Health inspection·November 22, 2024

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 two of four Licensed Nurses (Licensed Nurse (LN) H and Licensed Nurse (LN) O ) followed professional standards of practice when: Residents Affected - Few 1. LN H left medications by Resident 67's bedside without a physician order. 2. LN O did not follow facility policy when performing a blood glucose (Blood sugar) check for Resident 170. These failures had the potential to result in medication administration errors and inaccurate blood glucose tests which could have caused harm to the residents involved. Findings: Resident 67 Record review of Resident 67's Face Sheet (Facility demographic) indicated he was admitted to the facility on [DATE] with medical diagnoses including Encephalopathy (A general term for a group of conditions that cause brain dysfunction) and Diabetes Mellitus (A chronic disease characterized by high levels of blood sugar). During an observation and interview on 11/20/24 at 6:02 p.m., LN H was observed administering insulin (Injectable medication to treat high blood glucose levels) to Resident 67. A cup containing two capsules was observed at Resident 67's bedside table, untouched and unattended. Resident 67 was in his room with his wife sitting in a chair right next to his bed. LN H was asked what medications were in the cup. LN H stated they were Atorvastatin (A medication to treat high cholesterol levels) and Melatonin (A medication to support sleep). LN H stated she left them on Resident 67's bedside table at around 5:00 p.m., because Resident 67's wife preferred to administer them herself. LN H was asked if there was a physician order for that. LN H stated she did not know if there was an order. Record review of Resident 67's physician orders for November 2024, indicated, Atorvastatin Calcium Oral (By mouth) Tablet 20 MG (Milligrams) Give 1 tablet by mouth at bedtime for hyperlipidemia (High cholesterol) .Melatonin Oral Tablet 5 MG Give 1 tablet by mouth at bedtime. The November 2024 physician orders did not indicate Resident 67 was cleared for self-administration of medications, nor did it say it was acceptable for Resident 67's family to administer his medications. Record review of Resident 67's Medication Administration Record (MAR) for November 2024, indicated, both Melatonin and Atorvastatin were scheduled to be administered daily at 9:00 p.m. Page 1 of 22 055093 055093 11/22/2024 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 11/20/24 at 6:13 p.m., Resident 67's wife stated she administered Resident 67's Atorvastatin and Melatonin daily at around 7:30 p.m., and nurses, did not mind. This indicated that these medications were administered more than 1 hour before they were scheduled, therefore, this suggested there was a medication administration error being committed daily when the wife was present. Record review of the facility policy titled, MEDICATION ADMINISTRATION-GENERAL GUIDELINES, dated October of 2017, indicated, Medications are administered only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to administer medications .Medications are administered in accordance with written orders of the attending physician .Medications are administered at the time they are prepared .Medications are administered within 60 [NAME] of scheduled time (1 our before and 1 hour after) .Residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. Resident 170 Record review of Resident 170's Face Sheet (Facility demographic) indicated he was admitted to the facility on [DATE] with medical diagnoses including Traumatic Subarachnoid Hemorrhage (Bleeding in the brain) and Diabetes Mellitus. Record review of Resident 170's physician orders for November of 2024 indicated, Check blood sugar before meals for blood sugar monitoring related to Diabetes management. During a concurrent observation and interview on 11/20/24 at 4:24 p.m., LN O was checking Resident 170's blood glucose levels. LN O was observed cleaning Resident 170's finger with an alcohol wipe. After wiping the finger with the alcohol wipe, LN O proceeded to obtain a blood sample using a sterile lancet (Small blade or needle) before allowing the alcohol to dry, and immediately used the first drop of blood for the blood glucose test, which provided a reading that was recorded by LN O. LN O was asked the reason she had used the very first drop of blood (From Resident 170's fingertip) for the test. LN O stated Resident 170 was a hard bleeder, and if she wiped the first drop, he would not produce a second drop, and would have to be poked again. Record review of Resident 170's care plan for Diabetes indicated, [Resident 170] is at risk for hypoglycemia (Low blood glucose levels) and hyperglycemia (High blood glucose levels) R/T (Related to) type 2 diabetes .Observe/report signs and symptoms of hypoglycemia. The care plan did specify the steps for obtaining a blood for a glucose test, nor did it indicate Resident 170 was difficult to bleed. Record review of the facility policy titled, Obtaining a Fingerstick Glucose Level, last revised in October 2011, indicated, Wash the selected fingertip, especially the side of the finger, with warm water and soap. (Note: If alcohol is used to clean the fingertip, allow it to dry completely because the alcohol may alter the reading) .Obtain a blood sample by using a sterile lancet . Discard the first drop of blood if alcohol is used to clean the fingertips because alcohol may alter the results. 055093 Page 2 of 22 055093 11/22/2024 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of seventeen sampled residents (Resident 21) had intervention and supervision implemented to prevent falls. As a result, Resident 21 sustained four falls with minor injuries (Skin tears and bruises) in a period of ten months. This failure had the potential to result in further falls with injuries for Resident 21. Findings: Record review of Resident 21's Face Sheet (Facility demographic) indicated he was admitted to the facility on [DATE] with medical diagnoses including Chronic Obstructive Pulmonary Disease (A lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible) and Muscle Weakness (Loss of muscle strength). Record review of Resident 21s Brief Interview of Mental Status (BIMS-A cognition assessment) dated 10/11/24 indicated he received a score of 12, which indicated his cognition was moderately impaired (A score of 1-7 indicates the cognition is severely impaired, 8-12 indicates the cognition is moderately impaired, and 13-15 indicates the cognition is intact). Record review of a falls risk assessment titled, Morse Fall Risk Screen, dated 3/02/24 at 2:12 a.m., indicated Resident 21 was at high risk for falls. First Fall: Record review of an Interdisciplinary Note (IDT) for Resident 21 dated 9/05/24 at 10:17 a.m., indicated, unwitnessed fall with no injury 9/2/2023 around 1920 (7:20 p.m.). Pt (patient) was found on the bathroom floor by LN (Licensed Nurse), sitting on his bottom, no changes in baseline LOC (Level of consciousness) able to verbalize needs. Record review of Resident 21's care plan for falls initiated on 9/02/24 indicated interventions were initiated to prevent further falls such as, Continue PT (Physical therapy)/OT (Occupational therapy) as needed .Assist resident during toileting. During an interview with the Director of Nursing (DON) on 11/22/24 at 9:36 a.m., she stated the standard supervision of residents at the facility consisted of checking them every two hours. The DON was asked if supervision for Resident 21 was increased after the unwitnessed fall on 9/02/23. The DON stated it did not increase because Resident 21 was alert and oriented. Second Fall: Record review of an IDT note dated 10/20/23 at 10:10 a.m., indicated, IDT .met to discuss COC (Change of condition) of unwitnessed fall with minor injury (skin tear at R (Right) dorsal hand (Back of the hand), 3 skin tears at R posterior forearm RLE (Right lower extremity) skin tear and contusion (bruise)/swelling on R (Right) knee) on 10/17/23 around 1400 (2:00 p.m.). Pt had unwitnessed fall at the tow yard while out on pass from the facility. Pt claimed he lost his balance and he called 911 and was brought to ER (Emergency room) by paramedics. 