Health inspection·March 20, 2025

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the call light for one of 26 sampled residents (Resident 13) was within her reach. This failure had the potential for Resident 13's needs not being met. Residents Affected - Few Findings: During a review of Resident 13's admission Record, dated 3/18/25, the admission Record indicated Resident 13 was admitted to the facility on [DATE] with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD, a chronic lung disease causing difficulty in breathing). During a concurrent observation and interview on 3/17/25 at 10:53 a.m., in Resident 13's room, Resident 13 was lying in bed. Resident 13's call light was tied on the left bed rail and was hanging off the bed. Resident 13 stated she could not reach the call light where it was located. Resident 13 stated she uses her call light to call for assistance. During a concurrent observation and interview on 3/17/25 at 10:55 a.m., in Resident 13's room with the Director of Nursing (DON), the DON confirmed the location of Resident 13's call light. DON stated Resident 13 uses her call light. DON stated Resident 13's call light should be within Resident 13's reach. During an interview on 3/18/25 at 11:15 a.m., with Occupational Therapist (OT) 1, OT 1 stated Resident 13's call light should be placed on her lap in front of her because Resident 13 has limited range of motion with her arms. During the review of the facility's policy and procedure (P&P) titled, Communication- Call System, dated 10/9/24, the P&P indicated, The Facility will maintain a communication system to allow residents to call for staff assistance from their rooms and toileting/bathing facilities. Purpose: To ensure that residents have a means of contacting Facility Staff for assistance. Page 1 of 32 055331 055331 03/20/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. Based on interview and record review, the facility failed to ensure one of 26 sampled residents (Resident 1) was notified of a room/roommate change with a written notice that included the reason before the facility had changed the resident's room. This failure had the potential to result in negatively impacting Resident 1's emotional and psychosocial well-being. Findings: During an interview on 3/17/25 at 9:05 a.m. with Resident 1, Resident 1 stated she woke up to multiple male staff standing over her bed and was told to get up because she was moving to a different room. Resident 1 stated she was not notified of the room change prior to moving and did not want to change rooms. During a concurrent interview and record review on 3/19/25 at 4:51 p.m. with the Administrator (Admin), Resident 1's Electronic Health Record (EHR) was reviewed. The EHR did not show a bed change notification. The Admin confirmed Resident 1's room was changed in June 2023. The Admin stated, this is a problem and Resident 1 should have been notified. During a review of Resident 1's Progress Note, dated 6/15/23, the Progress Note indicated, .Move from 16B to now 12A . During a review of the facility's policy and procedure (P&P) titled, Room or Roommate Change, dated March 2018, the P&P indicated, Prior to changing a room or roommate assignment, the resident, the resident's representative (if available), and the resident's new roommate will be provided timely advance notice of such a change . The notice of a change in room or roommate assignment must be given in writing, and will include the reason(s) for such change. 055331 Page 2 of 32 055331 03/20/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation, interview, and record review, the facility failed to ensure the shower's water temperature was comfortable for one of 26 sampled residents (Resident 1). This failure resulted in Resident 1 not receiving a comfortable shower. Findings: During an interview on 3/17/25 at 9:05 a.m. with Resident 1, Resident 1 stated the shower's water never stayed warm. During a concurrent observation and interview on 3/19/25 at 7:55 a.m. with the Maintenance Director (Main) in the Spa Shower Room, the Main checked the shower's hot water temperature, and it read 90 degrees Fahrenheit after 3 minutes. The Main stated the temperature should have been 110 degrees Fahrenheit. During a review of the facility's policy and procedure (P&P) titled, Water Temperatures, dated 1/2/12, the P&P indicated, The Facility ensures water is maintained at temperatures suitable to meet residents' needs. 055331 Page 3 of 32 055331 03/20/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a copy of notice of transfer/discharge was sent to the Ombudsman (an advocate for residents of nursing homes) for two of 26 sampled residents (Residents 58 and 59) when: 1. Resident 58 was transferred to the hospital on 2/26/25. 2. Resident 59 was discharged home on [DATE]. These failures had the potential for residents to be inappropriately transferred or discharged which could result in violating their rights. Findings: 1. During a review of Resident 58's admission Record, dated 3/19/25, the admission Record indicated Resident 58 was admitted to the facility on [DATE] with a diagnosis of acute (short duration and requires immediate attention) pyelonephritis (kidney infection). During a review of Resident 58's Nursing Progress Note, dated 2/26/25, the Nursing Progress Note indicated Resident 58's had a fever of 100.6 Fahrenheit and a nurse practitioner ordered to send Resident 58 to the emergency room for further evaluation for possible sepsis (a life-threatening emergency that happens when your body's response to an infection damage vital organs). During a review of Resident 58's Physician's Order, dated 2/26/25 at 8:32 a.m., the Physician's Order indicated to transfer Resident 58 to (name of hospital) for further evaluation. During a concurrent interview and record review on 3/19/25 at 4:08 p.m., with the Director of Medical Record (DMR), Resident 58's medical record was reviewed. DMR stated when a resident is transferred to the hospital, nursing staff would notify the ombudsman and fill out the Notice of Proposed Transfer and Discharge document. The nursing staff then give the Notice of Proposed Transfer and Discharge to medical record and medical record would upload it in the resident's medical record. DMR confirmed there was no documented evidence the ombudsman was notified of Resident 58's transfer to the hospital on 2/26/25. During an interview on 3/19/25 at 4:30 p.m., with the Director of Nursing (DON) and the Director of Social Services (DSS), the DON stated she was not aware that the ombudsman had to be notified when a resident was transferred to the hospital. The DSS stated the facility only notifies the ombudsman when a resident was discharged home, but not when a resident was transferred to the hospital. During a phone interview on 3/20/25 at 9:05 a.m., with the facility's ombudsman, the facility's ombudsman stated she had communicated with the DSS to notify her when residents were transferred to the hospital and/or when residents were discharged home. The facility's ombudsman stated the facility does not notify her when residents were transferred to the hospital. During a phone interview on 3/20/25 at 10:25 a.m., with the facility's ombudsman, the facility's ombudsman confirmed that her office had not been notified of Resident 58's transfer to the hospital on 055331 Page 4 of 32 055331 03/20/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0623 2/26/25. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, Notice of Transfer/Discharge, dated October 2017, the P&P indicated, I. This notice applies to transfers or discharges that are initiated by the facility, not by the resident . III. Before the transfer or discharge occurs, the facility must notify the resident and if known, the responsible party, and Ombudsman of the transfer and reasons for the transfer, and document in the resident's clinical record. Residents Affected - Few 2. During a review of Resident 59's admission Record, dated 3/24/25, the admission Record indicated Resident 59 was admitted to the facility on [DATE] with a diagnosis of Alzheimer's disease (a brain disorder that slowly destroys a person's memory and thinking skills). During a review of Resident 59's Physician's Order, dated 12/20/24 at 6:20 p.m., the Physician's Order indicated to discharge Resident 59 to home. During an interview on 3/20/25 at 8:30 a.m., with the Assistant Administrator (AAdmin), the AAdmin stated there was no documented evidence the ombudsman was notified of Resident 59's discharged to home on [DATE]. During a phone interview on 3/20/25 at 10:25 a.m., with the facility's ombudsman, the facility's ombudsman stated she had communicated with the DSS to notify her when residents were transferred to the hospital and/or when residents were discharged home. The facility's ombudsman stated the facility did not notify her when Resident 59 was discharged home on [DATE]. During a review of the facility's policy and procedure (P&P) titled, Notice of Transfer/Discharge, dated October 2017, the P&P indicated, I. This notice applies to transfers or discharges that are initiated by the facility, not by the resident. III. Before the transfer or discharge occurs, the facility must notify the resident and if known, the responsible party, and Ombudsman of the transfer and reasons for the transfer, and document in the resident's clinical record. 