Health inspection·February 15, 2024

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews, record review, and facility policy review, the facility failed to ensure 1 (Resident #134) of 2 sampled residents reviewed for choices was assessed to self-administer their medication before the licensed nurse left the medication(s) with the resident to administer on their own. Residents Affected - Few Findings included: A review of the facility policy, titled, Self-Administration of Medications, revised in February 2021 revealed, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. Policy Interpretation and Implementation 1. As part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medications is safe and clinically appropriate for the resident. Per the policy, 3. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan. A review of Resident #134's admission Record revealed the facility admitted the resident on 10/25/2023, with diagnoses that included sepsis, right upper extremity cellulitis, muscle weakness, and adult failure to thrive. A review of Resident #134's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/25/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. A review of Resident #134's comprehensive care plan with an admission date of 10/25/2023, revealed no evidence the resident was care planned to self-administer their medication(s). A review of Resident #134's Order Summary Report with active orders as of 02/14/2024, revealed no physician order to indicate the resident could self-administer their medication(s). On 02/12/2024 at 9:21 AM, Resident #134 was observed to have five large white circular pills in a small cup. The resident stated the nursed handed them their pills and left the room. Licensed Vocational Nurse (LVN) #1 entered the resident's room and acknowledged he left the pills with the resident to take. During an interview on 02/13/2024 at 12:12 PM, LVN #1 stated he left Resident #134 unattended with a medication cup that contained their pills in it while he secured and cleaned up his medication cart. LVN #1 stated he knew not to leave medications with residents to self-administer and should not Page 1 of 12 055310 055310 02/15/2024 Marin Post Acute 234 N. San Pedro Rd San Rafael, CA 94903

F 0554 have left Resident #134 alone to take their pills. Level of Harm - Minimal harm or potential for actual harm During an interview on 02/14/2024 at 11:23 AM, LVN #4 stated it was never okay to leave Resident #134 to self-administer their medication(s). Residents Affected - Few During an interview on 02/14/2024 at 1:43 PM, the Director of Nursing (DON) stated no residents of the facility self-administered their medications and no resident had requested to self-administer their medications. The DON stated she expected the nurses to stay with the residents during medication administration for safety reasons and to verify that the residents took all their medications. The DON stated Resident #134 was not assessed to self-administer their medications. During an interview on 02/15/2024 at 8:20 AM, the Administrator stated he expected the clinical team to have evaluated a resident for the ability to safely self-administer medications prior to allowing a resident to self-administer their medications. 055310 Page 2 of 12 055310 02/15/2024 Marin Post Acute 234 N. San Pedro Rd San Rafael, CA 94903

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on interviews, record review, document review, and facility policy review, the facility failed to ensure their grievance policy revealed who the Grievance Official was, their contact information, and the contact information for independent entities to whom grievances may be files. The facility further failed to ensure there was documentation of a resident's grievance to include, the receipt of the grievance, a summary statement of the grievance, the steps taken to investigate the grievance , a summary of the pertinent findings/conclusion, any corrective action taken, whether the grievance was confirmed or not, and the date the written decision was issued to the resident for 1 (Resident #19) of 6 sampled residents reviewed for personal property. Findings included: A review of the facility policy titled, Resident Grievance/Complaint Procedures, revised in January 2017, revealed Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at this facility. Grievances also may be voiced or filed regarding care that has not been furnished. The policy did not reveal who the Grievance Official was, their contact information, or contact information for independent entities with whom grievances may be filed. A review of Resident #19's admission Record revealed the facility admitted the resident on 05/21/2023, with diagnoses to include metabolic encephalopathy, moderate persistent asthma, and chronic obstructive pulmonary disease. A review of Resident # 19's annual Minimum Data Set (MDS), with an Assessment Reference Date (ARD) date of 01/12/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) of 14, which indicated the resident was cognitively intact. In an interview on 02/12/2024 at 11:50 AM, Resident #19 stated the Administrator threw out about $75.00 worth of groceries they had been in the facility's refrigerator. Resident #19 also reported missing items such as slippers, sheets, and personal items. According to Resident #19, they had been reimbursed for some of the items, but not all of them. A review of the facility grievance log for the last six months revealed no evidence to indicate Resident #19 had voiced or filed a grievance related to their missing personal items or their food that had been discarded from the facility's refrigerator. In an interview on 02/13/2024 at 1:34 PM, the Administrator stated last Monday (02/05/2024) during rounds, Resident #19's food items in the refrigerator were discarded as they were not properly labeled. According to the Administrator, this was explained to the resident and the resident would be reimbursed. In an interview on 02/14/2024 at 9:42 AM, the Administrator stated if the resident concern/grievance was handled in real time, there would be no documentation of the concern/grievance. In an interview on 02/14/2024 at 11:46 AM, the Social Services Director stated Resident #19 had been refunded for all their missing items; however, the facility had no documentation to justify what 055310 Page 3 of 12 055310 02/15/2024 Marin Post Acute 234 N. San Pedro Rd San Rafael, CA 94903