055093 Page 3 of 22 055093 11/22/2024 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review indicated the care plan for falls was revised on 10/19/24 (two days after the fall) with only one new intervention. The new intervention indicated, Remind resident that he needs a companion to go out on pass. During an interview with the DON on 11/22/24 at 9:36 a.m., she was asked how they measured the intervention of reminding Resident 21 that he needed a companion when leaving the facility, and if staff were given an in-service about this new intervention. The DON stated an in-service was not completed because it was Licensed Nurses' responsibility to read the residents' care plans, and new interventions were endorsed to them verbally. The DON also confirmed and there was no documentation Licensed Nurses (assigned to Resident 21) were reminding Resident 21 to have a companion, every time he left the facility. Third Fall: Record review of an IDT note dated 4/11/24 at 9:53 a.m., indicated, IDT met .discuss about assisted fall with minor injury .at 4/10/2024 at around 1400 .Pt was standing next to bed, with brief being adjusted by CNA (Certified Nursing Assistant), when pt stated he felt his grip slip and began to fall to the right side. CNA assisted pt downward and to floor. Record review indicated the care plan for prevention of falls was revised on 4/10/24, but no new interventions were added that had not been attempted before. For example, it indicated, Check and assess resident for presence of pain .Determine cause of fall .Notify MD. These three interventions were aimed at providing care right after the fall, not at preventing further falls. The interventions indicated, Refer to Rehab (Rehabilitation). This intervention had been attempted before and had not been successful in preventing further falls (See care plan above initiated on 9/02/23). During an interview with the DON on 11/22/24 at 9:36 a.m., she stated supervision was not increased for Resident 21 after the fall on 4/10/24 because this was a witnessed fall. She also confirmed the only new intervention for falls after the fall on 4/10/24 was to refer Resident 21 to rehabilitation. The DON stated the falls were being caused by Resident 21's knee problems but was unable to provide documentation of this. Record review of a falls risk assessment titled, Morse Fall Risk Screen, dated 4/10/24 at 2:50 p.m., indicated Resident 21 was at high risk for falls. Fourth Fall: Record review of an IDT note dated 7/01/24 at 12:13 p.m., indicated, unwitnessed fall with minor injury (L (Left) foot skin tear) at 6/30/2024 around 1643 (4:43 p.m.). At around 1643, pt found on the floor next to bed by CNA. Pt claimed that he was trying to look for one of the nurses from the previous shift when interviewed. Record review indicated the care plan for prevention of falls was revised on 7/01/24, with interventions such as Have things needed by the resident within reach including call light .Provide assistance needed. There were no interventions in this care plan to increase supervision of Resident 21. Record review of a falls risk assessment titled, Morse Fall Risk Screen, dated 9/06/24 at 11:22 a.m., indicated Resident was at high risk for falls. 055093 Page 4 of 22 055093 11/22/2024 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with the DON on 11/22/24 at 9:36 a.m., she confirmed supervision was not increased after Resident 21's fall on 6/30/24. During an interview on 11/22/24 at 11:20 a.m., CNA N (Resident 21's assigned Certified Nursing Assistant) was asked what interventions were in place to prevent Resident 21 from falling. CNA N stated the Surveyor would have to ask a Licensed Nurse that question. CNA N was asked if she was familiar with Resident 21, to which she stated she was. Then CNA N stated they used a lift (Specialized medical device designed to assist individuals with limited mobility in transitioning from a seated to a standing position) for Resident 21's transfers. CNA N stated she checked on Resident 21 every 15 minutes but did not document. CNA N was asked if Resident 21 was at risk for falls. CNA N stated if he (Resident 21) was (At risk for falls), he would have a star next to his name on the door label and there was no star next to his name (Suggesting Resident 21 was not at risk for falls). During an observation on 11/22/24 at 11:38 a.m., it was noted there was a star right next to Resident 21's name on the door label, indicating he was at risk for falls. Record review of the facility policy titled, FALLS MANAGEMENT PROGRAM, last revised in January of 2019, indicated, The facility will provide residents with adequate supervision and assistive device to prevent accidents .After a fall incident, the Licensed Nurse will check the resident for a change in the level of consciousness .The Licensed Nurse will determine the cause of the fall and provide interventions to manage the falls and the reduce the risk of additional falls and injury .Care plan will be reviewed and updated with new interventions to minimize injury and limits risks of falls. 055093 Page 5 of 22 055093 11/22/2024 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review, the facility failed to ensure two of three medication carts (Medication cart for Station 2 and medication cart for Station 3), in addition to the medication room, were free of expired and outdated medications and medical supplies for residents. This failure had the potential to result in inadvertently using these products on residents, which could have caused them harm and infections. Findings: During a medication storage observation and interview on 11/18/24 at 10:55 a.m., with Licensed Nurse (LN) F, the medication Latanoprost 0.005% (A medication to treat increased pressure in the eye) was observed stored inside the medication cart for Station 2 with other active medications. This medication had an expiration date of 11/15/24 and belonged to Resident 47. LN F confirmed the finding and stated the Infection Preventionist (IP) and Director of Staff Development (DSD) were responsible for checking the medication carts every week to check for expired medications. LN F confirmed this expired medication should not be stored in the medication cart with other active medications. During a concurrent observation and interview with the Director of Nursing (DON) on 11/18/24 at 3:36 p.m., inside the medication room of the facility, more than 