Health inspection·June 3, 2025

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure two out of five sampled residents (Resident 1 and Resident 2) were treated with respect and dignity when: 1. A call light (a signal that residents in healthcare facilities use to alert staff when they need assistance) was not answered timely by facility staff, and 2. A foley catheter (FC, a hollow tube inserted into the bladder to drain or collect urine) drainage bag (bag that collects the drained urine) did not have a privacy cover. These failures had the potential to negatively affect residents' sense of dignity and privacy.[AV3] 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 was admitted to the facility in May of 2025 with diagnoses including Chronic Pain Syndrome (CPS, pain that lasts longer than three months) and Functional Quadriplegia (paralysis from the neck down, including legs, and arms, usually due to a spinal cord injury). A review of Resident 1's Minimum Data Set (MDS – a federally mandated resident assessment tool), dated 5/11/25, indicated Resident 1 was dependent on staff (staff does all the efforts and resident does none of the effort to complete the activity) for care with toileting and personal hygiene. A review of Resident 2's face sheet indicated Resident 2 was admitted to the facility in March of 2022 with diagnoses including Dysphagia (difficulty swallowing) and a need for assistance with personal care. A review of Resident 2's Brief Interview for Mental Status (BIMS, an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident), dated 3/7/25, indicated a score of 15, cognition in tact and no assessed memory problems. 1.During a concurrent observation and interview on 6/3/25 at 11:21 a.m., the call light for room [ROOM NUMBER] was on, indicating a need for assistance, and multiple staff were observed passing by without responding to the call light. Unlicensed Staff A, when stopped, stated she was a new employee and looked at the call light but did not respond to the residents in room [ROOM NUMBER] that were signaling for assistance. Page 1 of 6 055331 055331 06/03/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0557 Level of Harm - Minimal harm or potential for actual harm During an interview on 6/3/25 at 11:23 a.m., Resident 1 in room [ROOM NUMBER] acknowledge the call light was on for assistance and stated staff does not respond to the call light promptly. Resident 1 stated previously she had to wait for hours before staff answered her call light. Resident 1 stated sometimes she would yell and still no one would come. Resident 1 stated when staff do not respond to the call light promptly, she felt like staff did not care about her. Residents Affected - Few During a concurrent observation and interview on 6/3/25 at 11:39 a.m., Licensed Nurse (LN) B verified the call light for room [ROOM NUMBER] was still on. LN B stated everyone was responsible for answering call lights, and added, since everyone oversees answering call lights, call lights must be answered promptly, at least within 3 to 5 minutes. LN B stated there was no reason why a call light should not be answered promptly since anyone could answer it. LN B stated it was not acceptable for residents to wait over 15 minutes for call light to be answered. LN B stated not answering call light timely could make residents feel like staff did not recognize their needs or that the residents' needs did not matter. During an interview on 6/3/25 at 11:44 a.m., Unlicensed Staff C stated it was every staff's responsibility to respond to and answer call lights. Unlicensed Staff C added, call lights should be answered promptly, within two to three minutes, and it was not acceptable for residents to wait over 10 minutes for a call like to be answered. During an interview on 6/3/25 at 11:53 a.m., Resident 2 stated she had experienced waiting for about 30 minutes to an hour before staff have answered her call light. Resident 2 stated some staff just don't answer call lights timely. Resident 2 explained, it was very frustrating when her call light was on but no one was coming and she felt disrespected. During an interview on 6/3/25 at 1:30 p.m., the Director of Staff Development (DSD) stated answering a call light was everyone's responsibility per the facility's policy. The DSD stated call lights should be answered immediately within 2 to 3 minutes and it was not acceptable for residents to wait over 10 minutes for the call light to be answered. The DSD stated call lights should be answered in a timely manner to ensure the residents were safe and to prevent accidents and injuries. A review of the facility's policy and Procedure (P&P) titled Communication-Call System, revised 1/1/12, the P&P indicated, Purpose .To provide a mechanism for resident to promptly communicate with nursing staff . nursing staff will answer call bells promptly . 