055331 Page 5 of 32 055331 03/20/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assess and submit accurate data for one of 26 sampled residents (Resident 37) when: Residents Affected - Few 1. the Level I PASRR (Preadmission Screening and Resident Review- used to receive needed mental health services) screening was not reassessed upon admission to the facility. This failure had the potential for Resident 37 to not receive specialized mental health services to meet their needs. 2. the Minimum Data Set (MDS- an assessment tool used to guide resident care) did not reflect Resident 37's current status. This failure resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS). Findings: 1. During a review of Resident 37's admission Record, dated 3/20/25, the admission Record indicated Resident 37 was admitted to the facility on [DATE] with diagnoses of post-traumatic stress disorder (PTSD-mental health condition caused by experiencing or witnessing a traumatic event) anxiety disorder (mental health condition that involves excessive and persistent feelings of fear, worry, dread and uneasiness), and major depressive disorder (MDD- mental health condition caused by persistent feelings of sadness and loss of interest). During a concurrent interview and record review on 3/18/25 at 3:24 p.m. with Minimum Data Set Coordinator (MDSC), Resident 37's PASRR Level I, dated 6/22/23, and MDS 3.0 Section I- Active Diagnoses, dated 1/27/25, were reviewed. Resident 37's PASRR Level I completed by the discharging hospital indicated the result of the assessment was negative. Resident 37's MDS 3.0 Section I- Active Diagnoses indicated active diagnoses of PTSD, anxiety disorder and MDD. The MDSC stated Resident 37's PASRR Level I assessment was completed by the hospital prior to admission and results were negative. MDSC further stated the PASRR Level I should have been redone to accurately show Resident 37's active diagnoses and resubmitted by the facility. During a review of the facility's policy and procedure (P&P) titled, Pre-admission Screening Resident Review (PASRR), dated 6/12/24, the P&P indicated, .The facility staff will complete a PASRR . To ensure that all residents are screened for mental illness and intellectual disability (ID) or a related condition (RC). 2. During a concurrent interview and record review on 3/20/25 at 10:09 a.m. with Minimum Data Set Coordinator (MDSC), Resident 37's MDS 3.0 Section I- Active Diagnoses, dated 1/27/25, and Active Orders, dated 3/20/25 were reviewed. Resident 37's MDS 3.0 Section I- Active Diagnoses indicated under infections, Resident 37 had an active diagnosis of viral hepatitis (an infection that damages the liver). Resident 37's Active Orders indicated there was no treatment for viral hepatitis. The MDSC stated Resident 37's was discharged from the hospital with a diagnosis of Chronic Hepatitis B and further stated the MDS should have not been coded for an active infection. During an interview on 3/20/25 at 10:25 a.m. with Regional Nurse Consultant (RNC), RNC stated the facility received clarification for Resident 37's MDS active diagnoses and further stated the viral hepatitis should not been coded in MDS under active diagnoses. 055331 Page 6 of 32 055331 03/20/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0641 Level of Harm - Minimal harm or potential for actual harm During a review of CMS Long-Term Care Facility [LTCF] Resident Assessment Instrument [RAI] 3.0 User's Manual, dated October 2024, CMS LTCF RAI 3.0 User's Manual indicated, Code disease that have a documented diagnosis in the last 60 days and have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments . Example of inactive Diagnoses . the resident has recovered . with no residual effects and no continued treatment . Residents Affected - Few 055331 Page 7 of 32 055331 03/20/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a review of Resident 9's admission Record, dated 3/18/2025, the admission Record indicated Resident 9 was admitted to the facility on [DATE] with diagnoses of obesity and difficulty in walking. During an interview on 3/17/25 at 11:22 a.m., with Resident 9, Resident 9 stated she was in the facility mainly to receive rehabilitation services because she shattered her kneecap and broke her left femur last year. Resident 9 stated she had not been receiving physical therapy for some time now which concerned her because she had been in the facility for months. During a review of Resident 9's Physician's Progress Note, dated 3/4/25 by Physician 1, the Physician's Progress Note indicated Resident 9 had a left femur fracture status post ORIF (open reduction and internal fixation, a surgery used to stabilize and heal a broken bone) on 7/4/24 and debility (physical weakness). The Physician's Progress Note indicated for the assessment of debility for a plan of physical therapy three times per week for four weeks. The Physician's Progress Note further indicated Resident 9 was high risk for activities of daily living (ADLs, routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves) decline. During a review of Resident 9's Physician's Orders, dated 10/23/24, 11/6/24, 12/3/24, 12/30/24, 1/26/25 and 2/22/25, the Physician's Orders indicated physical therapy for three times a week for 4 weeks to include therex (therapeutic exercise), theract (therapeutic activity), gait training, and nm re-ed (neuromuscular re-education, techniques that helps a person regain normal, controlled movement patterns) for dx r.26.2 (diagnosis of difficulty in walking). During a review of Resident 9's care plan, there were no documented evidence of a physical therapy care plan. During an interview on 3/20/25 at 11:41 a.m., with the Admin, the Admin confirmed that there was no physical therapy care plan for Resident 9. The Admin further stated Resident 9 should have had a care plan for physical therapy. During the review of the facility's policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning, dated 9/7/23, the P&P indicated, 4. a. Within 7 days from the completion of the comprehensive MDS (Minimum Data Set, a federally mandated resident assessment tool) assessment, the comprehensive care plan will be developed. All goals, objectives, interventions, etc. will be included in the resident's comprehensive care plan. Additional changes or updates to the resident's comprehensive care plan will be made based on the assessed needs of the resident. Based on interview and record review, the facility failed to develop care plans for two of 26 sampled residents (Resident 1 and 9) when: 1. There was no fall care plan for Resident 1. This failure had the potential to cause multiple falls due to lack of interventions and proper monitoring. 2. There was no physical therapy (PT, the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise) care plan for Resident 9. This failure had the potential for Resident 9 to not receive the specific services necessary to meet her needs. 055331 Page 8 of 32 055331 03/20/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0656 Findings: Level of Harm - Minimal harm or potential for actual harm 1. During a review of Resident 1's admission Record, dated 3/20/25, the admission Record indicated Resident 1 was admitted on [DATE] with diagnoses of dementia (a decline in mental abilities, such as memory, thinking and reasoning), abnormalities of gait and mobility (abnormal movements and walking pattern), and difficulty in walking. Residents Affected - Few During a concurrent observation and interview on 3/19/25 at 7:55 a.m. with Resident 1 in her room, Resident 1 had a four-wheel walker next to her bed. Resident 1 stated she has had a lot of falls while residing in the facility, and the facility had not discussed how to prevent falls. During a concurrent interview and record review on 3/19/25 at 3:44 p.m. with the Director of Nursing (DON), Resident 1's Post Fall Evaluation, Neurological Check List, and Care Plans were reviewed. Resident 1's Post Fall Evaluation and Neurological Check List indicated Resident 1 had falls on 1/12/24, 7/29/24, 8/19/24, 9/7/24, and 11/5/24. Resident 1 did not have a fall care plan. The DON stated Resident 1 needed a fall care plan because she was high risk for falls. During a review of the facility's policy and procedure (P&P) titled, Fall Management Program, dated 3/13/21, the P&P indicated, The Facility will implement a Fall Management Program . The IDT [interdisciplinary team] will initiate, review and update the Resident's fall risk status and care plan at the following intervals: on admission, quarterly, annually, upon identification of a significant change of condition, post fall and as needed. 