10 syringes were found with an expiration date of 11/10/2024 in a storage container, stored with unexpired medical supplies. In addition, more than 10 syringe caps with an expiration date of 5/01/24 were found stored with unexpired supplies. An insulin syringe with an expiration date of 3/16/23 was found stored with unexpired medical supplies. Several COVID-19 tests with an expiration date of 12/19/23 were found stored in the medication room with unexpired medical supplies. The DON confirmed these findings and stated expired medical supplies may not be good to use after their expiration date. Photographs were taken as evidence. During a medication storage observation and interview on 11/19/24 at 11:05 a.m., with Licensed Nurse (LN) R, a bottle containing 30 collagen tablets was found inside a mailing package stored inside the medication cart of Station 3, with other active medications. LN R stated this medication belonged to a resident who had been discharged about a week prior, and the packet had arrived to the facility after the resident had been discharged . During an interview on 11/21/24 at 3:10 p.m., the DSD stated Licensed Nurses were assigned to check the medication carts assigned to them to ensure there were no expired or outdated medications. The DSD stated the medication room was assigned to be checked by the central supply department once a month to ensure there were no expired supplies in place for use. The DSD stated expired items could malfunction after their expiration date. Record review of the facility policy titled, MEDICATION STORAGE IN THE FACILITY, last revised in April of 2008 indicated, Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. 055093 Page 6 of 22 055093 11/22/2024 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to follow the recipe for pureed rice. This failure could lead to potential food safety issues, inconsistent quality of meals for residents, and nutritional deficiencies. Findings: A review of [NAME] Puree Recipe Book, recipe name Pureed Potatoes, Pasta, [NAME] and Other grains, the recipe indicated an ingredients of potatoes, pasta, rice cooked and drained, broth hot or hot 2 percent milk, margarine and thickener. A review of [NAME] Puree Recipe Book, recipe name Pureed Salad-Potato, Pasta and Other Grains the recipe indicated an ingredients of salads, potato and pasta type and thickener. During an observation on 11/20/24 at 11:40 a.m., [NAME] 1 did not follow the pureed recipe for rice when she did not add margarine and thickener when she prepared the pureed rice. During an interview on 11/20/24 at 10:12 a.m., the Registered Dietician (RD) stated it was expected cooks were following the recipes to ensure consistent quality food was served to the resident and to prevent potential health risks for the residents. During a concurrent observation and interview on 11/20/24 at 11:40 a.m., [NAME] E was observed looking at the recipe binder and stated she was looking for the recipe for pureed rice. [NAME] E verified she followed the Pureed Salads-Potato, Pasta and Other Grains recipe. [NAME] E verified using 10 scoops of rice and 1 and a half (1 ½) cup of broth. [NAME] E verified she did not add anything else. [NAME] E stated it was the facility's policy to ensure they follow the recipes when cooking to make sure residents were receiving the right amount of nutrients with food they were preparing. [NAME] E stated not following the recipes could lead to food not having the same flavor, residents may not eat the food and weight loss. During an interview on 11/20/24 at 3:20 p.m., the Dietary Manager (DM) stated staff should be following the recipes. The DM stated the facility should not use pureed salad recipe when making pureed rice. The DM stated it was important staff follow the correct recipe to provide residents with consistent quality food and proper portion control and to ensure food served for the residents were meeting their dietary needs. A review of the facility policy and procedure (P&P) titled Food Preparation, RDs for Healthcare 2018, the P&P indicated the facility will use approved recipes, standardized to meet the residents census .recipes are specific as to portion yield, method of preparation, amounts of ingredients . 055093 Page 7 of 22 055093 11/22/2024 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure residents were served with food that was palatable, attractive and at an appetizing temperature. These failures could put the residents at risk for illness, injury, malnutrition (lack of proper nutrition, caused by not having enough to eat, not eating enough of the right things), and poor nutritional status. Residents Affected - Some Findings: A review of Resident 18's face sheet (demographics) indicated he was admitted on [DATE] with a diagnosis of Essential Hypertension (HTN, high blood pressure) and Muscle weakness. Resident 18's Brief Interview for Mental Status (BIMS, used to get a quick snapshot of how well you are functioning cognitively -mental process involved in comprehension and gaining knowledge) dated 11/12/24 score was 15 indicating intact cognition. A review of Resident 22's face sheet indicated she was admitted on [DATE] with a diagnoses of Essential Hypertension and Atelectasis (partial or complete collapse of the lung). Resident 22's BIMS dated 11/8/24 score was 15 indicating intact cognition. During an observation on 11/20/24 at 1:00 p.m. [NAME] E did not sample the food she prepared. During an observation on 11/20/24 at 1:27 p.m., the food served did not have a pleasant presentation and looked unappealing and unappetizing. The dietary manager (DM) took the temperature of the food items on the test tray: temperature was as follow: rice at 130 degrees, chicken with lemon and thyme at 130 degrees and the burger patty was at 118 degrees. Per facility policy, hot foods should be held prior to service (the process of storing prepared food at a safe temperature before it is served) at 140 degrees or above. Upon sampling the chicken with lemon and thyme, it was dry, had a bland taste and was not able to taste the lemon. The rice and chicken with lemon and thyme when sampled was lukewarm. During an interview on 11/22/24 at 9:30 a.m. Resident 18 stated there was not a taste of lemon on the chicken. Resident 18 stated he recalled the chicken being dry and not having a lot of taste. Resident 18 stated he wished the chicken was not dry and hoped the food would have more flavor. During an interview on 11/22/24 at 3:07 p.m., Resident 22 stated the chicken was dry as a straw and was very bland and did not have a taste at all. Resident 22 stated she did not taste lemon in the chicken at all. Resident 22 stated the food was already lukewarm when she received it. During an interview on 11/22/24 at 9:52 a.m., the DM stated the temperatures taken on the food on test tray on 11/20/22 were not at a level where it was appetizing. The DM verified the food served did not appear appetizing at all. The DM stated if the food did not have flavor, was not served in an appealing manner and at a temperature that residents will enjoy, residents would be at risk of weight loss and residents not receiving the appropriate nutrients they need to stay healthy or get better. A review of the facility policy and procedure (P&P) titled Food Preparation, RDs for Healthcare 2018, the P&P indicated the food shall be prepared by methods that conserve nutritive value, flavor and appearance .prepared food will be sampled. The food and nutrition services employee who prepares 055093 Page 8 of 22 055093 11/22/2024 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0804 the food will sample it to be sure the food has a satisfactory flavor and consistency .hot foods should be held prior to service at 140 degrees or above . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 055093 Page 9 of 22 055093 11/22/2024 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 - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews and record reviews, the facility failed to ensure: 1A. two food items in the freezer were clearly labeled to identify what it was, when it was opened and when to discard the food item. 1B. one pitcher of tea was discarded by the use by date of 11/16/24. 2. one dented can (might contain bacteria that can make you sick, or even produce a toxin that can be deadly) was not separated from intact cans. These failures could put the residents at risk for: 1A. allergic reactions, health complications and food poisoning (infection or irritation of your digestive tract that spreads through foods). 1B.consuming tea that might contain bacteria which can cause abdominal pain, vomiting, diarrhea (three or more loose stools per day), and fever. 2. consuming food that was contaminated with molds, bacteria or the toxin produced by the bacteria Clostridium botulinum (causes Botulism, a rare but serious condition caused by a toxin that attacks the body's nerves and may cause life-threatening symptoms such as paralysis-loss of the ability to move and difficulty breathing). Findings: 1A and 1B. During a concurrent observation and interview on 11/18/24 at 9:38 a.m., the dietary Manager (DM) verified refrigerator number (#) 1 had a pitcher of tea, with a label indicating it was made on 11/9/24 and a discard date by 11/16/24. The DM verified this tea should have been discarded on 11/16/24 to ensure only items safe for residents' consumption were stored in the refrigerator. The DM stated not discarding the tea on the discard date could result to staff accidentally serving this tea to the residents. The DM stated this was a quality and safety issue. During a concurrent observation and interview on 11/18/24 at 9:48 a.m., there was a blue plastic bag containing brownish colored nuggets inside the freezer #6 which was unlabeled and undated. The dietary Manager (DM) verified the blue plastic bag with brownish colored nuggets was undated and had no label to identify what the content was. The DM stated he knew it was vegan chicken nuggets. The DM stated all items in the kitchen should be labeled so it should be easily distinguished from other food items. The DM stated the reason for this was to ensure correct items were being served to the residents. The DM stated that not clearly labeling what the food item was could put the residents at risk for being served a food item that they were allergic to or being fed with food item that was not appropriate for their diet. The DM stated this could be a safety risk for the residents. The DM stated food items should also be open dated with discard date. The DM stated it was important to ensure there was a discard date on food items to ensure quality control and to ensure residents were not fed food that were spoiled. The DM stated not discard dating a food item could put the residents at risk for eating food that were spoiled which could make them sick with gastrointestinal illness (GI, pertains to stomach and intestines) and diarrhea (loose stools). 055093 Page 10 of 22 055093 11/22/2024 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0812 Level of Harm - Minimal harm or potential for actual harm During an interview on 11/20/24 at 10:12 a.m., the Registered Dietician (RD) stated all food items in the kitchen should be labeled so staff would know what it was. The RD stated not properly labeling the food could result to staff mistaking it for something that it was not. The RD stated this was a safety issue for the residents as well. The RD stated the facility would not want to serve residents food that was not in accordance with their diet preference. Residents Affected - Some During a concurrent observation and interview on 11/20/24 at 10:18 a.m., the RD pulled a bag of white sticks out of the refrigerator. The RD and DM both verified the bag of white sticks in the refrigerator was not labeled on what it was. The RD stated that should have been labeled so staff could easily identify the food item. The DM verified it was hash brown. The RD stated she thought it was cheese. During an interview on 11/20/24 at 10:30 a.m., [NAME] 1 stated the food items should be labeled to identify what it was and should be open and discard dated to ensure staff were serving the right food for the residents and to ensure staff were only serving food items to the residents that was not past due to prevent them from getting sick. A review of the facility's policy and procedure (P&P) titled Storage of Food and Supplies RD's for Healthcare, Inc. 2017, it indicated it was the policy the food and supplies will be stored properly in a safe manner .labels should be visible, should be dated- month, date and year. A review of the facility's P&P titled General Receiving of Delivery of Food and Supplies RD's for Healthcare, Inc. 2018, it indicated to label all items with delivery date or use by date. 2. During a concurrent observation and interview on 11/18/24 at 10:04 a.m., the DM verified a large can of dented vanilla pudding was stored along with the intact cans where staff could access it and serve to the residents. The DM stated this can should have been removed from that shelf and should have been placed in a shelf dedicated for dented cans. The DM stated not removing the dented can in the shelf where staff could access it and serve to the residents put their safety at risk. The DM stated dented can might be chipped and might had allowed bacteria to enter the can. During an interview on 11/20/24 at 10:12 a.m., the RD stated dented cans should be separated from the intact cans and should not be placed with items that was going to be used for residents' consumption. The RD stated dented cans should be placed away from cans that would be used for residents' consumption. The RD stated using a dented can for resident consumption was unacceptable because bacteria could potentially get into a dented can. The RD stated this was a safety risk for the residents. During an interview on 11/20/24 at 10:30 a.m., [NAME] A stated dented cans should be separated from the ones to be used for residents' consumption. [NAME] A stated not separating the dented can from cans that were not dented could lead to staff accidentally using the dented can for residents' consumption. [NAME] A stated if that happened and a dented can was served to the resident, it could make the residents sick. A review of the facility's policy and procedure (P&P) titled Storage of Food and Supplies RD's for Healthcare, Inc. 2017, it indicated it was the policy the food and supplies will be stored properly in a safe manner . have a separate area for dented cans and damaged food items 055093 Page 11 of 22 055093 11/22/2024 