scale . 70-150 = 0 units; 151-200 = 2 units; 201-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units; 351-400 = 10 units; 401+ call prescriber, subcutaneously (injected just under the skin) with meals for DM2 [diabetes mellitus type 2] AND Inject 8 units subcutaneously with meals for DM2 AND Inject as per sliding scale: if . 201-250 = 1 units; 251-300 = 2 units; 301-350 = 3 units; 351+ = 10 units, subcutaneously at bedtime for DM2. A review of Resident 53's Medication Administration Record (MAR) for the period of January 2 to May 11, 2022 indicated the facility failed to administer bedtime insulin to Resident 53 according to the physician's order on 70 out of 130 nights, as follows: JANUARY 2022 (BS = Bedtime Blood Sugar) 1/26 - BS 207 - 4 units given (1 unit ordered) 1/27 - BS 190 - 2 units given (0 units ordered) 1/29 - BS 204 - 4 units given (1 unit ordered) 1/30 - BS 202 - 4 units given (1 unit ordered) FEBRUARY 2022 2/1 - BS 211 - 4 units given (1 unit ordered) 2/2 - BS 201 - 4 units given (1 unit ordered) 2/3 - BS 295 - 6 units given (2 units ordered) 2/5 - BS 202 - 4 units given (1 unit ordered) 055093 Page 22 of 29 055093 05/17/2022 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0760 2/6 - BS 164 - 2 units given (0 units ordered) Level of Harm - Minimal harm or potential for actual harm 2/7 - BS 152 - 2 units given (0 units ordered) 2/8 - BS 163 - 2 units given (0 units ordered) Residents Affected - Some 2/9 - BS 271 - 6 units given (2 units ordered) 2/10 - BS 181 - 2 units given (0 units ordered) 2/11 - BS 202 - 4 units given (1 unit ordered) 2/12 - BS 155 - 2 units given (0 units ordered) 2/13 - BS 202 - 4 units given (1 unit ordered) 2/14 - BS 195 - 2 units given (0 units ordered) 2/15 - BS 219 - 4 units given (1 unit ordered) 2/16 - BS 281 - 6 units given (2 units ordered) 2/17 - BS 192 - 2 units given (0 units ordered) 2/18 - BS 187 - 2 units given (0 units ordered) 2/19 - BS 271 - 6 units given (2 units ordered) 2/20 - BS 158 - 2 units given (0 units ordered) 2/21 - BS 191 - 2 units given (0 units ordered) 2/22 - BS 186 - 2 units given (0 units ordered) 2/23 - BS 194 - 2 units given (0 units ordered) 2/26 - BS 168 - 2 units given (0 units ordered) 2/27 - BS 235 - 4 units given (1 unit ordered) MARCH 2022 3/1 - BS 202 - 4 units given (1 unit ordered) 3/3 - BS 225 - 4 units given (1 unit ordered) 3/4 - BS 163 - 2 units given (0 units ordered) 3/5 - BS 198 - 2 units given (0 units ordered) 055093 Page 23 of 29 055093 05/17/2022 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0760 3/6 - BS 263 - 6 units given (2 units ordered) Level of Harm - Minimal harm or potential for actual harm 3/9 - BS 165 - 2 units given (0 units ordered) 3/10 - BS 180 - 2 units given (0 units ordered) Residents Affected - Some 3/11 - BS 239 - 4 units given (1 unit ordered) 3/12 - BS 221 - 4 units given (1 unit ordered) 3/13 - BS 153 - 2 units given (0 units ordered) 3/16 - BS 258 - 6 units given (2 units ordered) 3/17 - BS 221 - 4 units given (1 unit ordered) 3/18 - BS 192 - 2 units given (0 units ordered) 3/19 - BS 151 - 2 units given (0 units ordered) 3/20 - BS 235 - 4 units given (1 unit ordered) 3/21 - BS 201 - 4 units given (1 unit ordered) 3/22 - BS 233 - 4 units given (1 units ordered) 3/23 - BS 205 - 4 units given (1 unit ordered) 3/24 - BS 256 - 6 units given (2 units ordered) 3/25 - BS 166 - 2 units given (0 units ordered) APRIL 2022 4/13 - BS 178 - 2 units given (0 units ordered) 4/14 - BS 184 - 2 units given (0 units ordered) 4/16 - BS 219 - 4 units given (1 unit ordered) 4/17 - BS 160 - 2 units given (0 units ordered) 4/18 - BS 203 - 4 units given (1 unit ordered) 4/19 - BS 214 - 4 units given (1 unit ordered) 4/22 - BS 197 - 2 units given (0 units ordered) 4/23 - BS 193 - 2 units given (0 units ordered) 055093 Page 24 of 29 055093 05/17/2022 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0760 4/24 - BS 184 - 2 units given (0 units ordered) Level of Harm - Minimal harm or potential for actual harm 4/25 - BS 289 - 6 units given (2 units ordered) 4/26 - BS 156 - 2 units given (0 units ordered) Residents Affected - Some 4/27 - BS 220 - 4 units given (1 unit ordered) 4/28 - BS 288 - 6 units given (2 units ordered) 4/29 - BS 313 - 8 units given (3 units ordered) 4/30 - BS 291 - 6 units given (2 units ordered) MAY 2022 5/1 - BS 164 - 2 units given (0 units ordered) 5/2 - BS 196 - 2 units given (0 units ordered) 5/3 - BS 239 - 4 units given (1 unit ordered) 5/5 - BS 256 - 6 units given (2 units ordered) 5/6 - BS 156 - 2 units given (0 units ordered) 5/9 - BS 287 - 6 units given (2 units ordered) 5/11 - BS 183 - 2 units given (0 units ordered) During interviews on 5/12/22 at 10:50 a.m. and at 3 p.m., the Director of Nursing (DON) and the Nurse Consultant (NC) reviewed Resident 