055331 Page 9 of 32 055331 03/20/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice when: Residents Affected - Some 1. Resident 54 did not receive scheduled medications in a timely manner. 2. Certified Nurse Assistant (CNA) 1 was observed laying in Resident 37's bed using her personal cellphone. These failures increased the resident's potential to have unmet health needs and decreased the facility's potential to provide responsible and accurate care for residents. Findings: 1. During a concurrent observation and interview on 3/17/25 at 11:44 a.m. with Resident 54 in her room, Registered nurse (RN) 1 brought Resident 54 a medicine cup with 10 pills in it. RN 1 informed Resident 54 the medications in the cup were ibuprofen (medication used to treat pain), docusate (medication used to treat constipation), multivitamin and ascorbic acid (vitamin c supplement). Resident 54 stated her medications were always late and they should have been given with breakfast around 8 a.m. During a concurrent interview and record review on 3/20/25 at 3:21 p.m. with the Administrator (Admin), Resident 54's Medication Admin Audit Report (MAAR), dated 3/20/25 was reviewed. Resident 54's MAAR indicated Resident 54's docusate and ibuprofen were scheduled for 8 a.m. and were not received until 11:42 a.m. The MAAR further indicated Resident 54's ascorbic acid, ensure (supplement used to gain or maintain weight) and multivitamin were scheduled for 9 a.m. and were not received until 11:42 a.m. The Admin stated, That's not good and medications should have been administered an hour before or an hour after the scheduled time. During a review of the facility's policy and procedure (P&P) titled, Medication- Administration, dated 1/1/12, the P&P indicated, Medications may be administered one hour before or after the scheduled medication administration time . 2. During a concurrent observation and interview on 3/19/25 at 12:20 p.m. with CNA 1 in Resident 37's room, the privacy curtain separating Bed A from Bed B was drawn. Behind the curtain, CNA 1 was laying on Resident 37's bed and was using her personal cell phone. CNA 1 stated Resident 37 was in the dining room for lunch and further stated she should not have been in a resident's bed. During an interview on 3/19/25 at 3:59 p.m. with the Director of Nursing (DON), the DON stated staff should never be on their cellphones while in patient care areas and all staff were needed during mealtimes to ensure residents safety. The DON further stated staff should never lay in any resident's bed. During an interview on 3/19/25 at 4:38 p.m. with the Administrator (Admin), the Admin confirmed CNA 1 was in Resident 37's bed. The Admin stated staff should never be in residents bed or on their cellphones during work hours. During a review of the facility's policy and procedure (P&P) titled, Employee Relations Conduct, 055331 Page 10 of 32 055331 03/20/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0658 Level of Harm - Minimal harm or potential for actual harm dated January 2024, the P&P indicated, The Company considers professional conduct and compliance with the Company's policies and procedures to be an essential responsibility of an employee's job . the following are examples of conduct that are prohibited and will not be tolerated . malingering on the job . any use of a personal communication device in resident care areas . Residents Affected - Some 055331 Page 11 of 32 055331 03/20/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to assist one of 26 sampled residents (Resident 50) with feeding in a timely manner. Residents Affected - Few This failure had the potential for Resident 50 to lose weight. Findings: During a review of Resident 50's admission Record, dated 3/19/25, the admission Record indicated Resident 50 was admitted to the facility on [DATE] with diagnoses of spinal stenosis (a condition where the spinal canal, the bony tunnel that protects the spinal cord and nerve roots, becomes narrowed), failure to thrive (FTT- lack of appropriate weight gain or a decline, which can lead to further health problems) and need for assistance with personal care. During an observation on 3/17/25 from 12:37 to 1:14 p.m. in Resident 50's room, Resident 50 was lying in the bed with lunch tray on his bedside table. Resident 50 was nonverbal and staring at his lunch tray, but was unable to move his arms/hands to feed himself. During an interview on 3/17/25 at 1:14 p.m. with Director of Nursing (DON) outside the Resident 50's room, DON confirmed Resident 50 was a feeder (someone who needs assistance with feeding) and should not have waited a long time to be fed. During a concurrent observation and interview, on 3/18/25 from 12:02 to 12:40 p.m. with Certified Nursing Assistant (CNA) 2 in the Resident 50's room, Resident 50 was nonverbal and unable to move his arms/hands to feed himself. Resident 50's lunch tray was untouched for 38 minutes on his bedside table. CNA 2 stated she had two residents that needed help with feeding, so Resident 50 had to wait. During a review of Registered Dietitian (RD) progress note, dated 2/19/25, RD progress note specified Resident 50's weight loss intervention was adding one-on-one assistance with meals and snacks. During a review of the facility's P&P titled, Resident Rights - Accomodation of Needs, dated 1/1/12, the P&P indicated, To ensure that the Facility provides an environment and services that meet residents' individual needs .Residents' individual needs and preferences are accomodated to the extent possible . 055331 Page 12 of 32 055331 03/20/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the necessary services to attain the highest practicable physical, mental, and psychosocial well-being for one of 26 sampled residents (Resident 9) when physician's orders for physical therapy treatment (PT, the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise) were not provided. This failure resulted in Resident 9 feeling frustrated on her functional and physical progress. Residents Affected - Few Findings: During a review of Resident 9's admission Record, dated 3/18/2025, the admission Record indicated Resident 9 was admitted to the facility on [DATE] with diagnoses of obesity and difficulty in walking. During an interview on 3/17/25 at 11:22 a.m., with Resident 9, Resident 9 stated she was in the facility mainly to receive rehabilitation services because she shattered her kneecap and broke her left femur last year. Resident 9 stated she had not been receiving physical therapy for some time now which concerned her because she had been in the facility for months. During a review of Resident 9's Physician's Progress Note, dated 3/4/25 by Physician 1, the Physician's Progress Note indicated Resident 9 had a left femur fracture status post ORIF (open reduction and internal fixation, a surgery used to stabilize and heal a broken bone) on 7/4/24 and debility (physical weakness). The Physician's Progress Note indicated for the assessment of debility for a plan of physical therapy three times per week for four weeks. The Physician's Progress Note further indicated Resident 9 was high risk for activities of daily living (ADLs, routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves) decline. During a review of Resident 9's Physician's Orders, dated 12/30/24, 1/26/25 and 2/22/25, the Physician's Orders indicated physical therapy for three times a week for 4 weeks to include therex (therapeutic exercise), theract (therapeutic activity), gait training, and nm re-ed (neuromuscular re-education, techniques that helps a person regain normal, controlled movement patterns) for diagnosis of difficulty in walking. During a concurrent interview and record review on 3/18/25 at 11:22 a.m., with the Director of Rehabilitation (DOR), Resident 9's physical therapy notes and the physician's orders for physical therapy treatments were reviewed. The DOR stated Resident 9 was in the facility for skilled rehabilitation services. The DOR confirmed that Resident 9 had a physician's order dated 2/22/25 for physical therapy treatment three times a week for four weeks. The DOR confirmed there were no documented evidence of attempts to provide physical therapy treatment and/or physical therapy treatments were provided for Resident 9 from 1/14/25 - 3/16/25. The DOR stated Resident 9 did not receive the physical therapy treatments per