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews and record reviews, the facility failed to follow their policy on foods brought by family/ visitors when the food stored in resident's refrigerator by the nursing station did not have a use by date per their policy. This failure could lead to residents potentially consuming food that has gone past its safe consumption window, increasing the risk of foodborne illness due to bacteria growth, as well as potential issues with food quality and taste deterioration, which could impact resident nutrition and well-being. Residents Affected - Some Findings: A review of Resident 225's face sheet (demographics) indicated an admission date of 11/6/24 with a diagnoses of Essential Hypertension (HTN, high blood pressure) and Hyperlipidemia (HLP, abnormally high concentration of fats or lipids in the blood). During an observation on 11/19/24 at 3:48 p.m., Resident 225 had 6 food containers in the resident's refrigerator by the nursing station as follows, 2 containers of chilis, 1 container of meatloaf, 1 container of cage free egg salad, and 2 container of potato salads. All these containers did not have a use by date. During a concurrent observation and interview on 11/19/24 at 3:48 p.m., Licensed Nurse (LN) H and LN F verified Resident 225 food items did not have a use by date. During a concurrent observation, interview and Foods brought by Family/Visitors policy and procedure record review on 11/19/24 at 4:24 p.m., LN G verified Resident 225's food items had no use by date. LN G read the facility's policy and procedure (P&P) titled Foods brought by Family/Visitors. LN G verified the P&P indicated containers will be labeled with the resident's name, the item, and the use by date. LN G verified the P&P was not followed when Resident 225's food containers did not have a use by date. LN G stated not putting the use by date could result in serving a food item that was spoiled which could make the resident sick. During a concurrent interview and Foods brought by Family/Visitors P&P record review on 11/19/24 at 4:28 p.m., LN F stated the P&P was not followed when Resident 225's food items did not have a use by date. LN F stated it was important to make sure food items brought by family/visitor's had use by date to make sure residents were served food that was not spoiled and was still safe for residents to eat. During a concurrent interview and Foods brought by Family/Visitors P&P record review on 11/21/24 at 11:31 a.m., the Infection Preventionist verified the P&P indicated the containers should be labeled with the residents name, the item and the use by date. When shown a photograph of Resident 225's food items found in residents' refrigerator by the nursing station on 11/19/24, the Infection Preventionist (IP) stated Resident 225's food containers did not have a use by date. The IP verified the policy was not followed when there was no use by date indicated on Resident 225's food items. The IP stated it was important to make sure the use by date was indicated on the food stored in the resident's refrigerator by the nursing station to ensure residents would not be served food that was past use by date and to ensure food was still safe for consumption. The IP stated putting a use by date on food items lessen the risk of residents getting sick with food borne illness. During a concurrent interview and Foods brought by Family/Visitors P&P record review on 11/22/24 at 055093 Page 12 of 22 055093 11/22/2024 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0813 Level of Harm - Minimal harm or potential for actual harm 10:28 a.m., the Director of Nursing (DON) verified the policy was not followed when Resident 225's food items did not have a use by date. The DON stated it was important to put the use by date to prevent staff from serving food items that were spoiled for residents' safety. When shown a photograph of Resident 225's food items found in residents refrigerator on 11/19/24, the DON verified Resident 225's food containers did not have a use by date. Residents Affected - Some A review of the facility's P&P titled Foods Brought by Family/Visitors, revised 2013, the P&P indicated the containers will be labeled with the resident's name, the item and the use by date. 055093 Page 13 of 22 055093 11/22/2024 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to: Residents Affected - Some 1. Process soiled linens to prevent the spread on infection. 2 A. Offer hand hygiene (HH) to eight of nine residents (Resident 59, Resident 225, Resident 61, Resident 121, Resident 40, Resident 5, Resident 49, and Resident 120) before meals. 2 B. Perform HH prior to donning new gloves by one dietary staff , [NAME] E. 3. Use enhanced barrier precautions (A set of infection control measures that reduce the spread of multidrug-resistant organisms (MDROs) in nursing homes) when two nursing assistants working with Resident 33 who had a history of Methicillin-resistant Staphylococcus aureus (MRSA-A type of bacteria resistant to a certain type of antibiotics), did not follow the precautions. 4. Air dry kitchen utensils prior to storing in the kitchen drawers. These failures had the potential to result in the transmission of infections to the residents of the facility. Findings: 1. During a concurrent observation and interview on 11/21/24, at 10:07 a.m., with Laundry Staff D, it was observed that the facility's washing machine equipment was in use, but the temperature gauge was at 0 degrees Fahrenheit. Laundry Staff D stated that she observed earlier that day that the temperature gauge of the washing machine was at 160 degrees Fahrenheit. (Per CDC (Centers for Disease Control and Prevention) in nursing homes, the washing machine temperature should be at least 160 degrees Fahrenheit to kill bacteria and viruses). This surveyor took pictures and videos while doing the observation to indicate that the facility's washing machine equipment had a malfunction. During a concurrent observation and interview on 11/21/24, at 10:51 a.m., with the facility Administrator and Licensed Staff D, the Administrator stated there was another temperature gauge that was now missing. The Administrator stated that the temperature gauge, which was showing that it was at 0 degrees Fahrenheit, seemed newly installed, but he did not know who installed it. This surveyor did not feel any heat after touching the sides of the washing machine equipment. When the Administrator and Licensed Staff D were asked if the laundry kept a log of washing machine temperatures to determine previous temperature readings, both stated that the laundry did not keep temperature logs of their washing machine equipment. A review of a facility policy and procedure (P&P) titled, Departmental (Environmental Services)- Laundry and Linens, dated January 2014, indicated under, Purpose, the P&P indicated, The purpose of this procedure is to provide a process for the safe and aseptic (free from contamination caused by harmful bacteria, viruses, or other microorganisms) handling, washing, and storage of linen. Under Washing and other Soiled Linens, the P&P indicated, 1. Laundry may be processed in either low-temperature or high temperature cycles. For 055093 Page 14 of 22 055093 11/22/2024 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some high-temperature processing, wash linen in water that is at least 160 degrees Fahrenheit, for a minimum of twenty (25) minutes. For low-temperature processing, wash linen in water that is at least 71-77 degrees Fahrenheit and use a 125 part-per-million (ppm) chlorine bleach rinse if the material being washed can withstand leach and remain intact. A review of a CDC infection control laundry and bedding guidelines from the Guidelines for Environmental Infection Control in Healthcare Facilities (2003), indicated, .A temperature of at least 160°F (71°C) for a minimum of 25 minutes is commonly recommended for hot water washing. Water of this temperature can be provided by steam jet or separate booster heater. The use of chlorine bleach assures an extra margin of safety . 