F 0585 the resident's grievance was or how it was resolved. Level of Harm - Minimal harm or potential for actual harm In an interview on 02/15/2024 at 9:01 AM, the Director of Nursing (DON) stated any time a staff member acted on a resident grievance/complaint, there should be documentation to indicate what the grievance/complaint was and how it was resolved. The DON stated she would provide education to the social service staff on the grievance process. The DON acknowledged the facility did not implement the grievance process correctly. Residents Affected - Few In an interview on 02/15/2024 at 11:29 AM, the Administrator stated he had now informed the social service staff to document all actions taken related to a resident's grievance. In an interview on 02/15/2024 at 1:57 PM, the Administrator stated the facility's grievance policy had several holes in it and the entire policy and how things were done in the facility needed to be revamped. The Administrator acknowledged he was not aware of the components of the grievance policy or that residents should be provided with a written decision regarding the grievance findings. 055310 Page 4 of 12 055310 02/15/2024 Marin Post Acute 234 N. San Pedro Rd San Rafael, CA 94903

F 0600 Level of Harm - Minimal harm or potential for actual harm Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Based on record reviews, interviews, and facility policy review, the facility failed to ensure 1 (Resident #22) of 1 sampled resident reviewed for abuse, was not physically abused by another resident. Residents Affected - Few Findings included: A review of a facility policy titled, Abuse Prevention Program, revised in December 2016, revealed, Policy Statement Our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Policy Interpretation and Implementation As part of the resident abuse prevention, the administration will: 1. Protect our residents from abuse by anyone including, but not necessarily limited to : facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual. A review of Resident #22's admission Record revealed the facility admitted the resident on 09/16/2022, with diagnoses that included muscle weakness, hypertension, and cognitive communication deficit. A review of Resident #22's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/22/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. A review of Resident #350's admission MDS, with an ARD of 01/09/2023, revealed the facility admitted the resident on 01/05/2023. The MDS revealed Resident #350 had a BIMS score of 6, which indicated the resident had severe cognitive impairment. Per the MDS, the resident had active diagnoses to include non-Alzheimer's dementia and cancer. A review of Resident #350's Progress Notes, written by Registered Nurse (RN) #7 and dated 01/09/2023 at 11:22 PM, revealed a licensed nurse and a certified nursing assistant (CNA) witnessed Resident #350 strike another resident with a pole, as the resident laid in bed. A review of Resident #22's Progress Notes, written by RN #7 and dated 01/09/2023 at 10:41 PM, revealed the licensed nurse on duty heard a noise from the covid unit and when they arrived at the unit, they observed a resident (Resident #350) with a long pole in their hand. Per the Progress Note, the resident (Resident #350), who seemed confused and agitated, struck Resident #22 on their forehead three times while the resident laid in bed. The Progress Note indicated the residents were immediately separated by a licensed nurse and CNA. A review of Resident #22's Progress Notes, written by Licensed Vocational Nurse (LVN) #1 and dated 01/10/2023 at 3:10 PM, revealed the resident sustained a head injury due to a resident-to-resident physical altercation. In an interview on 02/14/2024 at 11:52 AM, Resident #22 stated when the incident occurred, the perpetrator (Resident #350) was confused and held a pole in their hand. Resident #22 stated Resident 055310 Page 5 of 12 055310 02/15/2024 Marin Post Acute 234 N. San Pedro Rd San Rafael, CA 94903

