Health inspection·December 4, 2025

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Allow resident to participate in the development and implementation of his or her person-centered plan of care. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure the resident's code status (defines what life-sustaining treatments (like CPR (cardiopulmonary resuscitation), intubation, shocks) a medical team should provide if a patient's heart stops or they stop breathing, guiding emergency care to match the patient's wishes) was accurately clarified, consistently documented, and incorporated into the resident's goals of care for one of six residents sampled for Advance Directives (Resident #5). This failure resulted in conflicting information regarding Resident #5's code status and had the potential to result in the resuscitation of a resident who wished to have a natural death.Review of Resident #5's physician's order dated [DATE] indicated the resident was designated Full Code (patient wants all possible life-sustaining treatments used if their heart stops or they stop breathing).Review of Resident #5's advance health care directive signed on [DATE] indicated both Full Code and DNR (a medical order instructing healthcare providers not to perform CPR if a patient's heart or breathing stops) were initialed by Resident #5, creating a conflicting determination.Review of Resident #5's POLST (Physician Orders for Life-Sustaining Treatment, a medical form that allows patients to clearly indicate their decision to have a Full Code or a DNR status) dated [DATE] indicated the resident elected DNR status.During an interview and concurrent record review on [DATE] at 10:40 a.m., Admissions Nurse stated he was responsible for entering the code status for residents in the facility's electronic medical records (eMR) system. Admissions Nurse reviewed the code status for Resident #5 in the eMR and verified Resident #5's code status was entered as Full Code. Admissions Nurse opened Resident #5's advance directive in the eMR and verified Resident #5 had initialed both places indicating she wished for prolonging her life and she did not wish to prolong her life. Admissions Nurse stated he was not aware she had initialed in both places and verified it should be clear on the advance directive which status Resident #5 was choosing. Admissions Nurse pulled out Resident #5's chart and reviewed her POLST. Admissions Nurse verified the advance directive was completed [DATE] and the POLST was completed [DATE]. Admissions Nurse verified Resident #5 had chosen DNR on the POLST. Admissions Nurse stated the advance directive and the POLST did not match and he needed to discuss this with Resident #5. Admissions Nurse stated that as a result of the discrepancy, the staff could potentially do CPR on a resident who wished to be a DNR. Admissions Nurse stated he would go talk to Resident #5 and her family.During an interview and concurrent record review on [DATE] at 11:32 a.m., Social Services Director (SSD) stated she recalled discussing the advance directive with Resident #5. SSD stated she gave the form to Resident #5 and when it was completed, she uploaded it to the eMR. SSD stated she reviewed advance directives when she uploaded them, but usually only looked to see if the healthcare power of attorney sections were completed. SSD opened Resident #5's advance directive in the eMR and verified Resident #5 had initialed both places indicating that she wanted Full Code status and DNR status. Referring to Resident #5's initials in both places, SSD stated, I missed that. SSD Page 1 of 21 055093 055093 12/04/2025 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated that Resident #5 may have been confused, but we should catch that if that's the case. During an interview on [DATE] at 12:33 p.m., Director of Nursing (DON) stated Admissions Nurse asked residents if they had an advance directive. DON stated it was her expectation that Admissions Nurse clarify the advance directive if it was unclear. DON stated she expected the physician order in the eMR, the advance directive, and the POLST to all be consistent. DON stated that if the POLST was signed by the resident and the physician on [DATE] it should have been updated in the eMR at that time. DON stated the medical records director was responsible for ensuring the physician's order and the POLST matched, and she expected the medical records director to come tell her if they were not consistent. Review of facility policy Resident Rights, last revised 2/2021, indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: be informed of, and participate in, his or her care planning and treatment. 055093 Page 2 of 21 055093 12/04/2025 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the dignity of three sampled residents (Resident 27, Resident 76 and Resident 52), when the residents reported missing clothing and personal items to the facility and the facility did not respond according to their Facility Policy and Procedure for Theft and Loss.This failure to follow their Policy and Procedure for theft and loss resulted in a loss of dignity and respect for the residents when they did not have access to clothing from home that felt familiar as well as personal item that were important to their day-to-day life in the facility. During an observation at the nurses' station, on 12/3/25 at 12:42 p.m., a binder titled THEFT /LOSS / GRIEVANCE, not dated, indicated there were no completed documents or forms for any residents.During an observation and interview with Resident 76 on 12/3/25 at 9:08 a.m., he stated he was missing a grey sweater and a red polo shirt. He stated when he was admitted to the facility staff did not label his clothing. He stated staff labeled his remaining clothing after he told Unlicensed Staff G his grey sweater and the red polo shirt were missing. He stated that no staff had followed up with him about the missing items.During an interview on 12/3/25 at 9:20 a.m., Resident 76 stated he had informed Unlicensed Staff G about his missing clothing this morning. He stated the facility did his laundry and when it came back his red shirt and grey sweater were missing and that was when staff wrote his name in whatever clothing he had left. He stated staff had not written his name on his clothing until then. Resident 27 stated the facility had lost his clothing and personal items and had offered to replace them. He stated they never followed up and then told him to go ahead and replace the items himself and give them receipt and they would repay him. He stated the facility had lost Everything. Resident 27 stated the facility had lost so much clothing it was ridiculous. He stated he had informed staff and felt the facility made it difficult to replace them. He stated the facility had not replaced anything and his relatives had stopped purchasing clothing and gifts for him because it got lost. Resident 76 and Resident 27 had stated they did not recall hearing from the facility about how to report the theft or loss of personal items.During an interview on 12/3/25 at 11:53 a.m., Resident 52 stated she had lost two black hoodies and two sweatpants (one green and one eggplant color). She stated she had informed Unlicensed Staff I they were missing from today's personal laundry delivery. Resident 52 stated she had multiple items got lost, had informed staff but nothing had been replaced.During an interview and record review on 12/3/25 at 12:15 p.m., Social Services stated the process if a resident reported a lost or stolen item was the staff were supposed to fill out a grievance form, she would review it with the resident and then resolve it as soon as possible. She stated for lost clothing she would look in the laundry lost and found. She stated if the item was not located anywhere she would attempt to replace or reimburse the resident She stated she would document the resolution of the resolution form and then place the documentation in the theft / loss binder. She reviewed the binder where documented theft / loss forms were stored and there was no documentation of reported loss of laundry or personal items for Resident 27, Resident 76 or Resident 52. She