53's Physician Orders and MAR for the period of January to May 2022 and confirmed the above medication errors. The DON and the NC stated it appeared Resident 53's mealtime insulin sliding scale was inadvertently used at bedtime, which had different values and resulted in the wrong doses given to Resident 53. The DON and NC stated they would investigate why the wrong insulin sliding scale was used. During an interview on 5/12/22 at 4:30 p.m. the DON and the NC stated the insulin medication errors for Resident 53 were caused by an [entry] fault in the facility's computerized MAR (Medication Administration Record) system that directed nurses to administer bedtime insulin to Resident 53 using the distinct mealtime sliding scale, which had higher doses than Resident 53's bedtime sliding scale. The DON and the NC demonstrated how the errors occurred. The DON and the NC accessed Resident 53's MAR in the computer and opened the bedtime insulin order, which indicated the correct bedtime sliding scale. The DON and the NC then clicked on the link to document the bedtime insulin administration and a second screen appeared displaying a field to type in Resident 53's blood sugar level. This screen also indicated the correct bedtime insulin sliding scale. The DON and the NC then typed a fictitious blood sugar level for Resident 53 and a third screen appeared indicating the corresponding number of insulin units to be administrated. This third screen, however, indicated insulin dosages corresponding to the mealtime instead of the bedtime insulin sliding scale. 055093 Page 25 of 29 055093 05/17/2022 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of facility policy titled Administering Medications, Revised December 2012, indicated: Medications shall be administered in a safe and timely manner, and as prescribed. A review of facility policy titled Insulin Administration, Revised September 2014, indicated the following: Preparation . The type of insulin, dosage requirements, strength, and method of administration must be verified before administration, to assure that it corresponds with the order on the medication sheet and the physician's order. Steps in the Procedure . check the order for the amount of insulin . double-check the order for the amount of insulin . re-check that the amount of insulin drawn into the syringe matches the amount of insulin ordered. 055093 Page 26 of 29 055093 05/17/2022 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview and record review, the facility failed to employ sufficient dietary personnel when the facility's food and nutrition services was short of one dietary aide and one cook. This failure resulted in the facility's Director of Food Services (DFS) performing the duties of dietary support personnel, such as processing food deliveries, assembling resident lunch trays, and transporting resident food carts, which resulted in perishable foods being left unrefrigerated outdoors and prevented the DFS from managing and overseeing the facility's food and nutrition service. Findings: During an observation on 5/11/22, at 8:20 a.m., there were four dietary support personnel working in the kitchen: [NAME] A, [NAME] B, Dietary Aide C, and Dietary Aide D. During the same observation, the Director of Food Services (DFS) was unloading, labeling, and storing a large quantity of boxes containing food and kitchen supplies placed on pallets outdoors next to the entrance of the kitchen. During an interview on 5/11/22, at 8:45 a.m., the DFS stated he was processing the facility's weekly food delivery that had been delivered, outside, by the vendor. The DFS stated that a dietary aide did this job, but he was short of one dietary aide, and for this reason he was processing the food delivery himself. The DFS stated it would take him the whole day to unload, label, and store all the food delivered. The DFS stated the dietary aide position had been unfilled for over a month. A review of the vendor's invoice for the 5/11/22 delivery indicated 144 boxes of food and kitchen supplies were delivered, including milk, cheese, eggs, ice-cream, yogurt, hamburger beef patties, roast beef, hot dogs, pork, fish, and French toast. During an observation on 5/11/22, at 9:55 a.m., the vendor's weekly food delivery remained outdoors exposed to the elements, including one box of frozen fish, one box of frozen pork, one box of frozen burgers, and one box of frozen French toast, all with an indication to keep frozen and stored at a temperature of zero Fahrenheit or lower. The DFS opened the food boxes and touched the contents to check if they were solid. The French toast was soft to the touch, indicating it was defrosting. During an observation on 5/11/22, at 11:30 a.m., the DFS was still unloading, labeling, and