Health inspection·April 10, 2025

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. 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 honor the residents' right to be informed of the plan of care when five of nine sampled residents were not told before admission that their physical therapy (treatment that helps improve how the body performs physical movements) would be done via telehealth (health-related services through live video call) or that they would only receive one session per week. This failure caused residents to feel let down, feel that their progress was slower than they expected, and caused Resident 7 and Resident 8 to not participate in physical therapy. Residents Affected - Some Finding: During an observation on 4/3/25 at 10:35 a.m., a staff member donned a gown and gloves at the doorway to Resident 1's room, and then entered the room bringing a walker and an iPad on wheels to Resident 1's bedside. A voice from the iPad gave instructions to Resident 1 to get up from the bed and go for a walk. The staff in the room assisted Resident 1 to get up and put a gait belt on the resident. The voice from the iPad instructed the Resident 1 to walk five laps in the room. Resident 1 walked back and forth to the door and his bed. The voice on the iPad stated, You're doing great, [Resident 1]! Resident 1 got back in bed, and the voice on the iPad stated, Wonderful! Great job, [Resident 1]. Thank you. The voice on the iPad asked the staff in the room how many feet she thought the resident walked and the staff responded, 20 feet. The voice on the iPad said goodbye to the resident and the staff rolled the iPad out of the room. During an interview on 4/3/25 at 10:48 a.m., Restorative Nursing Assistant (RNA, a healthcare aide who helps patients with activities of daily living, mobility, and strengthening exercises, working under the supervision of other healthcare professionals like nurses or therapists) verified the voice on the iPad was a physical therapist located in a city approximately 390 miles away. RNA stated she began assisting the physical therapist with telehealth sessions about two months ago when the facility's physical therapist resigned. During an interview on 4/3/25 at 11:05 a.m., Resident 2 stated she was here for rehabilitation. Resident 2 stated she worked with Physical Therapist (PT) A on Zoom and Occupational Therapist (OT, a healthcare professional who helps people of all ages who have physical, sensory, or cognitive problems regain independence in all areas of their lives) B in person. During an interview on 4/3/25 at 11:42 a.m. Rehabilitation (Rehab) Director stated PT coverage had been a challenge. Rehab Director stated they had been looking at all avenues with no success finding a PT to hire. Rehab Director stated they currently had PT A who did telehealth physical therapy sessions two days a week, and PT C who did telehealth physical therapy evaluations. Rehab Director stated the facility currently had 14 residents with orders for physical therapy. Rehab Director stated Page 1 of 4 055331 055331 04/10/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some PT A was seeing 9 residents today. Rehab Director stated some residents got physical therapy once a week, and some got physical therapy twice a week. Rehab Director verified the residents were limited to physical therapy no more than twice per week. Rehab Director stated PT A could see up to 10 or 11 residents per day. During an interview on 4/3/25 at 2:58 p.m., Rehab Director verified that one to two sessions per week of physical therapy was lower than industry standard and the residents would benefit from more. Rehab Director verified PT C was recommending only one to two sessions per week in her evaluations because she knew that was all they could accommodate. During an interview on 4/7/25 at 2:19 p.m., Resident 3 verified he was here to get therapy. Resident 3 stated he had the same strength now as when he got here. Resident 3 stated he had been here for several weeks and was getting less exercise now than in the beginning. Resident 3 stated that initially he thought he was making more progress, but now not so much. When queried, Resident 3 stated his wife had talked to the staff more than he had about his lack of progress. Resident 3 stated his plan was to go home but was not sure yet if he would be strong enough. Review of Resident 3's face sheet revealed an admission date of 2/20/25 and multiple diagnoses including left knee pain and difficulty in walking. Review of Resident 3's MDS (minimum data set, an assessment tool) dated 2/24/25 revealed a BIMS score of 13 (Brief Interview for Mental Status, a score of 13 to 15 indicates intact cognition). During an interview on 4/7/25 at 2:46 p.m., Resident 4 stated she had been here at the facility since late December 2024. Resident 4 stated she was supposed to be discharged home when she could walk, but currently could only take a few steps. Resident 4 stated she took advantage of as much physical therapy as she was able to. Resident 4 stated she had one telehealth session with PT A and RNA last week. Resident 4 stated she would like more physical therapy. Resident 4 stated she saw a man (another resident) walking today and said to herself, That's what I want to be able to do. Resident 4 stated she had been getting one session a week of physical therapy since December, I want more than that, I need more than that obviously if I'm going to be able to walk. Resident 4 stated when her husband was in a skilled nursing facility for rehab, he went daily. Resident 4 stated she thought she would be doing the same here. Resident 4 stated she did not know the physical therapy here would be telehealth. Resident 4 stated that when she found out the physical therapy was telehealth, I felt let down. Review of Resident 4's face sheet revealed and admission date of 12/24/24 with multiple medical diagnoses including difficulty in walking. Review of Resident 4's MDS dated [DATE] revealed a BIMS score of 14. During an interview on 4/7/25 at 3:20 p.m., Resident 5 verified he was getting physical therapy. Resident 5 stated, I desperately need physical therapy. Resident 5 stated he needed to be able to walk. Resident 5 stated his physical therapy sessions were with PT A on telehealth. Resident 5 stated his goal was to go home eventually. Resident 5 stated that at the hospital he was told this facility was skilled nursing and he would get the physical therapy that he needed. Resident 5 stated he was not told the physical therapy would be by telehealth. Resident 5 stated his social worker in the hospital told him the physical therapy would be three times a week. Review of Resident 5's face sheet revealed an admission date of 3/24/25 and multiple diagnoses including spinal stenosis (a condition where the spinal