stated there was supposed to be a report for each report of a resident loss of laundry or personal items and there was no documentation. She stated the facility did not follow the P&P and it would make the resident's feel like their stuff was not safe.During an interview on12/03/2025 at 12:50 p.m., Laundry Staff stated she picked up Resident clothing that was contained in a labeled bag. She stated the resident clothing would remain in the bag during washing and drying and was removed to be folded and returned to the resident. She stated each resident was supposed to have all their clothing labeled by the unlicensed staff when a resident was admitted . She stated sometimes the 055093 Page 3 of 21 055093 12/04/2025 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some laundry is not labeled but she washed it anyway.During an interview on 12/3/25 at 12:58 p.m., Unlicensed Staff J stated when a resident was admitted she was supposed to document all personal items on the inventory form and have the resident or the family sign it. She stated all items were supposed to be labeled and then put away. She stated if a resident reported a lost item of clothing, she would look in the laundry lost and found and then report it to the nurse who was supposed to document on a form and report it to someone.During an interview with Unlicensed Staff I on 12/3/25 at 1:02 p.m., she stated when a resident was admitted she would fill out the inventory sheet, sign it, have the resident sign and put the items away. She stated if the resident was having laundry done by the facility, we would label the clothing items. She stated if something was reported lost, she would check the closets and drawers of the resident and their roommate and then check in the laundry lost and found. She stated the facility P&P for lost items was to tell the nurse.During an interview on 12/3/25 at 2:54 p.m., the Director of Nursing stated she did not know that missing resident items were documented on and given to social services. She stated the Social Services person handled all lost items and grievances. She stated she was unaware of any lost items, lost item complaints from residents or any grievances.During an interview on 12/03/2025 at 3:00 p.m., Licensed Nurse K stated she did not know what the facility P&P for loss or theft was. She stated she would ask the Director of Nursing or Social Services if a resident stated they had lost personal items.During an interview with Unlicensed Staff G on 12/03/2025 at 3:08 p.m. he stated if a resident informed him of a lost item of clothing he would go look in the laundry department in the lost and found basked. He was unable to state the facility Policy and Procedure (P&P) for lost items and required prompting to state a lost form needed to be filled out and provided to the nurse. He stated he did not recall the last time he filled out a lost item form. He stated he did not remember Resident 6 telling him about lost grey sweater and lost red polo shirt. Unlicensed Staff G stated resident clothing was supposed to be labelled upon admission and to fill out a resident inventory list.During an observation, interview and record review on 12/4/25 at 1:50 p.m., Unlicensed Staff I reviewed Resident 52's clothing in the closet and drawers and compared it to the document titled INVENTORY OF PERSONAL EFFECTS, for Resident 52, date 8/22/25 and 9/2/25. Unlicensed Staff I stated she observed 12 pieces of clothing. She stated none of them matched Resident 52's description of her two missing sweatpants and two hoodies. She stated the items in the closet and the drawers did not match the inventory list.During a review of a facility Policy and Procedure titled Safeguarding Personal Property / Theft-and-Loss Policy, revised 10/25, it indicated Facility will exercise reasonable care to protect and promote the safety and security of personal belongings, while upholding residents' rights to personal choice and possession. 7. Personal property is required to be clearly marked with the resident's name and must be listed on Resident's inventory form. The name can be sewn on the garment or written with a permanent ink marker. Personal property such as TVs, radios, dentures, glasses, prosthetics etc. must be clearly marked (preferably inscribed or engraved) and identifiable. Staff shall assist Residents to properly label items as indicated. When personal property is reported missing, staff should immediately begin a search for the missing property. If the property is not readily found, a Theft and Loss report shall be completed and routed to Social Services Department for processing and resolution. Individual Theft and Loss reports shall include but not be limited to the following information: A description of the missing item(s); an estimated value of the item; date and time the theft or loss was discovered; the date and time theft or loss occurred (if determined); and action(s) taken. (theft/robbery) shall be immediately reported to facility Administrator and others in accordance with state and federal laws. Social Services will coordinate additional search, investigate circumstances, and work with 055093 Page 4 of 21 055093 12/04/2025 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident, family, &/or facility Administrator to determine how the loss will be resolved in accordance with policy.A review of Resident 76's medical record document titled admission RECORD, indicated Resident 76 was admitted to the facility 11/25/25 with diagnoses that included CELLULITIS of Left Lower Limb,(A severe infection of the skin and tissue), SEPSIS, (A severe infection), and MULSTPLE SCLEROSIS (A progressive disease of the nerves and spinal cord). A document titled Brief Interview for Mental Status (BIMS) indicated a score of 12, indicating mild cognitive impairment. A review of a medical record document for Resident 76 titled INVENTORY OF PERSONAL EFFECTS, dated 11/25/25 indicated one sweater and one shirt.A review of a medical record document for Resident 27 titled admission RECORD, indicated was admitted [DATE], with diagnoses that included INTERVETEGRAL DISC DISORDERS WITH MYELOPATHY, THORACIC REGION, (A condition where the spine degenerated causing severe chronic pain in the back, neck and arms), PARAPLEGIA (Inability to move lower extremities.), among others. An electronic medical record titled Brief Interview for Mental Status indicated a score of 15, indicating intact cognition. A review of a medical record document for Resident 27 titled INVENTORY OF PERSONAL EFFECTS, dated 10/30/25 indicated upon entry 40 personal items. An area of the document titled ACQUIRED AFTER ENTRY, dated 10/30/25 indicated 35 personal items. A review of a medical record document titled admission RECORD, for resident 52, indicated she admitted [DATE] with diagnoses that included NONDISPLACED COMMINUTED FRACTURE OF LEFT PATELLA SUBSEQUENT ENCOUNTER FOR CLOSED FRACTURE WITH ROUTINE HEALTING, (A fracture of the kneecap that had not moved out of place.), ATAXIA, (A dysfunction of the brain that can result in involuntary muscle movement, resulting in unstable walking, standing, eye rolling.), CHRONIC PAIN.An electronic medical record titled Brief Interview for Mental Status indicated a score of 12. 055093 Page 5 of 21 055093 12/04/2025 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and records review, the facility failed to provide a copy of the notice of discharge to the Office of the State Long-Term Care Ombudsman for one (Resident 74) of three sampled discharged residents.This failure had the potential for inappropriate and unsafe discharge and deprived Resident 74 of access to an advocate who can provide information of her options and rights.Findings: A review of Resident 74's electronic medical record indicated she was admitted on [DATE] with a diagnosis of stroke, Parkinson's disease, dementia, diabetes, atrial fibrillation and malnutrition. Resident 74 was discharged on 9/22/25. A review of Resident 74's discharge records did not indicate a copy of the notice of discharge was provided to the Ombudsman's office. During a concurrent interview and review of records with the Social Services Director (SSD) on 12/4/25 at 3:52 PM, the SSD confirmed Resident 74 was discharged on 9/22/25. The SSD verified the Notice of discharge was opened on 9/22/25 but was not completed nor sent to the Ombudsman. The SSD stated this should have been completed and sent to the ombudsman. The SSD also stated it was important the Ombudsman was notified of the resident discharge to ensure the resident's safety, to ensure the discharge plan was appropriate and for reference in case the resident wants to appeal the decision to discharge.A review of the facility's policy titled: Interdisciplinary team (IDT) discharge (DC) planning revised 1/1/17, indicated the purpose of discharge planning was to ensure a plan is in place to meet the resident/patient's continuing healthcare needs following discharge form the facility. 