physician's order from 1/14/25 - 3/16/25 because there was no physical therapy staff available to provide the service. During an interview on 3/18/25 at 11:44 a.m., with Resident 9, Resident 9 stated in January 2025 was when she stopped receiving physical therapy treatment. Resident 9 stated she felt frustrated for not receiving physical therapy treatment because her recovery was taking longer than expected. Resident 9 further stated physical therapy was important to her because her goal was to be able to walk enough distance so she would be able to go home. 055331 Page 13 of 32 055331 03/20/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 3/19/25 at 10:11 a.m., with the Director of Nursing (DON), the DON stated she was not aware that Resident 9 had not been receiving physical therapy treatment from 1/14/25 - 3/16/25. During a phone interview on 3/19/25 at 12:20 p.m., with Physician 1, Physician 1 stated he was not aware that Resident 9 had not been receiving physical therapy treatment from 1/14/25 - 3/16/25. Physician 1 stated Resident 9 was in the facility for rehabilitation services and should be getting physical therapy services in the facility. During an interview on 3/20/25 at 10:40 a.m., with the Administrator (Admin) and the Assistant Administrator (AAdmin), the Admin and AAdmin stated they were not aware that Resident 9 had not been receiving physical therapy treatment from 1/14/25 - 3/16/25. Admin stated the physician should have been notified for missed physical therapy treatments. During a concurrent interview and record review on 3/20/25 at 11:41 a.m., with the Admin, the Admin stated she confirmed with the DOR that Resident 9 did not receive physical therapy treatment from 1/14/25 - 3/16/25. Admin showed a documented attempt for physical therapy on 3/3/25 and no other documentation. 055331 Page 14 of 32 055331 03/20/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to label an enteral feeding (a method to provide food through a tube placed in the nose, the stomach, or the small intestine) bottle, an enteral feeding pump bag (a feeding bag consists of a feeding bag and tubing), and a syringe used for enteral feeding for one of 26 sampled residents (Resident 22). This failure had the potential for enteral feeding supplement and equipment to be misused by staff causing cross contamination for Resident 22. Findings: During a review of Resident 22's admission Record, dated 3/18/25, the admission Record indicated Resident 22 was admitted to the facility on [DATE] with a diagnosis of gastrostomy (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach) malfunction. During an observation on 3/17/25 at 9:50 a.m., in Resident 22's room, a Glucerna 1.5 (an enteral feeding formula) was observed infusing at 60 ml/hr (milliliter per hour, a unit of measurement). Upon further inspection, the bottle of Glucerna 1.5, an enteral feeding pump bag that contained a clear liquid substance, and a syringe inside an open bag were hanging on a pole unlabeled and undated. During a concurrent observation and interview on 3/17/25 at 9:58 a.m., with the Director of Staff Development (DSD), the DSD confirmed the bottle of Glucerna 1.5, the enteral feeding pump bag, and the syringe had were unlabeled with resident's name and undated. DSD stated the bottle of Glucerna 1.5, enteral feeding pump, and the syringe should had been labeled with the resident's name, resident's room number, and the expiration of the enteral feeding. During a review of Resident 22's Physician's Order, the following were indicated: 12/29/23 - Change the enteral tubing and syringe daily during night shift. 2/24/25 - Glucerna 1.5 kcal (kilocalorie, unit of measurement used in nutrition) at 60 ml/hr for 20 hours and 910 ml free water. On at 2 p.m. and off at 10 a.m. or until volume complete. During the review of the facility's policy and procedure (P&P) titled, Enteral Feedings, dated 9/7/2023, the P&P indicated, 13. Label bag and tubing with date and time hung. Hang time is for no more than 24 hour. 055331 Page 15 of 32 055331 03/20/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a Licensed Vocational Nurse (LVN) appropriately primed (removing air bubbles from the needle to ensures that the needle is open and working) a Lantus insulin (a long acting medication used to control high blood sugar) pen (a device resembling a pen that delivers insulin injection) before administering to one of 26 sampled residents (Resident 7). This failure had the potential to compromise the medication dose given to Resident 7. Findings: During a review of Resident 7's admission Record, dated 3/18/25, the admission Record indicated Resident 7 was admitted to the facility on [DATE] with a diagnosis of diabetes mellitus type 2 (high blood sugar). During a concurrent medication administration observation and interview on 3/19/25 at 8:05 a.m., of Resident 7's morning medications, with LVN 1, LVN 1 removed the cap of the Lantus insulin pen, turned the dial, and pressed the injection button. LVN 1 then attached and screwed the needle to the Lantus insulin pen. LVN 1 stated the pen needed to be primed before putting on the needle. During a medication administration observation on 3/19/25 at 8:13 a.m., with LVN 1, LVN 1 administered the Lantus insulin to Resident 7. During an interview on 3/19/25 at 9:13 a.m., with the Director of Nursing (DON), the DON stated before using the Lantus insulin pen, the nurse should prime the insulin pen with the needle attached to it. During a review of the Lantus How to use your Lantus SoloStar pen guideline, the guideline indicated, Step 2. Attach the Needle. Wipe the pen tip with an alcohol swab. Remove the protective seal from the new needle, line the needle up straight with the pen and screw the needle on . take off the outer needle cap and save it . Remove the inner needle cap and throw it away. Step 3. Perform a Safety Test. Dial a test dose of 2 units. Hold pen with the needle pointing up and lightly tap the insulin reservoir so that air bubbles rise to the top of the needle. This will help you get the most accurate dose. Press the injection button all the way in and check to see that insulin comes out of the needle. 055331 Page 16 of 32 055331 03/20/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the medication error rate was not greater than five percent when three identified medication errors out of 36 opportunities were observed: Residents Affected - Few 1. Losartan Potassium (medication to manage high blood pressure) was administered without obtaining a blood pressure prior to administration for one of 26 sampled residents (Resident 7). 2. Insulin Glargine [Lantus] (medication to manage high blood sugar) was administered outside of dosing parameter instructions for one of 26 sampled residents (Resident 7). 3. Metoprolol Succinate ER(medication to manage high blood pressure) was not administered per the physician's order for one of 26 sampled residents (Resident 7). These failures resulted in an overall facility medication error rate of 8.33% and had the potential to result in adverse health outcomes for Resident 7 and Resident 12. Findings: 1. During a review of Resident 7's Face Sheet (demographics), the Face Sheet indicated Resident 7 was admitted on [DATE] with the diagnoses including diabetes mellitus type 2 (disease that causes high blood sugar) and hypertension (high blood pressure). During a concurrent observation and interview on 3/19/25 at 7:51 a.m. with Licensed Vocational Nurse (LVN) 1 in Resident 7's room, LVN 1 administered one tablet of Losartan Potassium to Resident 7. LVN 1 did not obtain Resident 7's blood pressure prior to the medication administration. The medication label was reviewed with LVN 1 which indicated, Hold if SBP (measure of blood pressure) less than 110. LVN 1 confirmed she did not obtain Resident 7's blood pressure prior to administering the medication. During an interview on 3/19/25 at 9:50 am with the Director of Nursing (DON), DON stated it was her expectation that LVN 1 check the resident's blood pressure (BP) within 10 - 15 minutes prior to administration of blood pressure medications. During an interview on 3/20/25 at 7:15 a.m. with the Pharmacist, the Pharmacist stated the expectation was for LVN 1 to check the resident's BP one hour prior of administering Losartan. The Pharmacist stated Losartan was used to regulate BP and low BP could cause weakness, and sleepiness. During a review of the Order Summary Report, dated 3/19/25, the Order Summary Report indicated a doctor's order for Losartan Potassium 1 tablet by mouth one time a day for high blood pressure hold SBP <110, start date 2/9/25. During a review of the facility's policy and procedure (P&P) titled, Medication - administration, dated 1/1/12, the P&P indicated, Vital Signs, upon which administration of medications . are conditioned, will be performed . and the results recorded . i.e. B.P. 2. During a review of Resident 7's Face Sheet (demographics), the Face Sheet indicated Resident 7 was admitted on [DATE] with the diagnoses including diabetes mellitus type 2 (disease that causes 055331 Page 17 of 32 055331 03/20/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0759 high blood sugar) and hypertension (high blood pressure). Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 3/19/25 at 7:51 a.m. with Licensed Vocational Nurse (LVN) 1, in Resident 7's room, LVN 1 administered Insulin Glargine15 units (a unit of measure) via pre-filled pen. LVN 1 did not obtain Resident 7's blood sugar prior to administering the insulin. Residents Affected - Few During a record review on 3/19/25 at 10:43 a.m. of Resident 7's Pharmacy Order Summary Report, dated 3/19/25, the Pharmacy Order Summary Report indicted, Insulin Glargine Solution one time a day for diabetes, hold if b/s (blood sugar) is less than 120, start date 2/9/25. During a concurrent interview and record review on 3/19/25 at 11 a.m. Resident 7's Medication Administration Record (MAR) was reviewed with LVN 1, the MAR indicated Resident 7's blood sugar was 74. LVN 1 stated she did not obtain a blood sugar prior to administration of Insulin Glargine and she used the prior shift's blood sugar result of 74. LVN 1 confirmed insulin should not have been administered when Resident 7's blood sugar was less than 120. LVN 1 stated, I made a mistake. During a concurrent interview and record review of Resident 7's MAR, dated 3/19/25, with the Director of Nursing, (DON), The MAR indicated to hold Insulin Glargine for a blood sugar of less than 120. DON confirmed LVN 1 administered Insulin Glargine when Resident 7's blood sugar was 74. During an interview on 3/20/25 at 7:15 a.m. with the Pharmacist, the Pharmacist stated LVN 1 should have obtained Resident 1's blood sugar 1 hour prior to administering insulin and should not have administered insulin when the blood sugar was 74. During a review of the facility's policy and procedure (P&P) titled, Medication - administration, dated 1/1/12, the P&P indicated, Tests upon which administration of medications . are conditioned, will be performed . and the results recorded i.e. finger stick blood glucose monitoring (blood sugar). 3. During a review of Resident 7's Face Sheet (demographics), the Face Sheet indicated Resident 7 was admitted to the facility on [DATE] with the diagnoses including diabetes mellitus type 2 (disease that causes high blood sugar) and hypertension (high blood pressure). During an observation on 3/19/25 at 7:51 a.m. with Licensed Vocational Nurse (LVN)1 in Resident 7's room, LVN1 was observed administering Resident 7's morning medications. LVN 1 did not administer Metoprolol Succinate during the observation. During a concurrent interview and record review on 3/19/25 at 1:15 p.m. with LVN 1, Resident 7's Medication Administration Record, dated 3/19/25 was reviewed. LVN 1 verified that the Metoprolol Succinate ER was not administered per physician's order on 3/19/2025. LVN 1 stated, It was not available from the pharmacy. LVN 1 confirmed she did not notify the physician. During an interview on 3/20/25 at 7:15 a.m. with the Pharmacist, the Pharmacist stated that Metoprolol Succinate ER was used to regulate blood pressure (BP); when BP is too high it could cause chest pain, headaches, cause heart damage, and strokes. Low BP could cause weakness and sleepiness. During a record review of Order Summary Report, dated 3/19/25, the Order Summary Report indicated a doctor's order for Metoprolol Succinate ER give 1 tablet by mouth once a day for high blood pressure hold is SBP < 110, start 3/1/25. 055331 Page 18 of 32 055331 03/20/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0759 During a review of the facility's policy and procedure (P&P) titled, Medication - administration, dated 1/1/12, the P&P indicated, Medications . will be administered as prescribed. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 055331 Page 19 of 32 055331 03/20/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure insulin (medication used to reduce blood sugar) was not administered when blood sugar was below 120 (target range for blood sugar when insulin is not required) for one of 26 sampled Residents (Resident 7) for 10 out of 19 days in March 2025. This failure had the potential to result in low blood sugar symptoms for Resident 7. Residents Affected - Some Findings: During a review of Resident 7's Face Sheet (demographics), the Face Sheet indicated Resident 7 was admitted on [DATE] with the diagnoses including diabetes mellitus type 2 (disease that causes high blood sugar), hypertension (high blood pressure, Cognitive Communication Deficit (medical condition involving thinking process and attention), need for assistance with personal care. During a concurrent observation and interview on 3/19/25 at 7:51 a.m. with Licensed Vocational Nurse (LVN) 1, in Resident 7's room, LVN 1 administered Insulin Glargine 15 units via prefilled syringe to Resident 7. LVN 1 stated the Resident 7's blood sugar level (BS) was 74. During review of Resident 7's Pharmacy Order Summary Report, dated 3/19/2025, the Pharmacy Order Summary Report indicted the Insulin Glargine Solution be administered once a day for diabetes, hold if b/s (blood sugar) is less than 120, start date 2/9/25. During an observation on 3/19/25 at 10:50 a.m. in Resident 7's room, Resident 7 was observed lying in bed, sweating and lethargic (sleepy) but able to respond to questions. During a concurrent interview and record review on 3/19/2025 at 11:15 a.m. with LVN 1, Resident 7's Medication Administration Record (MAR) dated 3/19/2025 was reviewed. The MAR indicated that Resident's blood sugar during the 8:00 a.m. administration was 74. LVN 1 confirmed the Insulin order indicated to hold the insulin when blood sugar was under 120. LVN 1 stated, I made a mistake. During a concurrent observation and interview on 3/19/25 at 11:45 a.m. with LVN 1, LVN 1 verified Resident 7 had symptoms of low blood sugar; was sweating and lethargic. LVN 1 obtained Resident 7's blood sugar and stated it was 78. LVN 1 further stated she needed to treat the low blood sugar with orange juice and call the physician. During a concurrent record review and interview on 3/19/2025 at 11:50 a.m., Resident 7's March 2025 Medication Administration Record (MAR) was reviewed with the Director of Nursing (DON). DON confirmed LVN 1 documented the administration of Insulin Glargine at 8:00 a.m. when Resident 7's blood sugar was 74. DON stated LVN 1 should have held insulin administration for a blood sugar less than 120. Resident 7's MAR indicated blood sugar was below 120: 3/6/25- BS= 99, 3/7/25 -BS= 18, 3/12/25- BS= 87, 3/13/25BS=79, 3/14/25- BS=98, 3/15/25- BS=110, 3/17/25- BS=88, 3/18/25 BS= 92, 3/19/25 BS=74. DON confirmed there was a pattern of administering the am dose of insulin when Resident 7's blood sugar was below 120 on March 6, 7, 12, 13, 14, 15, 17, 18, 19. During an interview on 3/20/2025 at 7:15 a.m. with the Pharmacist, the Pharmacist stated that standard of practice was for a nurse to assess the resident's the blood sugar prior to administration of insulin and follow the physician's orders. 055331 Page 20 of 32 055331 03/20/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0760 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, Medication - administration, dated 1/1/12, the P&P indicated, Medications . will be administered as prescribed . Tests . upon which administration of medications . are conditioned, will be performed . and the results recorded . i.e. finger stick blood glucose monitoring (blood sugar). Residents Affected - Some 055331 Page 21 of 32 055331 03/20/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure medications, supplements, and supplies were appropriately labeled and stored in accordance with accepted standards of practice when: 1. A prescription nystatin powder (a medication to treat yeast or fungal infection of the skin) was found at Resident 9's bedside table. 2. Two medication bubble packs were left unattended on top of a medication cart. 3. Two used topical medications had no caps to cover the tubes in the treatment cart. 4. A collagen matrix dressing (a type of wound dressing that promotes wound healing) package and a Xeroform (a type of wound dressing that promotes wound healing) package dressing were found open in the treatment cart. 5. Five expired syringes with needles were found in the emergency cart. 6. The refrigerator storage for medications was not maintained at a safe temperature. 