2A. During observation on 11/18/24, the following were observed: at 12:51 p.m., CNA (Certified Nursing Assistant) A served Resident 59's lunch tray but was not heard or seen to encourage or offer hand hygiene to the resident and did not use the alcohol-based hand rub (ABHR) found at the door of the room. at 12:53 p.m., CNA A served Resident 225's lunch tray, but after moving the resident to an upright position, was not heard or seen offering or reminding hand hygiene to the resident. at 12:57 p.m., CNA A served Resident 61's lunch in the presence of another CNA in the room but was not heard to remind or offer HH to the resident. at 1:03 p.m., CNA B served Resident 121's lunch tray but was not heard or observed to offer HH to the resident. CNA B was not observed to use the AHR by the door of the room. at 1:07 p.m., CNA C served Resident 40's lunch tray but was not heard or seen to offer or remind HH to the resident. at 1:09 p.m., CNA C served Resident 5's lunch tray but was not heard or seen to offer HH to the resident. at 1:11 p.m., CNA B served Resident 49's lunch tray but was not heard of seen to offer HH to the resident. CNA B was not seen performing HH coming out the room. During an interview on 11/18/24, at 1:13 p.m., Resident 120's wife was asked if the CNA who served her husband's lunch tray offered, reminded, or encouraged HH to her husband, stated: no, he was not offered nor reminded HH before eating. During an interview on 11/18/24, at 4:27 p.m., CNA B stated she was not aware she had to remind residents to use the wet wipes in their meal trays when serving residents in their rooms. CNA B stated she knew in the dining room they encouraged the resident to use the wet hand wipes. CNA B stated she had to return the tray covers outside, but she did her HH after that. A review of the facility's policy and procedure (P&P) titled Handwashing/Hand Hygiene, revised 6/2021, the P&P indicated to use an alcohol based hand rub containing at least 62 percent alcohol; or alternatively, soap (antimicrobial- contains chemicals that kill or stop the growth of bacteria or non-antimicrobial) and water for the following situations: before or after eating food .before donning gloves .after removing gloves 055093 Page 15 of 22 055093 11/22/2024 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2 B. During a concurrent observation and interview on 11/20/24 at 11:15 am., [NAME] E verified she did not perform HH when she removed her gloves and donned a new glove. [NAME] E stated the facility policy was to ensure staff perform HH after removing gloves and prior to donning new gloves. [NAME] E stated it was for infection control measure. During an interview on 11/21/24 at 9:10 a.m., the Infection Preventionist (IP) stated it was the facility's policy to ensure staff were performing HH after removing gloves and prior to donning gloves. The IP stated performing HH prior to donning new gloves prevents contamination of gloves and the spread of bacteria. The IP stated, if the staff removed the gloves and donned new gloves without performing HH first, it meant the policy was not followed and it could be a safety risk for the residents. During an interview on 11/21/24 at 10:03 a.m., CNA L stated it was the facility's policy for staff to perform HH after removing gloves and prior to donning new gloves to prevent transmission of infection and to prevent cross commination so that residents were protected from infection. A review of the facility's policy and procedure (P&P) titled Handwashing/Hand Hygiene, revised 6/2021, the P&P indicated to use an alcohol based hand rub containing at least 62 percent alcohol; or alternatively, soap (antimicrobial- contains chemicals that kill or stop the growth of bacteria or non-antimicrobial) and water for the following situations: before or after eating food .before donning gloves .after removing gloves 3. Record review of Resident 33's Face sheet (Facility demographic) indicated she was admitted to the facility on [DATE] with medical diagnoses including Chronic Obstructive Pulmonary Disease (A lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible). Record review of a General Acute Care Hospital discharge summary for Resident 33 dated 10/07/24 at 10:18 a.m., indicated, recent admission in 6/24 for MRSA (Methicillin Resistant Staphylococcus Aureus-A type of bacteria resistant to a certain type of antibiotics) PNA (Pneumonia), which specified Resident 33 had a history of MRSA. Record review of a document titled, Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes, published by Centers for Disease Control and Prevention (National public health agency of the United States) on 6/28/24, indicated, Residents colonized with a novel or targeted MDRO (Multidrug-resistant organisms (MDROs) are bacteria that are resistant to more than one antibiotic and can be difficult to treat) are intended to remain on Enhanced Barrier Precautions (A set of infection control measures that use gowns and gloves to reduce the spread of multidrug-resistant organisms) for the duration of their stay in a facility. During an observation on 11/18/24 at 1:13 p.m., CNA P was observed working directly with Resident 33 in her room in close proximity, cutting her meat for lunch. CNA P's clothing was observed brushing against Resident 33's clothing. CNA P was not wearing a gown or gloves. Outside of Resident 33's room, a posting was taped to the wall indicating residents in Resident 33's room were on enhanced barrier precautions. During an interview with CNA P on 11/18/24 at 1:15 p.m., she confirmed not wearing a gown or gloves while working with Resident 33. CNA P stated she was unaware Resident 33 was on enhanced barrier precautions, as she was from a registry agency, and this was her first time assigned to Resident 33. 055093 Page 16 of 22 055093 11/22/2024 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 11/19/24 at 9:46 a.m., CNA Q was observed working with Resident 33. CNA Q was observed wearing gloves but no gown while brushing Resident 33's hair. Some of Resident 33's hair was observed to be touching CNA Q's exposed arms, and CNA Q's clothing was observed brushing against Resident 33's clothing. During an interview on 11/19/24 at 9:50 a.m., CNA Q confirmed he was required to wear a gown while in close contact with Resident 33, but stated he forgot to wear it. During an interview with the Infection Preventionist (IP) on 11/18/24 at 1:23 p.m., she stated staff performing high contact activities with Resident 33 were required to wear a gown and gloves because Resident 33 had a history of MRSA. Record review of the facility policy titled, Enhanced Barrier Precautions, dated 6/20/24, indicated, Enhanced Barrier Precautions (EBP)-used in conjunction with the standard precautions and expand the use of PPE (Personal protective equipment) to donning of gown and gloves during high-contact resident care activities and in situations of expected exposure to blood, body fluids, skin breakdown, or mucous membranes that provide opportunities for transfer of MDROs to staff hands and clothing to reduce transmission. 