055093 Page 6 of 21 055093 12/04/2025 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. Based on interview and records review, the facility failed to develop a plan of care to prevent the development of a pressure ulcer on one (Resident 24) of 19 sampled residents when Resident 24 developed pressure ulceration under the oxygen tubing over his left ear. This failure led to staff not having an individualized plan to follow to regularly monitor and ensure the oxygen tubing with ear protector is kept in place to prevent skin ulceration. Findings:During an initial observation and interview on 12/2/25 at 8:58 AM, Resident 24 was in bed, on oxygen therapy at a rate of 2 liters per minute supplied via nasal cannula (oxygen fed through transparent tiny tubing that splits into left and right tubes commonly applied at the back of the head and run over the ears and over the cheekbone to the nose). Resident 24's skin behind the ears under the oxygen tubing was very red. The cannula ear protector was over the left cheekbone instead of over the back of the ear. During an interview inside the room of Resident 24, Certified Nursing Assistant (CNA) E did not have a response when asked how the facility could prevent the development of pressure ulcer for a patient using a nasal cannula. During a follow-up visit on 12/3/25 at 9:55 AM, the skin under the oxygen tubing behind Resident 24's left ear was still very red, the canula ear protector was lying over the left cheekbone. During an interview on 12/3/25 at 10:05 AM, Licensed Nurse C was requested to check the skin under the nasal cannula tubing behind the ears of Resident 24. Licensed Nurse C confirmed Resident 24 has a broken skin behind the left ear. Licensed Nurse C stated the cannula ear protector was not effective. During a review of Resident 24's care plans focusing on: 1) the risk for skin breakdown related to impaired cognition, fragile skin, and impaired ability to move freely initiated on 11/15/25 and, 2) the need for special care related to oxygen use, initiated 11/26/25, both care plans did not include interventions to monitor skin integrity or ensure proper placement of the canula ear protector over the ears to prevent skin breakdown. During a concurrent interview and review of records on 12/4/25 at 10:10 AM with the Director of Nursing (DON), the DON stated staff should check skin integrity before and after application of oxygen. The DON stated, during medication pass, nurses should check for placement of the oxygen cannula and the ear protector. The DON reviewed Resident 24's care plans for risk of skin breakdown and special care for oxygen administration. The DON was unable to show interventions to monitor and prevent pressure ulceration related to use of nasal cannula tubing. A review of the facility's policy titled: Care plans, comprehensive person-centered. indicate the comprehensive, person-centered care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being. 055093 Page 7 of 21 055093 12/04/2025 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 records review, the facility failed to monitor and ensure proper placement of oxygen tubing and ear protector to prevent the development of pressure ulcer on one (Resident 24) of 19 sampled residents.This failure led to Resident 24 developing a pressure ulcer behind his left ear from oxygen cannula tubing pressure.Findings:During an initial observation on 12/2/25 at 8:58 AM, Resident 24 was in bed, on oxygen therapy at a rate of 2 liters per minute supplied via nasal cannula (oxygen fed through transparent tubing that splits into left and right tubes passed at the back of the head and run over the ears, and over the cheekbone to the nose). The skin behind the resident's ears under the oxygen tubing was very red especially the left ear with the tubing pressed against the skin creating an indentation. The cannula ear protector was over the left cheekbone. During a follow-up visit on 12/3/25 at 9:55 AM, the skin under the oxygen tubing behind Resident 24's left ear was very red with some dried blood, the canula ear protector was lying over the left cheekbone. During an interview on 12/3/25 at 10:05 AM, Licensed Nurse C was requested to check the skin under the nasal cannula tubing behind the ears of Resident 24. Licensed Nurse C confirmed the skin behind the left ear of Resident 24 is broken. Licensed Nurse C stated the cannula ear protector was not effective. A review of Resident 24's face sheet indicated he was admitted to the facility on [DATE] with a diagnosis of life-threatening blood infection, progressive decline in mental abilities, and a disorder that makes it difficult to speak.A review of Resident 24's admission assessment dated [DATE], and Braden scale for predicting pressure sore risk dated 6/9/25, indicated he was at risk for developing pressure ulcer and had a bedsore on admission. A review of the following Nursing Progress Notes did not indicate the pressure injury on Resident 24's left ear was noted or documented: Order Administration Noted dated 12/2/25 at 3:58 PM and 12/2/25 at 10:40PM during oxygen saturation monitoring Skilled Services Documentation by Nursing dated 12/2/25 at 11:12 PM indicated there was no pressure or skin-related issues on skin assessment Order Administration dated 12/3/25 at 7:15 AM and 12/3/25 at 2:50 PM during oxygen saturation monitoring.On 12/3/25 at 3:10 PM, a Change in condition for skin wound or ulcer was documented. During an interview on 12/4/25 at 10:10 AM with the Director of Nursing (DON), the DON stated staff should check skin integrity before and after application of oxygen. During medication pass, nurses should check for placement of the oxygen cannula and cannula ear protector. The DON located on her computer Resident 24's care plans for risk of skin breakdown and special care for oxygen administration. The DON was unable to find intervention in the care plan to monitor and prevent pressure ulceration related to nasal cannula tubing. A review of the facility's policy titled: Prevention of pressure ulcers/injuries taken from the (C)2001 MED-PASS, Inc, revised 7/2017, indicated under Risk assessment - inspect the skin on a daily basis when performing or assisting with personal are or activities of daily living (ADL), identify any signs of developing pressure injuries and inspect pressure points. Residents Affected - Few 055093 Page 8 of 21 055093 12/04/2025 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and record review, the facility failed to properly administer tube feeding to one of one resident sampled for tube feeding (Resident #8) when Resident #8 was found laying flat during tube feeding administration. This failure had the potential to result in aspiration (inhaling foreign substances like food, liquids, saliva, or stomach contents into the lungs, which can lead to pneumonia, a lung infection) of the tube feeding formula, difficulty breathing, aspiration pneumonia, and hospitalization. Review of Resident #8's face sheet (demographics) indicated an admission date of 5/28/24 and multiple medical diagnoses including but not limited to cerebral infarction (stroke caused by a blockage in the brain), dysphagia (difficulty swallowing), and gastrostomy (a surgically inserted tube that brings nutritional formula through the abdomen directly into the stomach).Review of Resident #8's physician orders indicated