canal, which houses the spinal cord and nerves, 055331 Page 2 of 4 055331 04/10/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some narrows, causing pressure on these structures) and difficulty in walking. Review of Resident 5's MDS dated [DATE] revealed a BIMS score of 15. Review of Resident 5's physical therapy evaluation, dated 3/25/25, revealed the treatment approach would be one session per week. Further review of Resident 5's physical therapy evaluation revealed at the end of the document that the original treatment approach entered by PT C had been for three physical therapy sessions per week and Rehab Director had changed the frequency of physical therapy sessions from three to one. During an interview on 4/8/25 at 2:55 p.m., Rehab Director verified that she changed PT C's recommendation for Resident 5 to get three days a week of physical therapy to one day a week. Rehab Director stated, I changed it because we couldn't provide [physical therapy] 3 times a week. During an interview on 4/9/25 at 2:17 p.m., PT A stated she began doing telehealth physical therapy sessions for the facility about six weeks ago. PT A stated she would like to do more than one to two sessions per week with the residents, but she was unable to due to her schedule. PT A stated the residents were introduced to the fact that physical therapy was done through telehealth during the initial evaluation with PT C. PT A stated she got a verbal consent from the residents to do her sessions through telehealth at the beginning of each session, but she was not aware of any written consent for telehealth. During an interview on 4/9/25 at 2:30 p.m., with Director of Staff Development (DSD) and Medical Records Director, DSD stated she was involved in the admission process for new residents. DSD stated there was no consent for telehealth that she knew of. DSD stated the marketing director informed prospective residents that physical therapy was done by telehealth. Medical Record Director stated there was no written consent for telehealth, the consent for telehealth was verbal. During an interview on 4/10/25 at 1:34 p.m., Marketing Director stated she sometimes interacted with residents before their admissions, depending on the situation. Marketing Director stated she did not talk to prospective residents about therapy but told them they would have an initial evaluation on admission and the therapist would provide further detail about therapy. Marketing Director verified she did not tell residents the physical therapy would be via telehealth. When queried, Marketing Director stated all consents were obtained after admission. Marketing Director stated she had not shared with the case managers at the transferring hospitals that the physical therapy program was telehealth or that it was limited to one to two days per week. During an interview on 4/10/25 at 1:39 p.m., Family Member (FM) 6 verified she was Resident 3's spouse. When queried, FM6 stated she did not feel the facility was providing any therapy. FM6 stated Resident 3 had had no improvement in his mobility. FM6 stated they were not told about the physical therapy program here before Resident 3 came here. FM6 verified she was not told physical therapy would be one day per week and was not told it would be telehealth. FM6 stated this made her feel horrified. During an interview on 4/10/25 at 2:36 p.m., OT B stated part of the occupational therapy realm was to make sure the resident was strong enough to walk from the bed to the bathroom to the wheelchair. OT B stated that since there was no fulltime PT, the residents were not walking often enough so it was slowing down his progress with the residents. OT B stated physical therapy and occupational therapy complimented each other, so when the residents did not get full time physical therapy it took him longer to reach his goals for the residents. During an interview on 4/10/25 at 3:03 p.m., Resident 7 stated he was originally sent here for 055331 Page 3 of 4 055331 04/10/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some therapy. Resident 7 stated no one told him physical therapy would be telehealth. Resident 7 stated that when he found out it was telehealth, I didn't like that at all. Resident 7 stated he did one session of telehealth physical therapy and did not like it. Resident 7 stated he did not do any more physical therapy after that. When queried, Resident 7 stated he did not like that the telehealth was not one-on-one. Review of Resident 7's face sheet revealed an admission date of 3/28/25. Resident 7's MDS dated [DATE] indicated a BIMS score of 13. During an interview on 4/10/25 at 3:08 p.m., Resident 8 stated she was not that big on telehealth physical therapy. Resident 8 stated she had a fractured right knee. Resident 8 stated she needed to do physical therapy, and she needed it to be one-on-one. Resident 8 stated she did not know physical therapy was telehealth before she came here. Resident 8 stated she called the hospital after she got here to tell the case managers (that the physical therapy was via telehealth) and they were shocked. Resident 8 stated she got a printout at the hospital that showed the facility had a full rehab department. Resident 8 stated she tried doing the telehealth physical therapy, but it didn't work for me. Resident 8 stated, If I had gotten both therapies twice a day every day, I would have been further along than I am. Resident 8 stated she would not be coming back here after her knee surgery next week. Review of Resident 8's face sheet revealed an admission date of 2/9/25 and multiple medical diagnoses that included a fractured lateral condyle of the right tibia (a break at the top of the larger bone of the lower leg) and difficulty in walking. Review of Resident 8's MDS dated [DATE] indicated a BIMS score of 15. During an interview on 4/10/25 at 3:26 p.m., Administrator stated prospective residents were informed by Marketing Director that certain services at the facility were telehealth. Administrator stated she was not aware that Marketing Director was not telling people about telehealth physical therapy or that physical therapy was one or two days per week. Administrator stated, They should know it's going to be telehealth. Administrator stated she was not aware Rehab Director was changing the recommendations of PT C on the evaluations. Administrator stated, I would think we would want to go with the initial recommendation. Review of facility policy Resident Rights, last revised 1/2012, indicated, Residents of skilled nursing facilities have a number of rights under state and federal law. The facility will promote and protect those rights. These rights include, but are not limited to, a resident's right to: . Choose a physician and treatment and participate in decisions and care planning . 055331 Page 4 of 4