7. Expired medications were observed in one of two medication carts, cart one. 8. Unsecured medication was observed at the bedside for one of 26 sampled residents (Resident 26). These failures had the potential for residents to receive outdated and/or ineffective medications which could result in adverse clinical outcomes for drug diversion (the illegal distribution or abuse of prescription drugs or their use for purposes not intended by the prescriber). Findings: 1. During a review of Resident 9's admission Record, dated 3/18/25, the admission Record indicated Resident 9 was admitted to the facility on [DATE] with a diagnosis of obesity. During a concurrent observation and interview on 3/17/25 at 11:26 a.m., with Resident 9, in Resident 9's room, a bottle of nystatin powder was on the bedside drawer. Resident 9 stated she used the nystatin powder underneath her skin folds. Resident 9 stated she ordered the bottle of nystatin powder from an outside pharmacy because she was told by the facility that her insurance would not pay for it. During a concurrent observation and interview on 3/17/25 at 11:35 a.m., in Resident 9's room, with the Director of Nursing (DON), the DON confirmed the bottle of nystatin powder on Resident 9's bedside drawer. DON stated Resident 9 did not have an order to keep medication by her bedside. During the review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, dated April 2008, the P&P indicated, Medications and biologicals are stored safely, securely, and properly . 055331 Page 22 of 32 055331 03/20/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. During a medication administration observation on 3/19/25 at 8:50 a.m., for Resident 12, with Licensed Vocational Nurse (LVN) 1, LVN 1 left two medication bubble packs on top of the medication cart and went inside Resident 12's room. LVN 1's back was towards the medication cart while tending to Resident 12. During an interview on 3/19/25 at 9:03 a.m., with LVN 1, LVN 1 confirmed that she had left a bubble pack of Propranolol (a medication for high blood pressure) and a bubble pack of Losartan (a medication for high blood pressure) on top of the medication cart and stated she should not have left the two medications bubble packs unattended. During an interview on 3/19/25 at 9:13 a.m., with the Director of Nursing (DON), the DON stated medications should be put back inside the medication cart and not be left unattended on top of the medication cart. During the review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, dated April 2008, the P&P indicated, Medications and biologicals are stored safely, securely, and properly. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. 3. During a concurrent medication storage observation and interview on 3/18/25 at 4:30 p.m., with the Infection Preventionist (IP), a rolled up tube of Santyl ointment (a topical medication used to remove damaged or burned skin) and a rolled up tube of Ketoconazole cream (a medication used to treat fungal skin condition) were found with no cap covering in the treatment cart (a cart with wound care medications and supplies). IP confirmed the Santyl ointment and the Ketoconazole cream did not have cap coverings. IP stated the Santyl ointment and the Ketoconazole cream should have been discarded. During the review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, dated April 2008, the P&P indicated, Medications and biologicals are stored safely, securely, and properly. M. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closure are immediately removed from stock, disposed according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. 4. During a concurrent medication storage observation and interview on 3/18/25 at 4:32 p.m., with the Infection Preventionist (IP), a Collagen matrix dressing package and a Xeroform gauze dressing package were found opened in the treatment cart (a cart with wound care medications and supplies) unlabled and undated. IP stated the Collagen matrix and Xeroform gauze packages could be reused but should be labeled with open date and time and placed inside a secure plastic bag. During an interview on 3/20/25 at 11 a.m., with the Director of Staff Development (DSD), the DSD stated once the Collogen dressing and Xeroform gauze packages were opened, they should be discarded. During the review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, dated April 2008, the P&P indicated, Medications and biologicals are stored safely, securely, and properly. M. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closure are immediately removed from stock, disposed according to procedures for medication disposal, and reordered from the pharmacy if a current order exists. 5. During a concurrent emergency cart inspection and interview on 3/18/25 at 3:28 p.m., with the 055331 Page 23 of 32 055331 03/20/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0761 Level of Harm - Minimal harm or potential for actual harm Director of Nursing (DON), five expired 1 milliliter (a unit of measurement) syringe with hypodermic safety needle (a very thin, hollow tube with one sharp tip) were found in the emergency cart drawer. The five syringes with the needles had an expiration date of 2/28/25. DON confirmed the five expired syringes with the needles in the drawer and she stated they should not be in the emergency cart drawer. The DON stated the night shift nurse checks the cart supplies and for expired supplies. Residents Affected - Some During the review of the Emergency Cart Supply Checklist, dated March 2025, the checklist indicated, Nurses on 11 p.m. - 7 a.m. shift is responsible to check Emergency Cart every day . Nurses will sign and date to reflect that they have checked and everything is in place as required. 6. During a concurrent interview, and record review on 3/18/25 at 2:15 p.m. with the Director of Nursing (DON), in the medication room, the Medication Refrigerator Temp Log dated March 2025 was reviewed. The Medication Refrigerator Log indicated, Medication refrigerator needs to be 36 - 46 degrees Fahrenheit or is out of range. The log also directed staff to document interventions when the temperature was out of range. Staff documented the temperature was below 36 degrees 24 out of 40 times during the month of March 2025. No comments were documented regarding the temperatures being out of range. DON stated she was unaware that the temperatures were out of range and staff should have notified the DON and the Director of Maintenance so they could correct the issue. During an interview on 3/20/25 at 7:15 a.m. with the Pharmacist, the Pharmacist stated that refrigerated medications need to be kept at a temperature between 36 - 46 degrees Fahrenheit to preserve their therapeutic effectiveness. During a review of the facility's policy titled, Medication Storage in the Facility, dated April 2008, the policy indicated, Medications requiring refrigeration . between 36 - 46 Fahrenheit. 7. During a concurrent observation and interview on 3/19/2025 at 12:50 p.m. with Director of Staff Development (DSD), at medication cart 1, two Bisacodyl suppositories were observed with expiration dates of 11/2024 and 8/2024. DSD confirmed the medications were expired and should not be in the medication cart. During a review of the facility's policy titled, Medication Storage in the Facility dated April 2008, the policy indicated, outdated . medications . are immediately removed from stock. 8. During a review of Resident 26's Face Sheet (demographics), the Face Sheet indicated Resident 26 was admitted to the facility on [DATE] with the diagnoses including heart failure (disease of the heart), anxiety (disorder of excessive worry or fear), and depression (mental health condition with persistent sadness). During a concurrent observation and interview on 3/19/25 at 8:15 a.m. with Licensed Vocational Nurse (LVN) 1, in Resident 26's room, a medicine cup of clear yellow tinged liquid was observed on Resident 26's bedside table. LVN1 stated the clear yellow liquid in the medicine cup was Lactulose (liquid medication used to treat constipation) and was left from the previous shift. During an interview on 3/19/25 at 9:13 a.m. with Director of Nursing (DON), DON stated the expectation was for nursing staff to observe residents consume medications during administration. The DON stated medications were never to be left at the bedside because another resident could take them. DON stated it was not safe to leave medication on Resident 26's bedside table. 