an order, dated 10/30/25, for tube feeding 20 hours per day from 2 p.m. to 10 a.m.Review of Resident #8's care plan, dated 7/23/24, indicated a focus area of Risk for Aspiration related to tube feeding with an intervention to keep head of bed 30 degrees during and for 60 minutes after tube feed. During a phone interview on 12/1/25 at 3:39 p.m., Resident #8's family member stated she had found Resident #8's head of bed and feet at different elevations while the tube feeding was running. She stated she had to inform staff of the importance of the head of the bed being up when she found Resident #8 with the head of her bed down and having trouble breathing. During an observation on 12/3/25 at 9:12 a.m., Resident #8 was in bed with with her tube feeding being administered by a tube feeding pump. The head of the bed was raised but Resident #8 had slid down in the bed and was laying flat. During an observation and concurrent interview on 12/3/25 at 9:20 a.m., Licensed Nurse A verified she was Resident #8's nurse. Licensed Nurse A observed Resident #8's position in her bed. Licensed Nurse A stated Resident #8 was a little low in the bed and that she was not positioned at 30 degrees. Licensed Nurse A verified Resident #8's tube feeding was currently running. Licensed Nurse A stated she would get someone to help to reposition Resident #8. When queried, Licensed Nurse A stated she monitored for Resident #8's position during her tube feeding by coming to check on her every hour. Licensed Nurse A stated the CNAs (certified nursing assistants) knew as well that Resident #8 needed to be at 30 degrees, there was a sign above the bed so everyone knew that her head of bed needed to be up at 30 degrees. During an interview on 12/4/25 at 12:33 p.m., Director of Nursing (DON) stated it was her expectation for residents during tube feeding to be positioned with their head of bed at 30 degrees elevated. DON stated the nurse was responsible for monitoring for the resident's position while the tube feeding was running. Review of facility policy and procedure Enteral Feedings Safety Precautions, last revised 11/2018, indicated, Preventing aspiration: . 3. Elevate the head of the bed (HOB) at least 30 [degrees] during tube feeding and at least 1 hour after feeding. 055093 Page 9 of 21 055093 12/04/2025 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and record reviews, the facility failed to ensure two out of four sampled residents' (Residents 5 and 68) pain was adequately and timely addressed. These failures left Resident 5 distressed, tearful, feeling like she was dying and experiencing 12/10 (Twelve out of Ten), severe pain for 30 minutes before receiving her narcotic (strong but addictive pain medicine) pain medication and Resident 68 feeling frustrated and enduring pain while having to wait for over an hour to receive his routine narcotic medication.Findings:A review of Resident 5's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated an admission date of 6/2025, with a diagnosis of pathological fracture of left femur (broken bone in the thigh caused by disease) and malignant neoplasm (cancerous tumor) of the bone.A review of Resident 5s Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident), dated 8/28/25, resulted in a score of 12 out of 15, indicating moderately impaired cognition (MCI, some memory issues, confusion, or difficulty with daily tasks, requiring potential assistance). A review of Resident 5s EMAR (Electronic Medical Administration Record) for 12/2025, indicated an order for Oxycodone Hydrochloride (narcotic) 5 milligram (mg, unit of measurement) two tablets every six hours for pain management; hold for sedation or respiratory rate of less than 12. It indicated Resident 5 received this medication on 12/2/25, routinely ordered to be administered at 6:00 PM. A review of Resident 68s face sheet indicated an admission date of 5/2025, with a diagnosis of polyneuropathy (condition where multiple nerves in the body are damaged, leading to symptoms like pain, numbness, tingling, and weakness) and chronic pain (ongoing pain lasting longer than 3-6 months). A review of Resident 68 BIMS, dated 11/4/25, resulted in a score of 15 out of 15, indicating intact cognition. A review of Resident 68's EMAR for 12/2025, indicated an order for Tylenol (acetaminophen) 325 mg two tablets by mouth every six hours for mild pain (pain level (PL) 1 to 3), routinely scheduled to be administered at 6:00 PM. Resident 68's 12/2025, EMAR indicated he received this medication on 12/3/25, scheduled at 6:00 PM, for a PL of 6 out of 10 (moderate pain). A review of the facility medication administration schedule indicated every six hours meant a medication should be administered routinely at 6:00 AM, 12:00 PM, 6:00 PM and 12:00 AM. During a concurrent observation and interview on 12/02/2025 at 4:48 PM, Licensed Nurse (LN M) verified Resident 5 was complaining of (c/o) severe pain on her left hip all the way to the groin with a pain level (PL) of 12/10. LN M stated Resident 5 could not receive the oxycodone during this time as it was not due yet. Resident 5 was on the verge of crying and could be seen grimacing, and Resident 5 stated it was due to the extreme pain she was experiencing at the moment. LN M verified Resident 5 had an order for Oxycodone Hydrochloride (narcotic) 5mg two tablets every six hours for pain management; hold for sedation or respiratory rate of less than 12. LN M stated this narcotic was scheduled to be given at 6:00 PM, and the earliest LN M could give it to Resident 5 was 5:00 PM. LN M stated, although Resident 5 was in severe pain, LN M still needed to follow the physician's order. LN M was observed to be pacing back and forth multiple times from the medication cart into Resident 5s room while interviewing Resident 5 repeatedly about her pain. Meanwhile, Resident 5 was noted with furrowed brows and appeared to be guarding her left thigh. LN M verified Oxycodone was finally administered at 5:22 PM. When asked if there was anything LN M could have done so that Resident 5 could receive the Oxycodone the moment Resident 5 was c/o severe pain and thus alleviate her hip and groin severe pain faster, the LN M did not respond. During a concurrent interview and EMAR record review, dated 12/3/2025, on 12/04/2025 at 10:39 AM, the Minimum Data Set Coordinator (MDSC) 1 stated the facility defined mild pain at 1 to 3 level, moderate pain at 4 to 6 level, and severe pain at 7 to 10 Residents Affected - Few 055093 Page 10 of 21 055093 12/04/2025 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few level. MDSC 1 verified, based on Resident 5s 12/3/2025, EMAR, she did c/o severe pain on the PM shift. MDSC 1 stated residents should not be left in severe pain for a long period of time. When asked what staff should do when a resident was c/o of 12/10 PL and a narcotic was not due yet, MDSC 1 stated the nurse should have called the physician to notify of the need to address Resident 5s c/o severe pain and request a narcotic to relieve the pain if the narcotic was not due yet. MDSC 1 stated 12/10, was really severe pain and should be addressed immediately. MDSC 1 stated Resident 5 should not endure 12/10 PL and stated it was not appropriate for Resident 5 to be left in severe pain for over 30 minutes while waiting for a narcotic to be administered. MDSC 1 stated, leaving Resident 5 in severe pain, could result in anger and frustration. During an interview on 12/04/2025 at 10:56 AM, Resident 5 stated she was really distressed when she experienced a PL 12/10 about two days ago, and the nurse could not give her the narcotic pill at that time. Resident 5 stated she felt it was unnecessary to wait for half an hour before being able to take her narcotic pill. Resident 5 stated it was frustrating and distressing on her part to be in such severe pain and thought she would die from pain at that time. Resident 5 stated she understood the nurses were busy but Resident 5 wished she was not left to be in severe pain for half an hour. Resident 5 stated she hoped this incident would never occur again and wished the facility could do better on ensuring Resident 5s c/o of pain was managed timely. During