Health inspection·March 24, 2025

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. Based on interviews and record reviews, the facility failed to ensure a copy of the notice of transfer was sent to the representative of the Office of the State Long-Term Care (LTC) Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) for one out of two sampled residents (Resident 1), when the facility was not able to provide evidence that the notice of transfer was sent to the Ombudsman. This failure had the potential to put Resident 1 at risk of being inappropriately transferred or discharged from the facility. Findings: A review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 1 admitted to the facility in November of 2024. During an interview on 3/24/25 at 12:05 p.m., the Social Services Director (SSD) stated a notice of transfer form should have been completed by the nurse when Resident 1 was transferred out of the facility to an emergency department (ED, a hospital facility that provides immediate, unscheduled medical care for those with urgent or life-threatening conditions) on 11/22/24. The SSD stated a copy of this form should be in Resident 1's electronic health record and be sent to the Ombudsman. SSD stated it was important to send a copy of the form to the Ombudsman to protect the resident's rights. During an interview on 3/24/25 at 12:57 p.m., the Director of Nursing (DON) confirmed the facility failed to notify the Ombudsman when Resident 1 was transferred to the ED on 11/22/24 because this regulation [law] was pretty new . The DON stated it was important to notify the ombudsman when a resident was transferred to the hospital to protect the resident from an unsafe discharge. During an interview on 3/24/25 at 1:50 p.m., the Medical Record Director (MRD) verified there was no documentation nor evidence to indicate the Ombudsman was notified when Resident 1 was transferred to the ED on 11/22/24. A review of All Facilities Letter (AFL, a communication sent to health facilities, providing information on changes in healthcare requirements, enforcement, new technologies, scope of practice, or general information affecting the health facility) AFL-17-27, dated 12/26/2017, indicated . Effective January 1, 2018, . a LTC facility to notify the local LTC Ombudsman at the same time notice is provided to the resident or the resident's representatives when a . transfer or discharge occurs .The facility is required to provide a copy of the notice to the LTC Ombudsman . if a resident is subject to . transfer to a general acute care hospital on an emergency basis . Page 1 of 3 055331 055331 03/24/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based on interviews and record reviews, the facility failed to ensure one out of two sampled residents (Resident 1) was free from unnecessary psychotropic medications (drugs that affect the brain and central nervous system to treat mental health conditions) when prescribed a psychotropic medication without: 1. non-pharmacologic interventions (NPIs, treatments or therapies that do not involve the use of medications) in place to address residents' behavior, and 2. monitoring of behaviors, response to the anti-anxiety (AA, psychotropic medication used to reduce symptoms of anxiety- fear, worry) medication, including side effect (SE, reaction to a medicine) or adverse drug reaction (ADR, dangerous harmful reaction to drugs) in place These failures put the Resident 1 at risk of side effects and adverse drug reactions related to psychotropic medication use. Findings: A review of Resident 1's face sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 1 admitted to the facility in November of 2024 with diagnoses of dementia (a progressive state of decline in mental abilities), cognitive communication deficit (CCD, a communication difficulty stemming from impairments in thought processes like attention, memory, or executive functions). A review of Resident 1s electronic medical record (EMAR, a digital version of a traditional paper medication administration record used in healthcare settings to track and document medication administration), for 11/2024, indicated there was no NPI, target behavior monitoring, SE or ADRs monitoring while Resident 1 was prescribed an AA. A review of Resident 1's progress notes dated, 11/22/25 to 11/23/25, indicated there was no NPI, target behavior monitoring, SE or ADRs monitoring while Resident 1 was prescribed an AA medication. During an interview on 3/24/25 at 11:50 a.m. Licensed Nurse (LN) A stated NPI would be used to address residents' behavior first, then if ineffective, LN may give psychotropic medications. LN A stated staff should monitor residents' response to AA medication. LN A stated behavior, SE and ADRs should also be monitored when residents were prescribed an AA medication. LN A stated monitoring behaviors was important to determine if AA medication was effective in addressing behaviors. LN A stated monitoring for SE/ADRs were important to ensure residents safety. During an interview on 3/24/25 at 12:57 p.m., the Director of Nursing (DON) stated NPIs should be attempted first in addressing residents' behavior and if ineffective, the LN may administer psychotropic medication. The DON stated behavior monitoring, SE and ADR monitoring was important for residents on AA medication to ensure current dose of AA medication was effective in addressing residents' behavior. The DON stated monitoring for SE and ADRs was important to identify and mitigate risk associated with taking AA medications. The DON stated these monitoring would be on EMAR. 055331 Page 2 of 3 055331 03/24/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 3/24/25 at 2:30 p.m., the DON verified Resident 1s EMAR did not indicate Resident 1s behavior, SE and ADR were monitored while prescribed an AA medication. The DON also verified there were no NPIs in place when Resident 1 was ordered an AA medication. A review of the facility's policy and procedure (P&P) titled, Behavior/Psychoactive Medication Management , revised 1/25/24, indicated .any order for psychoactive medication must include a specific behavior manifestation .depending on the specific classification of psychoactive medication, the resident should be observed and or monitored for SE or ADRs . 055331 Page 3 of 3