F 0600 #350 yelled that he/she wanted to kill someone, so they yelled for help and pressed their call light. Level of Harm - Minimal harm or potential for actual harm During an interview on 02/14/2024 at 2:00 PM, the MDS Coordinator stated she was the manager on duty when the altercation occurred between Resident #22 and Resident #350. The MDS Coordinator stated she heard someone and when she arrived a CNA had already separated the residents. Per the MDS Coordinator, Resident #350 was confused, threw a trash can, and stated something about getting out of here. The MDS Coordinator stated she instructed the nurse to notify the Administrator, Director of Nursing (DON), and 911. According to the MDS Coordinator, the police came and talked with the residents and the physician gave an order to send the resident out to the hospital. The MDS Coordinator stated she did not recall anything more about the incident. Residents Affected - Few A telephone interview was attempted with the former DON on 02/15/2024 at 9:58 AM. A voicemail message was left, and no return call was received. A telephone interview was attempted with LVN #1 on 02/15/2024 at 10:00 AM. A voicemail message was left, and no return call was received. In a telephone interview on 02/15/2024 at 10:02 AM, RN #7 indicated she did remember the incident that occurred between Resident #22 and Resident #350, but not any of the details. RN #7 stated she documented in the resident's medical records and referred the surveyor to her documentation. During an interview on 02/15/2024 at 11:25 AM, the DON stated she did not work at the facility when the incident occurred between Resident #22 and Resident #350. However, she stated it was her expectation was for staff to report the incident right away to the nurse supervisor and the abuse coordinator. 055310 Page 6 of 12 055310 02/15/2024 Marin Post Acute 234 N. San Pedro Rd San Rafael, CA 94903

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interviews, record reviews, document review, and facility policy review, the facility failed to timely report an allegation of physical abuse to the state agency that involved 1 (Resident #22) of 1 sampled resident reviewed for abuse. Findings included: A review of a facility policy titled, Abuse Investigation and Reporting, revised in July 2017, revealed, All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Findings of abuse investigations will also be reported. Per the policy, 2. An alleged violation of abuse, neglect, exploitation or mistreatment will be reported immediately, but not later than: a. Two (2) hours if the alleged violation involves abuse OR has resulted in serious bodily injury; or b. Twenty-four (24) hours if the alleged violation does not involve abuse AND has not resulted in serious bodily injury. A review of Resident #22's admission Record revealed the facility admitted the resident on 09/16/2022, with diagnoses that included muscle weakness, hypertension, and cognitive communication deficit. A review of Resident #22's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/22/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 12, which indicated the resident had moderate cognitive impairment. A review of Resident #350's admission MDS, with an ARD of 01/09/2023, revealed the facility admitted the resident on 01/05/2023. The MDS revealed Resident #350 had a BIMS score of 6, which indicated the resident had severe cognitive impairment. Per the MDS, the resident had active diagnoses to include non-Alzheimer's dementia and cancer. A review of Resident #350's Progress Notes, written by Registered Nurse (RN) #7 and dated 01/09/2023 at 11:22 PM, revealed a licensed nurse and a certified nursing assistant (CNA) witnessed Resident #350 strike another resident with a pole, as the resident laid in bed. A review of Resident #22's Progress Notes, written by RN #7 and dated 01/09/2023 at 10:41 PM, revealed the licensed nurse on duty heard a noise from the covid unit and when they arrived at the unit, they observed a resident (Resident #350) with a long pole in their hand. Per the Progress Note, the resident (Resident #350), who seemed confused and agitated, struck Resident #22 on their forehead three times while the resident laid in bed. The Progress Note indicated the residents were immediately separated by a licensed nurse and CNA. A review of Resident #22's Progress Notes, written by Licensed Vocational Nurse (LVN) #1 and dated 01/10/2023 at 3:10 PM, revealed the resident sustained a head injury due to a resident-to-resident physical altercation. In an interview on 02/14/2024 at 8:16 AM, the Administrator stated a report was not submitted to the state agency as one of the residents had a diagnosis of dementia. 055310 Page 7 of 12 055310 02/15/2024 Marin Post Acute 234 N. San Pedro Rd San Rafael, CA 94903