an interview on 12/03/2025 at 6:11 PM, LN N, Resident 68's primary nurse at that time, stated Resident 68 was c/o 7 out of 10, pain on his right leg. LN N stated Resident 68 was in severe pain. LN N stated leaving Resident 68 in severe pain could affect his quality of life. During a concurrent observation and interview on 12/03/2025 6:20 PM, with LN N present, Resident 68 stated acetaminophen did not help with his severe pain and preferred the narcotic pill. LN N stated acetaminophen was scheduled routinely at 6:00 PM, and Resident 68 could not be administered the narcotic until 8:00 PM. LN N verified the order for the acetaminophen was to give it for mild pain. LN N stated, although Resident 68 was c/o severe pain, LN N would still administer the acetaminophen since this was a routine order from the physician. When asked if administering acetaminophen was appropriate and could adequately alleviate Resident 68 c/o severe pain since acetaminophen was ordered for mild pain only, and Resident 68 was c/o 7 out of 10 pain, LN N stated acetaminophen was not adequate enough to alleviate Resident 68s c/o severe pain, but was unsure of what to do and decided to just follow the physician order. LN N stated, if a resident was left in pain, they could feel upset, angry and frustrated. During an interview on 12/04/2025 at 10:03 AM, Resident 68 stated he always experienced right leg pain. Resident 68 stated last night he experienced 7 out of 10 pain level in his right leg and was given acetaminophen which did not help at all with his pain. Resident 68 stated he talked to the staff about it, but they were insistent to give acetaminophen despite his c/o severe pain and acetaminophen being ineffective, but the staff still administer this medication because, it was the doctor's order. Resident 68 stated, although he was experiencing severe pain, he had to wait until it was time for him to receive the narcotic pill. Resident 68 stated it was a waste of his time, and also frustrating to be receiving acetaminophen as he knew, and the nurses knew it would not help with his pain. Resident 68 stated he wished the facility could better control his pain because at this time, the facility was poor in taking care of his pain. During a concurrent interview and EMAR record review, dated 12/3/2025, on 12/04/2025 at 10:18 AM, MDSC 1 verified staff had administered acetaminophen for Resident 68s c/o severe pain on 12/3/25 PM, shift and verified acetaminophen was ordered for mild pain only. MDSC 1 stated it was not appropriate to administer acetaminophen for moderate or severe pain. MDSC 1 stated, although it was not time for Resident 68 to receive the narcotic pill yet, the nurse should have called the physician at that time to request it be given at the time when 055093 Page 11 of 21 055093 12/04/2025 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0697 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 68 needed it to immediately address Resident 68s severe pain. MDSC 1 stated, if left in severe pain, a ripple effect could occur and could negatively affect residents. During an interview on 12/04/2025 at 12:13 PM, the Director of Nursing (DON) stated the facility defined mild pain at 1 to 3 level, moderate pain at 4 to 6 level and severe pain at 7 to 10 level. The DON stated it was not appropriate for staff to give acetaminophen for c/o moderate or severe pain when the physician order was to give acetaminophen for mild pain only. During an interview on 12/04/2025 at 12:13 PM, the DON stated staff should have called the doctor to request a stronger pain medication to address a resident's pain if a resident was not due for a narcotic yet. The DON stated it was not acceptable to leave residents in severe pain for a long time. The DON stated it was also important to address residents' pain as soon as possible and not to keep residents in a state of severe pain. The DON stated leaving a resident in pain could lead to that resident experiencing increased pain and agitation. A review of the facility's policy and procedure (P&P) titled, Administering Pain Medications, revised 10/2010, the P&P indicated, .pain management program is based on a facility wide commitment to resident comfort.Pain Management is defined as the process of alleviating the residents pain to a level that is acceptable to the resident. A review of the facility's P&P titled, Administering Medications, revised 4/2019, the P&P indicated, .medications are administered in accordance with the prescribers order. A review of the Numeric Pain Rating Scale (NPRS, a widely used, unidimensional measure of pain intensity that provides a simple, quick, and reliable assessment of pain), it indicated 1-3 as mild pain, 4 to 6 as moderate pain and 7 to 10 as severe pain. 055093 Page 12 of 21 055093 12/04/2025 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews and record reviews, the facility failed to follow the physician's orders for three out of three sampled residents (Residents 11, 63 and 68) when: 1. Residents 11 and 63 did not received their insulin before meals as ordered. 2. Resident 68 received pain medication that was ordered to relieve mild pain only when Resident 68 was complaining of severe pain.This failure could result in:1. Inappropriate Diabetes management, which could result in blood sugar spike (hyperglycemia) followed by a potential delayed low blood sugar (hypoglycemia) several hours later. 2. increased pain and suffering. Findings:1.A review of Resident 11s face sheet (resident demographics) indicated an admission date of 11/2025 with a diagnosis of Diabetes Mellitus (DM, disorder characterized by difficulty in blood sugar control and poor wound healing) and Stage 3 chronic kidney disease (kidneys have mild to moderate damage and are less able to filter waste and fluid out of your blood).A review of Resident 11s EMAR (Electronic Medication Administration Record) for 12/2025 indicated an order for Insulin Aspart injection 100 unit/ml (milliliter) inject 8 unit subcutaneously (under the skin) before meals at 7:00 AM, 12:00 PM and 5:00. The EMAR documentation indicated Resident 11 received 8 units of insulin on 12/2/25 at 5:00 PM.A review of Resident 63s face sheet indicated an admission date of 9/2025 with a diagnosis of DM and Stage 3B chronic kidney disease (more severe half of Stage 3, where kidneys struggle to filter waste, leading to potential buildup and complications). A review of Resident 63s EMAR for 12/2025 indicated an order for Humalog solution 100 unit/ml (insulin lispro human) inject as per sliding scale: 0-69 0 follow hypoglycemic protocol, 70-150 0, 151-200 2, 201-250 4 unit, 251-300 6, 301-350 8, 351-400 10, 401+ call prescriber subcutaneously before meals. The EMAR documentation indicated that on 12/2/25 at 5:00 PM, with a blood sugar of 190, Resident 63 received 2 units of Humalog insulin.During a concurrent observation and interview on 12/02/2025 at 5:58, LN M verified Resident 63s order for Humalog solution 100 unit/ml (insulin lispro human) inject as per sliding scale was to be administered before meals. LN M was present when Resident 63 stated he was done with dinner and was now eating dessert. LN M proceeded to check Resident 63s blood sugar level and administered the insulin while Resident 63 was eating his dessert. During a concurrent observation and interview on 12/02/2025 at 6:22 PM, Licensed Nurse (LN) M verified the physician order for Insulin Aspart injection 100 unit/ml, inject 8 unit subcutaneously before meals at 7:00 AM, 12:00 PM and 5:00 PM. With LN M present, Resident 11 verified he had eaten his dinner. LN M checked Resident 11s blood sugar level and proceeded to draw the insulin. When asked why the order for aspart injection before meals on the EMAR was highlighted red, LN M stated she was already late checking Resident 11s blood sugar and administering the insulin. LN M verified blood sugar level was supposed to be checked prior meals and insulin was to be given prior to meals per physician's order.During an interview on 12/03/2025 at 3:39 PM, LN P stated the physician's order should always be followed. LN P stated blood sugar level should be checked before meals