055331 Page 24 of 32 055331 03/20/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0761 Level of Harm - Minimal harm or potential for actual harm During a review of Order Summary Report, dated 3/19/25, the Order Summary Report, indicated Resident 26 was prescribed Lactulose Oral Solution . two times a day. During a review of Medication Administration Report (MAR), dated 3/20/25, the MAR indicated Resident 26 was administered Lactulose twice a day at 8:00 a.m. and 5:00 p.m. Residents Affected - Some During a review of the facility's policy and procedure (P&P) titled, Medication - Administration, dated 1/1/2012, the P&P indicated, Medications . will be administered as prescribed . During a review of the facility's policy and procedure (P&P) titled, Medication Storage in the Facility, dated April 2008, the P&P indicated, Medications . are stored safely and securely . accessible only to licensed personnel. 055331 Page 25 of 32 055331 03/20/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure that food was stored in safe and sanitary conditions in the food service department when: Residents Affected - Some 1. The kitchen refrigerator and the Dry Food Storage Area contained food that was not labeled and not covered. 2. The emergency food storage area contained food that was not labeled and expired. These failures had the potential to expose residents to food contamination and food-borne illnesses (sickness by consuming contaminated food or drinks). Findings: 1. During an observation on 3/17/25 at 8:30 a.m., in the kitchen refrigerator, there were seven cucumbers, inside an open box uncovered with no date. During an interview on 3/17/25 at 8:36 a.m. with DM in the kitchen, DM stated the expectation was for staff to label and date all food to prevent cross-contamination and food-borne illnesses. DM further stated the expiration date was important to ensure the residents consumed a safe food product. During an observation on 3/17/25 at 8:46 a.m., in the Dry Food Storage Area, there were individual-packed Italian dressings and yellow mustards in a box with no received and/or expiration date. DM confirmed that these items had no date and they should. During a review of the facility's policy and procedure (P&P) titled, P-DS52 Food Storage and Handling, dated 2/29/2024, the P&P stated 9. Fresh Vegetable Storage . f. Label and date all food items . c. Label and date all food items . 13. Dry Storage Area . h. Label and date all storage products. During a review of the 2022 Federal Food and Drug Administration (FDA) Food Code, Section 3-302.11, titled Packaged and Unpackaged Food - Separation, Packaging, and Segregation, dated 1/18/2023, the FDA food code indicated, FOOD shall be protected from cross contamination by: . storing the food in packages, covered containers, or wrapping. 2. During a concurrent observation and interview on 3/17/25 at 11:00 a.m., with Dietary Manager (DM) in the emergency food storage area, there were six gelatin boxes with no received and/or expiration date and six cans of three-bean salad with expiration date of 2/23/25. DM confirmed the six gelatin boxes and six cans of three-bean salad were expired and not safe to consume. DM further stated it could cause food-borne illnesses and should be discarded right away. DM stated she was the only one restocking and checking the emergency food storage area. During a review of the facility's policy and procedure (P&P) titled, P-DS52 Food Storage and Handling, dated 2/29/2024, the P&P stated 10. Canned Vegetable Storage . c. Label and date all food items . 13. Dry Storage Area . h. Label and date all storage products. 055331 Page 26 of 32 055331 03/20/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0825 Provide or get specialized rehabilitative services as required for a resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide physical therapy treatment (PT, the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise) as ordered by a physician for one of 26 sampled residents (Resident 9). This failure had the potential for Resident 9 to not attain her highest possible level of physical and functional well-being. Residents Affected - Few Findings: During a review of Resident 9's admission Record, dated 3/18/25 admission Record indicated Resident 9 was admitted to the facility on [DATE] with diagnoses of obesity and difficulty in walking. During an interview on 3/17/25 at 11:22 a.m., with Resident 9, Resident 9 stated she was in the facility mainly to receive rehabilitation services because she shattered her kneecap and broke her left femur last year. Resident 9 stated she had not been receiving physical therapy for some time now which concerned her because she had been in the facility for months. During a review of Resident 9's Physician's Progress Note, dated 3/4/25 by Physician 1, the Physician's Progress Note indicated Resident 9 had a left femur fracture status post ORIF (open reduction and internal fixation, a surgery used to stabilize and heal a broken bone) on 7/4/24 and debility (physical weakness). The Physician's Progress Note indicated for the assessment of debility for a plan of physical therapy three times per week for four weeks. The Physician's Progress Note further indicated Resident 9 is high risk for activities of daily living (ADLs, routine tasks/activities such as bathing, dressing, and toileting a person performs daily to care for themselves) decline. During a review of Resident 9's Physician's Orders, dated 12/30/24, 1/26/25 and 2/22/25, the Physician's Orders indicated physical therapy for three times a week for 4 weeks to include therex (therapeutic exercise), theract (therapeutic activity), gait training, and nm re-ed (neuromuscular re-education, techniques that helps a person regain normal, controlled movement patterns) for dx r.26.2 (diagnosis of difficulty in walking). During a concurrent interview and record review on 3/18/25 at 11:22 a.m., with the Director of Rehabilitation (DOR), Resident 9's physical therapy notes and the physician's orders for physical therapy treatments were reviewed. The DOR stated Resident 9 was in the facility for skilled rehabilitation services. The DOR confirmed that Resident 9 had a physician's order dated 2/22/25 for physical therapy treatment three times a week for four weeks. The DOR confirmed there were no documented evidence of attempts to provide physical therapy treatment and/or physical therapy treatments were provided for Resident 9 from 1/14/25 - 3/16/25. The DOR stated Resident 9 did not receive the physical therapy treatments per physician's order from 1/14/25 - 3/16/25 because there was no physical therapy staff available to provide the service. During an interview on 3/18/25 at 11:44 a.m., with Resident 9, Resident 9 stated in January 2025 was when she stopped receiving physical therapy treatment. Resident 9 stated she felt frustrated for not receiving physical therapy treatment because her recovery was taking longer than expected. Resident 9 further stated physical therapy was important to her because her goal was to be able to walk enough distance that she would be able to go home. During an interview on 3/19/25 at 10:11 a.m., with the Director of Nursing (DON), the DON stated 055331 Page 27 of 32 055331 03/20/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0825 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few she was not aware that Resident 9 had not been receiving physical therapy treatment from 1/14/25 3/16/25. During a phone interview on 3/19/25 at 1220 p.m., with Physician 1, Physician 1 stated he was not aware that Resident 9 had not been receiving physical therapy treatment from 1/14/25 - 3/16/25. Physician 1 stated Resident 9 was in the facility for rehabilitation services and should be getting physical therapy services in the facility. During an interview on 3/20/25 at 10:40 a.m., with the Administrator (Admin) and the Assistant Administrator (AAdmin), Admin and AAdmin stated they were not aware that Resident 9 had not been receiving physical therapy treatment from 1/14/25 - 3/16/25. Admin stated the physician should have been notified for missed physical therapy treatments. During a concurrent interview and record review on 3/20/25 at 11:41 a.m., with the Admin, the Admin stated she confirmed with the DOR that Resident 9 did not receive physical therapy treatment from 1/14/25 - 3/16/25. Admin showed a documented attempt for physical therapy on 3/3/25 and no other documentation. 