storing the boxes of food and kitchen supplies delivered earlier in the morning. During an observation on 5/11/22, at 12:35 p.m., the DFS was assembling resident lunch trays. During an observation on 5/11/22, at 13:05 p.m., the DFS was pushing resident food carts to the resident units. During an interview on 5/12/22, at 9:10 a.m., the DFS stated he needed five full-time dietary aides to run the kitchen but currently had three full-time and another three on-call dietary aides, who worked an average of eight hours per week each. The DFS stated he also needed three full-time cooks but only had two. A review of the facility's FACILITY ASSESSMENT's Staffing Plan, undated, indicated the need for 4-5 dietary aides and 3-4 cooks to meet the needs of the residents. 055093 Page 27 of 29 055093 05/17/2022 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some A review of the facility's policy and procedure titled Staffing, dated October 2017, indicated Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. A review of the facility's policy and procedure titled Director of Food Services indicated the primary purpose of the position was to assist the Dietician in planning, organizing, developing and directing the overall operation of the Food Services Department in accordance with current federal, state, and local standards, guidelines and regulations governing our facility, and as may be directed by the Administrator, to assure that quality nutritional services are provided on a daily basis and that the Food Services Department is maintained in a clean, safe and sanitary manner. 055093 Page 28 of 29 055093 05/17/2022 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to ensure food was prepared and stored in sanitary manner when perishable food intended for residents was left unrefrigerated outdoors for over 1.5 hours and one of four dietary support personnel did not have their hair fully restrained/covered while preparing resident food. These failures created the potential for foodborne illness in a vulnerable resident population and for food to become contaminated and improper for resident consumption. Findings: During an observation on 5/11/22, at 8:20 a.m., there were four dietary support personnel working in the kitchen: [NAME] A, [NAME] B, Dietary Aide C, and Dietary Aide D. During the same observation, the Director of Food Services (DFS) was unloading, labeling, and storing a large quantity of boxes containing food and kitchen supplies placed on pallets outdoors next to the entrance of the kitchen. During an interview on 5/11/22, at 8:45 a.m., the DFS stated he was processing the facility's weekly food delivery that had been left by the vendor outside. The DFS stated that a dietary aide did this job, but he was short of one dietary aide, and for this reason he was processing the food delivery himself. The DFS stated it would take him the whole day to unload, label, and store all the food delivered. The DFS stated the dietary aide position had been unfilled for over a month. A review of the vendor's invoice for the 5/11/22 delivery indicated 144 boxes of food and kitchen supplies were delivered, including milk, cheese, eggs, ice-cream, yogurt, hamburger beef patties, roast beef, hot dogs, pork, fish, and French toast. During an observation on 5/11/22, at 9:55 a.m., the vendor's weekly food delivery remained outdoors exposed to the elements, including one box of frozen fish, one box of frozen pork, one box of frozen burgers, and one box of frozen French toast, all with an indication to keep frozen and stored at a temperature of zero Fahrenheit or lower. The DFS opened the food boxes and touched the contents to check if they were solid. The French toast was soft to the touch, indicating it was defrosting. During an observation on 5/11/22, at 10:45 a.m., Dietary Aide C was preparing salads for residents in the kitchen. Dietary Aide C had her hair restrained by a hair net, but the hair net covered only the top half of her hair, leaving the bottom half of her hair un-restrained. A review of the Food and Drug Administration (FDA) Food Code 2017 indicated: A FOOD that is labeled frozen and shipped frozen by a FOOD PROCESSING PLANT shall be received frozen. Also, Stored frozen FOODS shall be maintained frozen. A review of facility policy and procedure titled Food Receiving and Storage, revised October 2017, indicated: Foods shall be received and stored in a manner that complies with safe food handling practices. A review of facility policy and procedure titled Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, dated October 2017, indicated: Hair nets or caps and/or beard restraints must be worn to keep hair from contacting exposed food, clean equipment, utensils and linens. 055093 Page 29 of 29