to ensure accurate reading and insulin should be administered per physician's order. LN P stated if insulin was administered after a meal and the order was to administer the insulin before meals then it was a medication error. LN P stated not following the physician order on when to check the blood sugar and when to administer the insulin was a safety risk to the resident.During an interview on 12/03/2025 at 3:45 PM, LN M stated she did not follow the physician's order when LN M checked Residents 11 and 63s blood sugar level after meals and had given their insulin after meals as well. LN M stated these were both medication errors. LN M stated the orders for Residents 11 and 63s were to check their blood sugar level and give insulin before meals. LN M stated checking the blood sugar level after meals yields inaccurate high blood sugar level result which could lead to over medicating the resident with insulin which was a safety risk for the resident.During an Residents Affected - Some 055093 Page 13 of 21 055093 12/04/2025 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some interview on 12/03/2025 at 3:53 PM, the Infection Preventionist (IP) stated physician's order should always be followed. The IP stated that giving the insulin after meals when the physician ordered the insulin to be given before meals was a medication error. The IP stated it was also an error to check a resident's blood sugar level after meals as this would result in inaccurately high blood sugar result. The IP stated not following the physician's order to check the blood sugar level before meals and instead checking it after a resident had their meals could result to high blood sugar level reading which could lead to giving the resident an increased amount of insulin. The IP stated this inaccuracy was a medication error and a safety issue that could lead to hypoglycemic episodes.2. A review of Resident 68 face sheet (resident demographics) indicated an admission date of 5/2025 with a diagnosis of polyneuropathy (condition where multiple nerves in the body are damaged, leading to symptoms like pain, numbness, tingling, and weakness) and chronic pain (ongoing pain lasting longer than 3-6 months).A review of Resident 68 BIMS dated 11/4/25 resulted in a score of 15 out of 15 indicating intact cognition.A review of Resident 68s EMAR for 12/2025 indicated an order for Tylenol (acetaminophen) 325 mg 2 tablets by mouth every 6 hours for mild pain (pain level 1 to 3) (Reference range: mild pain at 1 to 3 level, moderate pain at 4 to 6 level, and severe pain at 7 to 10 level) The EMAR indicated Resident 68 received this medication on 12/3/25 at 6:00 PM for a pain level of 6 out of 10 (moderate pain).During a concurrent interview and EMAR record review on 12/03/2025 at 6:20 PM, with LN N present, Resident 68 stated acetaminophen did not help with his pain, and he preferred narcotic pill. LN N verified acetaminophen was ordered for mild pain only and Resident 68 was currently in severe pain. LN N administered acetaminophen to address Resident 68s severe pain. When asked if LN N was following the physicians order when he administered Resident 68 the acetaminophen which was ordered for mild pain when Resident 68 was complaining of severe pain, LN N was silent. LN N stated the physician's order must always be followed.During an interview on 12/04/2025 at 10:18 AM, the Minimum Data Set coordinator (MDSC 1) stated administering acetaminophen to address moderate or severe pain was inappropriate when an order was to administer acetaminophen for mild pain only. She stated this was considered a medication error. MDSC1 stated the physician's order should always be followed.During an interview on 2/04/2025 at 12:13 PM, the Director of Nursing (DON) stated the facility defined mild pain at 1 to 3 level, moderate pain at 4 to 6 level and severe pain at 7 to 10 level. The DON stated it was not appropriate for staff to give acetaminophen for a complaint of moderate or severe pain when the physician order was to give acetaminophen for mild pain only. The DON stated the physician's order must be followed for resident's safety.A review of the facility's P&P titled Administering Medications, revised 4/2019, the P&P indicated.medications are administered in accordance with the prescribers order. 055093 Page 14 of 21 055093 12/04/2025 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 - Few 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 observations, interviews and record reviews, the facility failed to ensure:only medications that were prescribed by the physician were administered for two out of four sampled residents (Residents 2 and 45). 2. two out of four sampled residents (Residents 2 and 45) were allowed to keep medications at bedside without safe administration assessment and physician order.These failures had the potential to put residents at high risk for masking of serious medical condition and adverse drug reactions.Findings:A review of Resident 2s face sheet (resident demographics) indicated an admission date of 7/2025 with a diagnosis of Hypertension (high blood pressure) and hyperlipidemia (high cholesterol)A review of Resident 45s face sheet indicated an admission date of 11/2025 with a diagnosis of muscle weakness and cellulitis (a skin infection that causes swelling and redness) of right and left lower limb.During a concurrent observation and interview on 12/01/2025 at 10:44 AM, Resident 45 was noted with refresh eye drops at bedside. Resident 45 stated she had the eye drops there since last month and had been administering them herself. Resident 45 stated staff had seen the eye drop at her bedside but had not said anything about it.During a concurrent interview and physician order summary (healthcare professional's written instruction specifying the care, services, treatment and medications a patient should receive) (POS) record review dated 2/01/2025 at 10:48 AM, Licensed Nurse (LN) O stated Resident 45 had no order for refresh eye drops as far as she could recall. After checking the POS, LN O verified Resident 45 had no physician's order for refresh eye drops, no physician order that Resident 45 may keep the refresh eye drops at bedside or that Resident 45 could self-administer the refresh eye drops. LN O stated in order for Resident 45 to self-administer refresh eye drops and keep them at bedside, it had to be ordered by the physician. LN O stated she suspected the family member snuck in the refresh eye drops and did not tell the staff. During a concurrent observation and interview on 12/01/2025 at 12:30 PM, Resident 2 was noted with hydrogen peroxide on top of her bedside drawer. Resident 2 stated she had it there since admission and was bought from home. Resident 2 stated staff knew about the hydrogen peroxide and she uses it herself for her tooth issue and some wounds. Resident 2 stated the hydrogen peroxide had no physician order and staff did not check whether she was safe to self-administer the hydrogen peroxide.During a concurrent observation, interview and POS record review on 12/02/2025 at 2:56 PM, LN O verified Resident 2 had hydrogen peroxide on top of bedside drawer. LN O verified the physician did not order the hydrogen peroxide. LN O stated hydrogen peroxide was a medication and thus need a valid physician order prior to administration. LN O stated at the moment, Resident 2 should not be allowed to use, keep at bedside nor self-administer the hydrogen peroxide since Resident 2 did not have a self-administration assessment and the hydrogen peroxide had no physician order yet.During an interview on 12/02/2025 at 3:07 PM, LN O stated keeping medications at bedside, self-administering medication without proper assessment and administering medication without a physician order was a safety risk to the residents.During an interview on 12/02/2025 at 3:30 PM, the Director of Nursing (DON) verified hydrogen peroxide and refresh eye drops needed to have a physician's order prior to administration. The DON stated residents who wished to self-administer medications or needed to keep medications at bedside needed to have a completed self-administration assessment first per facility