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In a follow-up interview on 02/14/2024 at 12:25 PM, the Administrator acknowledged that he did not report the incident to the state agency within the required timeframe. During an interview on 02/15/2024 at 11:25 AM, the Director of Nursing stated she did not work at the facility when the incident occurred between Resident #22 and Resident #350. However, she stated it was her expectation that the incident be reported to the state agency within the required timeframe. A review of a fax transmittal report revealed the facility notified the state agency on 01/10/2023 at 10:42 AM of the allegation of physical abuse that involved Resident #22 and Resident #350. Per the report, on the evening of 01/09/2023 at approximately 6:30 PM, Resident #350 removed a pol from the facility's covid unit barrier, entered the room of Resident #22, and struck Resident #22 on their forehead with the pole. 055310 Page 8 of 12 055310 02/15/2024 Marin Post Acute 234 N. San Pedro Rd San Rafael, CA 94903

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm Based on interviews, record review, and facility policy review, the facility failed to ensure a Level II mental health evaluation was completed for 1 (Resident #56) of 2 sampled residents reviewed for preadmission screening and resident review (PASARR). Residents Affected - Few Findings included: A review of the facility policy titled, Pre-admission Screening and Resident Review, revised in December 2016 revealed, The objective of the PASARR policy is to ensure that individuals with mental illness and intellectual disabilities receive the care and services that they need in the most appropriate setting. Per the policy, c. Upon completion of the Level II screen, the facility will review the screen recommendations and determine the facility's ability to provide the specialized services outlined. A review of Resident #56's admission Record, revealed the facility admitted the resident on 05/23/2023, with diagnoses that included chronic post-traumatic stress disorder and depression. A review of Resident #56's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/30/2023, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. Care Services, dated 06/02/2023, revealed Resident #56 had a positive Level I screening and a Level II mental health evaluation was required. A review of Resident #56's medical record revealed no evidence to indicate a Level II mental health evaluation was completed. During an interview on 02/13/2024 at 9:32 AM, the MDS Coordinator stated she was not aware why Resident #56's Level II mental health evaluation was not completed. According to the MDS Coordinator, she would ensure the Level II mental health evaluation was completed. During an interview on 02/15/2024 at 8:55 AM, the Director of Nursing (DON) stated the MDS Coordinator was responsible for ensuring the Level II mental health evaluation was completed. The DON stated the MDS Coordinator should have followed up on the resident's Level II mental health evaluation. During an interview on 02/15/2024 at 11:18 AM, the Administrator stated the MDS Coordinator was responsible for ensuring any Level I or Level II evaluation was completed. 055310 Page 9 of 12 055310 02/15/2024 Marin Post Acute 234 N. San Pedro Rd San Rafael, CA 94903