055331 Page 28 of 32 055331 03/20/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow and implement infection control practices for three of 26 sampled residents (Residents 7, 55, and 1) when: Residents Affected - Few 1. Physical Therapist Assistant (PTA) 1 was not wearing a gown while proving care to Resident 7 who was on Enhanced Barrier Precautions (EBP, are infection control intervention designed to reduce the spread of multidrug-resistant organism, MDROs - a germ that is resistant to many antibiotics) 2. Restorative Nursing Assistant/ Certified Nursing Assistant (RNA) 1 was not wearing a gown while repositioning and changing blanket of Resident 55 who was on EBP. 3. Resident 1 was not placed on EBP. This failure had the potential to result in the spread of infectious diseases among residents, staff, and visitors. Findings: 1. During a review of Resident 7's admission Record, dated 3/18/25, the admission Record indicated Resident 7 was admitted to the facility on [DATE] with a diagnosis of chronic ulcer (open sore or wound) of the right foot. During an observation on 3/17/25 at 12:32 p.m., at the outside of Resident 7's room, a sign of Enhanced Barrier Precautions was posted on the wall next to Resident 7's room door. The EBP sign indicated, Everyone must perform hand hygiene before entering the room. Anyone participating in any of these six moments must also: [NAME] (put on) gown and gloves. Morning and evening care, toileting and changing incontinence brief, device care or use, wound care, changing linens, and transferring and preparing to leave room. Change and discard gown and gloves and perform hand hygiene between each resident and before leaving room. Inside Resident 7's room, Resident 7 was lying in bed. PTA 1 was observed with a facemask and gloves attempting to assist Resident 7 in a wheelchair. PTA 1 did not have a gown on her. PTA 1 clothes were touching Resident 7's bedsheets and PTA 1 was moving Resident 7's legs. During an interview on 3/17/25 at 12:38 p.m., with PTA 1, PTA 1 stated that per the nurse, she only needed to wear gloves. During a review of Resident 7's Care Plan for limited physical mobility related to right foot diabetic (high blood sugar) ulcer dated 2/10/25, the Care Plan indicated Resident 7 was placed in Enhanced Barrier Precautions. During an interview on 3/18/25 at 8:47 a.m., with the Infection Preventionist (IP), the IP stated Resident 7 was on EBP because Resident 7 had a chronic wound and a history of MSSA (Methicillin-Susceptible Staphylococcus Aureus, an infection caused by a type of bacteria commonly found on the skin). IP stated the PTA should had worn a gown when transferring Resident 7. During the review of the facility's policy and procedure (P&P) titled, Infection Prevention & Control [NAME] Enhanced Barrier Precautions, dated 5/28/24, the P&P indicated, Purpose to reduce the risk 055331 Page 29 of 32 055331 03/20/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of transmission of epidemiologically (study of of distribution, determinants, and control of disease in population) important microorganisms by direct or indirect contact. Process . 2. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities for those at risk of transmission or acquisition of MDROs: . c. Transferring within the resident room. Rehabilitation and use of EBP 27. Per the CDC (Center for Disease Control and Prevention), Therapist should use gowns and gloves when working with residents on Enhanced Barrier Precautions in the therapy gym or in the resident's room of they anticipate prolonged, close body contact where transmission of MDROs to the therapist's clothes is possible. 2. During a review of Resident 55's admission Record, dated 3/19/25, the admission Record indicated Resident 55 was admitted to the facility on [DATE] with a diagnosis of chronic kidney disease (a condition in which the kidneys gradually lose their ability to filter waste products from the blood). During a concurrent observation and interview on 3/17/25 at 9:56 a.m., outside of Resident 55's room, a sign of Enhanced Barrier Precautions was posted on the wall next to Resident 55's room door. The EBP sign indicated, Everyone must perform hand hygiene before entering the room. Anyone participating in any of these six moments must also: [NAME] (put on) gown and gloves. Morning and evening care, toileting and changing incontinence brief, device care or use, wound care, changing linens, and transferring and preparing to leave room. Change and discard gown and gloves and perform hand hygiene between each resident and before leaving room. Inside Resident 55's room, Resident 55 was lying in bed. RNA 1 was observed with a facemask and hand gloves repositioning and changing the blanket of Resident 55 . RNA 1 did not have a gown on her. RNA 1's clothes were touching resident 55's bedsheets, clothes, and blanket. RNA 1 stated that she was not aware that Resident 55 had EBP precautions. RNA 1 confirmed she should be wearing gown during high contact care with Resident 55. During an interview on 3/17/25 at 10:18 a.m., with the Infection Preventionist (IP), the IP stated Resident 55 was on EBP because Resident 55 had a chronic wound (a wound that fails to heal within an expected timeframe) and a foley catheter (tube inserted into the bladder to drain urine). IP stated the RNA 1 should had worn a gown when repositioning and changing the blanket of Resident 55. During the review of the facility's policy and procedure (P&P) titled, Infection Prevention & Control Manual Enhanced Barrier Precautions, dated 5/28/24, the P&P indicated, Purpose to reduce the risk of transmission of epidemiologically (study of of distribution, determinants, and control of disease in population) important microorganisms by direct or indirect contact. Process . 2. For residents for whom EBP are indicated, EBP is employed when performing the following high-contact resident care activities for those at risk of transmission or acquisition of MDROs: . 3. During a review of Resident 1's Face Sheet (demographics), the Face Sheet indicated Resident 1 was admitted to the facility on [DATE] with diagnoses including cellulitis (infection) of the left lower limb, non-pressure chronic ulcer (wound) of the skin of other sites on the body, and needed assistance with personal care. During a concurrent observation and interview on 3/18/25 at 11:00 a.m. with Registered Nurse (RN) 2, outside Resident 1's room, RN 2 stated that Resident 1 had an open wound on the left heal which had a dressing change daily and had been present since admission. RN 2 verified that there was no EBP alert posted outside Resident 1's room. During a concurrent observation and interview on 3/18/25 at 11:50 a.m. with Infection Preventionist (IP), outside Resident 1's room, there was no EBP sign posted. IP stated that Resident 1 needed EBP 055331 Page 30 of 32 055331 03/20/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0880 sign posted for open wounds. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy titled, Enhanced Barrier Precautions, Infection Prevention & Control Manual, dated 7/5/24, the policy indicated, Post the appropriate EBP sign on the resident's room door to inform caregivers of the EBP required. Residents Affected - Few During a review of the All Facilities Letter (AFL- memo issued by the California Department of Public Health) dated 06/13/24, the AFL indicated, skilled nursing facilities should implement Personal Protective Equipment (PPE) to prevent the spread of Multidrug-resistant Organisms (MDRO). Specifically, Enhanced Barrier Precautions (EBP), which involve the use of gloves and a gown during high-contact care activities (person hygiene and linen changes) for residents who have indwelling devices, chronic wounds, or MDROs. 055331 Page 31 of 32 055331 03/20/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide a sanitary environment when one of 26 sampled residents (Resident 3) was observed with black insects crawling in her bed. This failure had the potential to result in Resident 3 being exposed to insect bites and potentially triggering an allergic reaction. Finding: During a review of Resident 3's Face Sheet (demographics) dated 3/20/25, the Face Sheet indicated Resident 3 was admitted to the facility on [DATE] with the diagnoses including cognitive communication deficit (communication difficulties arising from impairments in thinking process, memory, attention span, executive functions), need for assistance with personal care, and generalized muscle weakness. During a concurrent observation and interview on 3/20/25 at 12:30 p.m. with Certified Nursing Assistant (CNA) 2 in Resident 3's room, Resident 3 was observed lying in bed. CNA 2 pulled back Resident 3's blankets and tiny black insects scattered around the bed linens and on Resident 3's legs. CNA 2 stated that Resident 3 was dependent for all care and had difficulty making her needs known. CNA 2 stated this issue had been reported to environmental services a couple months ago. During a concurrent observation and interview on 3/20/25 at 12:33 p.m. in Resident 3's room, with Director of Nursing (DON), DON stated, there are ants in the resident's bed. During an interview on 3/20/25 at 1:00 p.m. with housekeeper (EVS), EVS stated that she had observed the insects in Resident 3's room today. During a review of the facility's policy and procedure (P&P) titled, Housekeeping - General, dated 1/1/12, the P&P indicated, Housekeeping is to ensure the facility is clean, sanitary . at all times . to promote the health and safety of residents. 055331 Page 32 of 32