policy. The DON stated if these were not done, then the facility policy was not followed. The DON stated it was important to have physicians order for these medications although these were considered over the counter medications. The DON stated residents needed to complete a self-administration assessment to determine whether they were safe to self-administer medications or keep medications at 055093 Page 15 of 21 055093 12/04/2025 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 - Few bedside. The DON stated it was a safety issue to allow resident to self-administer a medication, allow a resident to keep medication at bedside and administer medication without a physician order and proper assessment. The DON stated the potential harm to the residents includes over or under medication and accidental ingestion by other residents resulting in adverse drug reaction.A review of the facility's policy and procedure (P&P) titled Self Administering Medication:, revised 12/2016, the P&P indicated.as part of their overall evaluation, staff and practitioner will assess each residents mental and physical abilities to determine whether self-administration is clinically appropriate for the resident.self-administered medication must be stored in a safe and secure place which is not accessible by other residents.A review of the facility's P&P titled Administering Medications, revised 4/2019, the P&P indicated.medications are administered in accordance with the prescriber's order. 055093 Page 16 of 21 055093 12/04/2025 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 Based on observations, interviews and record reviews, the facility:A. did not implement Enhanced Barrier Protection (EBP, an infection control intervention, primarily used in nursing homes, that involve the use of gowns and gloves during high-contact resident care activities to reduce the transmission of Multidrug-Resistant Organisms (MDROs, microorganisms, primarily bacteria, that are resistant to one or more classes of antimicrobial agents) ) for one out of three sampled residents (Resident 53) when Resident 53s surgical thoracic wound was treated using Negative Pressure Wound Therapy (NPWT/wound vac, a treatment that uses a sealed dressing, connected to a vacuum pump to apply continuous or intermittent suction to a wound).B. did not follow the manufacturers recommendation on the appropriate contact time when sanitizing the glucometer (small, portable medical device used to measure the amount of sugar (glucose) in a drop of blood) before using it to check three out of three sampled residents blood sugar.C. failed to ensure staff observed hand hygiene (hand washing) prior to performing task and prior to donning new gloves when providing care for one out of four sampled residents (Resident 30).D. failed to ensure adequate monitoring for Legionella bacteria (naturally found in water but become a health risk in man-made systems like hot tubs, cooling towers, and water heaters when inhaled as mist or vapor from contaminated water) in the facility's water system.These failures could result in cross contamination and higher infection risk, germs to spread rapidly and residents getting sick with infection and put the residents at risk for serious diseases like Legionnaire's disease. Findings: Residents Affected - Some A.A review of Resident 53's face sheet indicated an admission date of 11/2025 with a diagnosis of infection and inflammatory infection due to internal device of spine. A review of Resident 53's physician order summary (POS,a healthcare professional's written instruction specifying the care, services, treatment and medications a patient should receive) indicated that on 11/19/25, the physician ordered the wound vac to treat Resident 53's thoracic surgical wound. During a concurrent observation and interview on 12/01/2025 at 11:20 AM, Resident 53 stated she had a surgical wound on her back and nurses did the treatment. It was noted there was no EBP signage noted by the door to alert staff to practice EBP following high contact resident care activities. Resident 53 stated staff did not wear gown when they did her wound treatment, while changing her briefs, during dressing or transferring. During an interview on 12/02/2025 at 3:11 PM, Licensed Nurse (LN) P verified Resident 53 had a surgical wound on her back currently being treated using a wound vac. LN P verified Resident 53 was not placed on EBP. LN P stated he did not wear gown when he was treating Resident 53's surgical back wound. LN P stated residents on wound vac should be placed on EBP for residents and staff safety. LN P stated EBP should be in place for residents on wound vac to prevent wound infection and to prevent cross contamination. During an interview on 12/02/2025 at 3:19 PM, the Infection Preventionist (IP) verified Resident 53 had a wound vac but was not placed on EBP which she should have been. The IP stated it was an oversight on her part. The IP stated it was important for residents with open wound requiring dressing and residents with wound vac to be placed on EBP to ensure residents safety and to prevent risk of spreading infections. During an interview on 12/02/2025 at 3:30 PM, the Director of Nursing (DON) verified residents with wound vac should be placed on EBP per facility policy. The DON verified Resident 53 should be on 055093 Page 17 of 21 055093 12/04/2025 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 EBP and stated since Resident 53 was not initially placed on EBP, then the facility policy was not followed. The DON stated it was important for a resident to be placed on EBP if treated with wound vac to prevent cross contamination and prevent the spread of infection. A review of the CDC poster titled Enhanced Barrier Precaution which the facility currently used, it indicated.enhanced barrier precaution providers and staff must also wear gloves and gowns for the following high contact resident care activities: device care or use.wound care: any skin opening requiring a dressing. A review of the facility's policy and procedure (P&P) titled Enhanced Barrier Precaution, dated 8/2022, the P&P indicated.EBPs were indicated for residents with wounds and or indwelling medical devices regardless of their MDRO colonization. B.A review of Resident 4 face sheet indicated an admission date of 10/2025 with a diagnosis of Diabetes Mellitus (DM, disorder characterized by difficulty in blood sugar control and poor wound healing) and Stage 5 chronic kidney disease (severe kidney damage) A review of Resident 11's face sheet indicated an admission date of 11/2025 with a diagnosis of DM and Stage 3 chronic kidney disease (kidneys have mild to moderate damage and are less able to filter waste and fluid out of your blood). A review of Resident 63s face sheet indicated an admission date of 9/2025 with a diagnosis of DM and Stage 3B chronic kidney disease (more severe half of Stage 3, where kidneys struggle to filter waste, leading to potential buildup and complications). During an observation on 12/02/2025 at 5:35 PM, Licensed Nurse (LN) M used the super sani cloth purple top germicidal wipe to sanitize the glucometer. LN M did not observe the recommended 2 minutes contact time to sanitize the glucometer. LN M used the glucometer to check Resident 4's blood sugar level 70 seconds after sanitizing the glucometer. During an observation on 12/02/2025 at 5:58 PM, LN M super sani cloth purple top germicidal wipe to sanitize the glucometer. LN M inserted the glucose test strip while the glucometer was still wet. LN M did not follow the 2 minutes recommended contact time to sanitize the glucometer prior to checking Resident 11's blood sugar level. During a concurrent observation and interview on 12/02/2025 at 6:12 PM, LN M used the super sani cloth purple top germicidal wipe to sanitize the glucometer. LN M verified the glucometer was still wet when LN M inserted the glucose test strip and LN M verified not waiting for the 2 minutes contact time to sanitize the glucometer prior to checking Resident 11's blood sugar level. During an interview on 12/03/2025 at 3:39 PM, LN P verified the facility used the super sani cloth purple top germicidal