4. During a concurrent observation and interview on 11/20/24 at 11:51 a.m. [NAME] E checked the 2 drawers on the preparation table by the kitchen window and verified utensils were still wet when it was stored in the drawers. [NAME] E stated this was unacceptable because moisture attracts germs and bacteria. [NAME] E stated this could put residents at risk for getting sick if you used a utensil that had germs. During a concurrent observation and interview on 11/20/24 at 11:54 a.m., [NAME] M checked the 2 drawers on the preparation table by the kitchen window and verified utensils were still wet when it was kept in the drawers. [NAME] M stated these utensils should be air dried and completely dried prior to storage. [NAME] M stated keeping the utensils in the drawer while it's still wet could result to cross contamination which could result to residents getting sick. During a concurrent observation and interview on 11/20/24 at 12:04 p.m., the Dietary Manager (DM) opened the 2 drawers on the preparation table by the kitchen window and verified utensils were still wet when it was kept in the drawers. The DM stated this was not acceptable. The DM stated storing the utensils in the drawers while it was still wet was a risk for cross contamination and breeding ground for bacteria. The DM stated utensils should be air dried prior to storing it in the drawer. The DM stated moisture attracts germs. The DM stated keeping the utensils inside the drawer while still wet was an infection control issue. The DM stated it was a safety concern as well because it put residents at risk for getting sick. During an interview on 11/21/24 at 11:31 a.m., the Infection Preventionist (IP) stated all utensils should be air dried prior to storing in the drawers. The IP stated moisture attracts bacteria or germs. The IP stated using utensils that had germs and bacteria could result to residents getting sick with food borne illness (an illness caused by contamination of food and occur at any stage of the food production, delivery and consumption chain). A policy and procedure for utensils storage was requested but not provided. A review of the ServSafe blog titled NFSM 2021- Week 3- Cleaning and Sanitizing Dishes dated 055093 Page 17 of 22 055093 11/22/2024 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0880 9/2021, it indicated to Air-dry all items. NEVER use a towel to dry items. Doing this could contaminate the items.? Make sure they are completely dry before stacking or storing them. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 055093 Page 18 of 22 055093 11/22/2024 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record reviews, the facility failed to ensure hot water was available for use to the shared bathrooms in rooms (rms) 26-28 and 27-29 when the hot water temperature in these rooms were below 105 degrees. This failure resulted in Resident 48 who was in RM [ROOM NUMBER] complaining of inconvenience and unpleasantness of using cold water to wash her hands for over a week. This failure also put the residents at risk for not washing their hand due to discomfort, residents could then get sick and spread infection (invasion and growth of germs in the body) to others. Findings: A review of Resident 48's face sheet (demographics) indicated an admission date of 2/28/2023. Resident 48's diagnoses included Essential Hypertension (HTN, high blood pressure), Muscle Weakness and Anxiety disorder (AD, a group of mental health conditions that cause fear, dread and other symptoms that are out of proportion to the situation). Resident 48's Minimum Data Set assessment (MDS, a federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) dated 11/12/24 indicated staff provided set up assistance with Resident 48's daily care. Resident 48's Brief Interview for Mental Status (BIMS, a mandatory assessment used to identify cognitive (anything related to thinking, learning, and understanding) impairment in long-term care facilities) dated 11/12/24 score was 15 indicating intact cognition. Resident 48 was continent (ability to control) of both bowel and bladder function. Resident 48 uses the shared bathroom in rms 26-28. During an interview on 11/18/24 at 11:30 a.m., Resident 48 stated the hot water on her bathroom sink had been broken for over a week now. Resident 48 stated the Maintenance Director was supposed to fix it but had left. Resident 48 stated it was inconvenient and unpleasant to use cold water when washing her hands. Resident 48 stated she uses the shared bathroom in rms 26-28 and washes her hand after using the bathroom so not having a hot water to use for hand washing was inconvenient. Resident 48 stated not having a hot water available for use was a safety hazard. Resident 48 stated they needed hot water and wished the problem with the unavailability of hot water to use would be fixed soon. During an interview on 11/19/24 at 1:48 p.m., Certified Nursing Assistant (CNA) J stated having hot water for resident to wash their hand was important. CNA J stated not having hot water readily available for use to wash hands put the residents at risk for getting sick and infections. During an interview on 11/19/24 at 1:52 p.m., Licensed Nurse (LN) F verified there was no hot water coming out of Resident 48's bathroom faucet for over a week now. LN F stated she might have verbally reported this issue to the maintenance. LN F stated it was important to have hot water available for use as residents would not want to wash their hand with cold water. LN F stated not washing hands could put the residents at risk for diarrhea (3 or more loose stool per day). LN F stated a lot of infection could be transferred via hands. LN F verified Resident 48 uses the bathroom and washes her hand in the bathroom sink. During a concurrent observation and interview on 11/19/24 at 2:02 p.m., the Director of Nursing (DON) verified there was no hot water coming out of the faucet in the shared bathroom in rms 26-28. The DON stated she was not aware there was no hot water coming out of Resident 48's bathroom faucet for 055093 Page 19 of 22 055093 11/22/2024 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some over a week now. The DON stated it was important to make sure there was hot water available for resident's use. The DON stated older residents were prone to cold and not having hot water available could deter residents from washing their hands. The DON stated not washing hands could lead to sickness and diseases and was a big infection control issue. The DON stated not washing hands would put residents at risk for Clostridium Difficile (C.Diff, infection of the colon, the longest part of the large intestine) and diarrhea. During a concurrent observation and interview on 11/20/24 at 3:00 p.m., the surveyor tested the water temperature