F 0689 Level of Harm - Minimal harm or potential for actual harm Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observations, interviews, record review, and facility policy review, the facility failed to ensure 1 (Resident #57) of 3 sampled residents reviewed for accidents was assessed for smoking. Residents Affected - Few Findings included: A review of the facility policy titled, Smoking Policy-Residents, revised in October 2023, revealed, This facility has established and maintains safe resident smoking practices. Per the policy, 7. Resident smoking status is evaluated upon admission. If a smoker, the evaluation includes: a. current level of tobacco consumption; b. method of tobacco consumption; c. desire to quit smoking; and d. ability to smoke safely with or without supervision (per a completed Safe Smoking Evaluation). A review of Resident #57's admission Record revealed the facility admitted the resident on 01/09/2024 with diagnoses that included nicotine dependence and chronic obstructive pulmonary disease. A review of Resident #57's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/13/2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. T A review of Resident #57's Nursing-Smoking Observation/Assessment dated 01/09/2024, revealed the resident denied smoking or the use of all tobacco products. A review of Resident #57's care plan, initiated on 02/01/2024, revealed the resident had the potential for injury related to smoking. Intervention directed staff to assess the resident's ability to smoke safely. On 02/13/2024 at 1:49 PM, Resident #57 was observed in the main lobby with two packs of cigarettes and a lighter in their possession. In an interview on 02/13/2024 at 2:17 PM, Resident #57 stated they sometimes kept their cigarettes and lighter. On 02/13/2024 at 2:38 PM, Resident #57 went outside and lit their cigarette. There was no staff in the area to provide supervision for the resident. Later the Director of Nursing (DON) arrived and informed the resident they should have a staff member with them. The DON was noted to ask the resident if they had any more cigarettes in their possession and the resident replied, no. In an interview on 02/13/2024 at 2:55 PM, the DON stated Resident #57 did not smoke when they were admitted to the facility. The DON stated she had asked staff to complete a smoking assessment once she realized the resident began to smoke. Per the DON, she was not sure if a smoking assessment had been completed. In an interview on 02/13/2024 at 3:08 PM, the Activities Director (AD) stated Resident #57 began smoking about three weeks ago. The AD stated he was not sure if a smoking assessment had been completed for Resident #57 as the assessment is completed by a nurse. In an interview on 02/15/2024 at 11:18 AM, the Administrator indicated his expectation was for 055310 Page 10 of 12 055310 02/15/2024 Marin Post Acute 234 N. San Pedro Rd San Rafael, CA 94903

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few residents to be assessed upon admission. The Administrator stated if there was a change, a new assessment should be completed. The Administrator confirmed a smoking assessment had not been completed for Resident #57. In an interview on 02/15/2024 at 11:21 AM, the DON stated a new assessment should have been completed when the staff found out Resident #57 began to smoke. 055310 Page 11 of 12 055310 02/15/2024 Marin Post Acute 234 N. San Pedro Rd San Rafael, CA 94903

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, record reviews, interviews, and facility policy review, the facility failed to ensure the medication error rate was 5% or less. There were two medication errors out of 29 opportunities, which yielded a medication error rate of 6.89%. This deficient practice was affected 2 (Resident #54 and Resident #75) of 8 residents observed for medication administration. Residents Affected - Few Findings included: A review of the facility policy titled, Administering Medications, revised in April 2019, revealed, Medications are administered in a safe and timely manner, and as prescribed. Per the policy, 4. Medications are administered in accordance with the prescriber orders, including any required time frame. The policy revealed, 10. The individual administering the medication checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication. 1. A review of Resident #75's Order Summary Report, revealed the facility admitted the resident on 07/28/2021. The Order Summary Report revealed an order dated 08/16/2023, for a lidocaine external patch 4% to be applied topically to the resident's right hip every morning and at bedtime for pain. During medication administrator observation on 02/13/2024 at 7:06 AM, Registered Nurse (RN) #2 applied a lidocaine external patch to Resident #75's left hip. During an interview on 02/13/2024 at 2:59 PM, RN #2 acknowledged she applied the lidocaine patch to Resident #75's left hip. RN #2 confirmed the patch should have been applied to the resident's right hip. 2. A review of Resident #54's Order Summary Report, revealed the facility admitted the resident on 05/27/2023. The Order Summary Report revealed an order dated 06/01/2023, for memantine hydrochloride (HCI) 10 milligrams (mg) by mouth one time a day for dementia. During medication administration observation on 02/13/2024 at 7:30 AM, Licensed Vocational Nurse (LVN) #3 did not administer Resident #54 10 mg of memantine HCI. During an interview on 02/13/2024 at 1:55 PM, LVN #3 acknowledged she did not administer memantine HCI to Resident #54. During an interview on 02/14/2024 at 11:20 AM, the Director of Nursing stated staff were expected to follow physician's orders for the administration of medications. During an interview on 02/14/2024 11:29 AM, the Administrator stated he expected staff to administer resident medications according to the physician's orders. 055310 Page 12 of 12