wipe to sanitize the glucometer. LN P thought glucometer should have a 5 minutes contact time with the sanitizing wipe solution prior to using the glucometer to check a residents' blood sugar level. LN P stated if the contact time to sanitize the glucometer using the super cloth purple top germicidal wipe was under 2 minutes, then it would not be effective in getting rid of the bacteria or germs in the glucometer and could result in cross contamination. LN P stated residents could end up getting sick or infected. During an interview on 12/03/2025 at 3:45 PM, LN M verified the facility used the super sani cloth 055093 Page 18 of 21 055093 12/04/2025 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 purple top germicidal wipe to sanitize the glucometer and would only wait between 1 to 3 seconds before using the glucometer. When shown the super sani cloth purple top germicidal wipe, LN M verified the contact time to kill bacteria and viruses was 2 minutes. LN M confirmed she was not following the recommended contact time whenever she was disinfecting the glucometer. LN M stated it was important to follow the recommended contact time when sanitizing the glucometer to ensure bacteria and viruses were killed. LN M stated not following the recommended contact time when sanitizing the glucometer could result in spread of infection. During an interview on 12/03/2025 at 3:53 PM, the Infection Preventionist (IP) verified the facility used the super sani cloth purple top germicidal wipe to sanitize the glucometer. The IP verified the glucometer needs to have a 2-minute contact time with the wipe's solution prior to use. The IP stated not ensuring there was 2 minutes contact time could result to infection and could result to not killing all the bacteria present in the glucometer. A review of the super sani cloth germicidal disposable wipe description indicated.the disinfecting wipe was.effective against 34 microorganisms in 2 minutes.fast contact time allows for a quick room turnover. ideal for daily use in fast-paced environments that require short contact times and broad coverage of microorganisms. C. During an observation on 12/3/25 at 9:25 AM, Certified Nursing Assistant (CNA) B was observed providing care for Resident 30. CNA B loosened and opened Resident 30's brief (undergarment), wiped clean her perineal area, disposed of the brief into the waste bin, adjusted the plastic lining of the waste bin and proceeded to apply a clean brief on the resident. CNA B was not observed to change her gloves from the time she opened the resident's brief to the time she applied the clean brief. During an interview on 12/3/25 at 9:50 AM, CNA B stated said should have changed her gloves between changing soiled to clean brief. During an observation on 12/3/25 at 11:32 AM, Licensed Nurse (LN) D was observed providing wound care to Resident 30. LN D removed the dressing covering the wound on the lower back above the tailbone of Resident 30. LN D cleansed the wound with normal saline then removed his gloves and disposed of it. LN D then put on new gloves without performing hand hygiene, applied medication and covered the wound with foam dressing. During an interview on 12/3/25 at 11:43 AM, LN D sadly confirmed he had not performed hand hygiene prior to donning a new pair of gloves. During an interview on 12/4/25 at 9:59 AM with the Director of Nursing (DON), the DON stated staff should perform hand hygiene before tasks and before putting on new gloves. When performing wound care, staff should wash hands before and after the procedure. DON stated after removing wound dressing, staff should remove gloves, perform hand hygiene and put on new gloves. The DON confirmed they follow CDC standards of practice. A review of the Centers for Disease Control (CDC) webpage on Clinical safety: Hand hygiene for healthcare workers dated 2/27/24 (https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html) indicated, if tasks require gloves, perform hand hygiene before putting on gloves and touching the patient or the patient's surroundings, and always clean hands after removing gloves. Change gloves and clean hands when gloves become soiled with blood or body fluids after a task, and when moving from a soiled body site to a clean body site on the same patient. 055093 Page 19 of 21 055093 12/04/2025 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 D. During an interview on 12/04/2025 at 1:00 PM, the Infection Preventionist (IP) stated they call to inform the local health department if they suspect the presence of Legionella. The Local health department does the testing for the presence of Legionella. During an interview with the facility Administrator on 12/4/25 at 2:27 PM, the Administrator stated they do not do tests for the presence of Legionella in the water system. The Administrator stated that when they suspect growth or presence of Legionella, they notify the local health department, and they test. During an interview with the Maintenance Director on 12/4/25 at 2:42 PM, he stated he had been monitoring water temperature but when his logs were reviewed, he confirmed he was monitoring water temperatures in residents' rooms and bathrooms to ensure safety of temperature for residents use. A review of the facility's policy titled Legionella water management program dated effective 6/12/24 indicated its purpose is to identify areas in the water system where Legionella bacteria can grow and spread and to reduce the risk of Legionnaire's disease. The elements of the program include specific measures used to control the introduction and or spread of Legionella, and control limits or parameters that are acceptable and that are monitored. Further review of the water flow diagram did not indicate markers in the water system where Legionella bacteria can grow and spread and where parameters may be monitored. 055093 Page 20 of 21 055093 12/04/2025 South Marin Health & Wellness Center 1220 South Eliseo Drive Greenbrae, CA 94904

F 0881 Implement a program that monitors antibiotic use. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to develop an antibiotic use protocol in addition to a system to effectively monitor the use of antibiotics.This failure can result in inappropriate use of antibiotics that can lead to the development of antibiotic-resistant organisms, difficulty treating infections and severe health complications. Findings:During an interview on 12/04/2025 at 1:00 PM, the facility Infection Preventionist (IP) stated the facility use the McGeer criteria ( an evidence-based guideline for defining infections in long-term care facilities (LTCFs), focusing on specific group of symptoms and laboratory results for respiratory, gastrointestinal, and urinary infections) to guide treatment. On further interview the IP stated aside from the McGeer criteria they have no other protocol they use for antibiotic stewardship (a coordinated effort in healthcare to ensure antibiotics are used appropriately-only when needed, with the right drug, dose, and duration-to improve patient outcomes, combat the serious threat of antimicrobial resistance, and preserve the effectiveness of antibiotics). The Agency for Healthcare Research and Quality (AHRQ) home page on Nursing home antimicrobial stewardship guide, last reviewed on 9/2017, indicating a Minimum criteria for antibiotic tool a decision support tool for use of prescribers to determine whether it is necessary to treat a potential infection with antibiotics was shown to the IP. The IP stated she is not aware of the protocol and have not used this kind of tool. During an interview on 12/4/25 at 2:56 PM with the Medical Director, the Medical Director stated she is not aware of a protocol to use before antibiotic is considered for a suspected infection. The Medical Director stated she was not familiar with the decision support tool from the AHRQ homepage before it was described to her. A review of the facility's policy titled, Antibiotic stewardship program revised 6/2021, indicated the program was to promote appropriate use of antibiotics, limiting antibiotic resistance, treatment efficacy and resident safety. Residents Affected - Some 055093 Page 21 of 21