coming off the faucet by allowing the water to run for 20 seconds before taking the temperature of running water for about 20 seconds. CNA K verified the water temperature coming out of the faucet in the bathroom in rms 26-28 was 84.8 degrees and the shared bathroom in rms 27 and 29 was 87 degrees. CNA K verified the hot water was not hot enough in the shared bathroom in rms 6-28 and 27-29 faucet. CNA K stated the water coming out of the shared bathroom in rms 6-28 and 27-29 faucet was not hot enough and residents may not be comfortable on washing their hands if it was not hot enough. CNA K stated not washing hands could result to cross contamination and residents could get sick. During a concurrent observation and interview on 11/21/24 at 3:26 p.m., the Administrator (ADM) tested the water temperature in the shared bathroom in rms 26-28 and 27-29 faucet using the facility thermometer. The water was allowed to run for 35 seconds prior to ADM taking the temperature. The ADM kept the thermometer in running water for 25 seconds. The ADM verified the hot water temperature in the shared bathroom in rms 26-28 was 84 degrees and the water temperature in the shared bathrooms in rms 27-29 was 86 degrees. The ADM verified the water temperature was not meeting the hot water temperature. The ADM stated the policy was for hot water to be at least 105 degrees. A review of the facility's policy and procedure (P&P) titled Water Temperatures, Safety of revised 12/2009, the P&P indicated water heaters that service residents rooms, bathrooms, common areas shall be set to temperatures of no more than 120 degrees . 055093 Page 20 of 22 055093 11/22/2024 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Record review of Resident 21's Face Sheet (Facility demographic), indicated he was admitted to the facility on [DATE] with medical diagnoses including Chronic Obstructive Pulmonary Disease (A lung disease characterized by chronic obstruction of lung airflow that interferes with normal breathing and is not fully reversible) and Diabetes Mellitus (A chronic disease characterized by high levels of blood sugar). Residents Affected - Some Record review of Resident 21's Minimum Data Set (MDS-An assessment tool) dated 10/11/24 indicated his Brief Interview of Mental Status (BIMS-A cognition [the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses] assessment) score was 12, which indicated his cognition was moderately impaired. During a concurrent observation and interview with Resident 21 on 10/19/24 at 10:23 a.m., he was observed with two black flies, approximately 1/4 inch in length standing his clothing. Resident 21 attempted to scare them away with his hands, but they flew in circles and stood on his clothing again. During the interview, Resident 21 stated this problem with the flies was an ongoing problem. Photographs were taken as evidence with Resident 21's permission. During a second observation and interview on 11/23/24 at 11:14 a.m., Resident 21 was again observed with a black fly on his hair. With Resident's permission, a photograph was taken as evidence. Resident 21 confirmed feeling the fly on his hair. During an interview with the Infection Preventionist (IP) on 11/21/24 at 3:32 p.m., she stated flies could get into residents' food and cause foodborne illnesses. She also stated flies could fly from one resident to another, spreading germs and causing infection control issues. Record review of the facility policy titled, Pest Control, last revised in May of 2008 indicated, This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents. Based on observation, interviews and record reviews, the facility failed to maintain an effective pets control program when flies were observed in the facility, bothering two residents, Resident 38 and Resident 21. This failure posed a health risk to residents as flies carries and spread diseases like food poisoning, salmonella (food poisoning caused by infection (invasion or growth of germs in the body) with the salmonella bacterium), Escherichia coli (E. coli, a sickness you get from the E.coli bacteria that causes a lot of diarrhea (3 or more loose stool per day) related illnesses) and staphylococcus (group of bacteria that causes skin infection). Flies could also contaminate food and could infest (present in large numbers) open wounds. Findings: A review of Resident 38's face sheet (demographics) indicated an admission date of 8/9/24. Resident 38's diagnoses included Hyperlipidemia (HLP, high concentration of fats or lipids in the blood) and Sepsis (body's extreme reaction to an infection, without prompt treatment, it can lead to death). Resident 38's Brief Interview for Mental Status (BIMS, a short cognitive (conscious intellectual activity such as thinking, reasoning, and remembering) screening tool used to assess a person's cognitive functioning dated 11/8/24 score was 9 indicating moderate cognitive impairment (person may need extra help with daily activities or specific tasks, and may be in cognitive decline). 055093 Page 21 of 22 055093 11/22/2024 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 11/18/24 at 12:57 p.m., a black colored fly was noted to land on the rim of Resident 38's cup of pudding. During a concurrent observation and interview on 11/18/24 at 12:59 p.m., Licensed Nurse (LN) I verified it was a fly that landed on the rim of Resident 38's cup of pudding. LN I stated it was not acceptable to have flies in the facility because flies could make resident sick with gastrointestinal (GI, relating to the stomach and the intestines) illness. LN I stated flies brings disease. During an interview on 11/20/24 at 10:18 a.m., the Registered Dietician was shown a photograph taken on 11/18/24, of the fly on the rim of Resident 38's cup of pudding. RD verified it was a fly in Resident 38's pudding. The RD stated it was not acceptable to have flies in the facility because flies carry disease which could make the residents sick. During an interview on 11/20/24 at 10:20 a.m., the Dietary Manager (DM) was shown a photograph taken on 11/18/24, of the fly on the rim of Resident 38's cup of pudding. The DM verified it was a fly in Resident 38's pudding. The DM stated flies carried germs and could cross contaminate food which could result to residents getting sick. When asked if their pest control management was effective, the DM did not respond. During an observation on11/20/24 at 1:18 p.m., while waiting for the meal cart to be inspected and meal tray to be distributed, a fly was seen hovering in the hallway where the therapy room was. During an interview on 11/21/24 at 9:10 a.m., the Infection Preventionist (IP) was shown a photograph taken on 11/18/24, of the fly on the rim of Resident 38's cup of pudding. The IP stated the facility should not have flies. The IP stated flies carry bacteria and germs and could potentially make residents sick. The IP verified it was a fly on the rim of Resident 38's cup of pudding. During an interview on 11/22/24 at 10:30 a.m., the Director of Nursing (DON) was shown a photograph taken on 11/18/24, of the fly on the rim of Resident 38's cup of pudding. The DON verified it was a fly on the rim of Resident 38's cup of pudding. The DON stated the facility should not have flies. The DON stated flies brings GI illness and infection. 055093 Page 22 of 22