2. During a concurrent observation and interview on 6/3/25 at 11:23 a.m., Resident 1 had a FC hanging on the right side of the bed with no cover on the drainage bag. Resident 1 stated staff never placed a cover on her FC drainage bag and did not think the facility had any FC drainage bag covers. During a concurrent observation and interview on 6/3/25 at 11:32 a.m., LN B verified Resident 1s FC drainage bag had no cover. LN B stated the facility policy was to ensure FC drainage bag were covered even when in bed to protect residents' privacy and dignity. LN B stated not placing a cover on the drainage bag could make the resident feel upset, ashamed, humiliated and could lead to increase discomfort around visitors. During an interview on 6/3/25 at 11:44 a.m., Unlicensed Staff C stated it was the facility's policy to ensure FC drainage bag was covered even when resident was in bed. Unlicensed Staff C stated it was a dignity issues cause not putting a cover on a FC drainage bag could result in resident feeling humiliated or undignified. 055331 Page 2 of 6 055331 06/03/2025 San Rafael Healthcare & Wellness Center, LP 1601 5th Avenue San Rafael, CA 94901

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 6/3/25 at 1:30 p.m., the DSD stated it was the facility's policy to ensure FC drainage bags were covered. The DSD stated if the FC drainage bag was not covered it meant the facility policy was not followed and would be a privacy and dignity issue for the resident. A review of the facility policy and procedure (P&P) titled Catheter- Care of, revised 6/10/21, the P&P indicated, . the resident's privacy and dignity will be protected by placing cover over drainage bag . A review of the facility's P&P titled Resident's Rights revised 1/1/12, the P&P indicated, .Purpose .To promote and protect the rights of all residents .state and federal laws guarantee basic rights to all residents of the facility, these right includes privacy and confidentiality . 055331 Page 3 of 6 055331 06/03/2025 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 observations, interviews and record reviews, the facility failed to provide service aligned with professional standards for one out of five sampled residents (Resident 1) when medication was left unattended on Resident ' s overbed table. Residents Affected - Few This failure had the potential for the medication to be taken by unintended persons with potentially serious consequences. 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 was admitted to the facility in May of 2025 with diagnoses including Dysphagia (difficulty swallowing). A review of Resident 1's care plan (CP, a detailed, written document that outlines a resident's individual needs, goals, and how their care will be managed), date initiated 10/25/24, indicated, The resident requires tube feeding [TF, a medical device used to provide nutrition and medication to people who are unable to swallow safely] r/t [related to] dysphagia . During a concurrent observation and interview on 6/3/25 at 11:23 a.m., in Resident 1's room, there was a whitish watery substance in plastic cup and a syringe in a cup on Resident 1's overbed table. Resident 1 verified the whitish watery substance in plastic cup was her medication that the nurse left there. Resident 1 indicated she did not know why the medication was left and added, staff would sometimes leave her medications at her bedside or overbed table. During a concurrent observation and interview on 6/3/25 at 11:39 a.m., Licensed Nurse (LN) B verified the whitish watery substance in the medicine cup on Resident 1's overbed table, appeared to be Resident 1's medication. LN B stated it was the facility's policy not to leave medications at residents' bedside as it was a big safety concern. LN B added, the facility had a lot of confused residents who wandered around that could go to another residents' rooms and ingest the medication that was left unattended at the bedside. During an interview on 6/3/25 at 1:22 p.m., the Director of Staff Development (DSD) verified Resident 1's medications were given via feeding tube and Resident 1's medication was left unattended at Resident 1's overbed table. The DSD stated the nurse in charge of Resident 1 had called her because she was having trouble administering the medication. The DSD stated the nurse left the medication at Resident 1's bedside unattended. The DSD acknowledged it was a safety issue to leave a medication at bedside unattended and could lead to serious consequences which could harm residents. A review of the facility's policy and procedure (P&P) titled Specific Medication Administration Procedure effective 4/2008, the P&P indicated, .To administer medications in a safe and effective manner .[medication] once removed from the package or container, unused doses should be disposed of in accordance with the medication destruction policy . A review of the facility's policy and procedure (P&P) titled, .Self-Administration of Medications, dated 4/2008, indicated, .Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the rooms . 055331 Page 4 of 6 055331 06/03/2025 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 Based on observation, interviews and record reviews, the facility failed to a safe and sanitary environment for three out of five sampled residents when: Residents Affected - Few 1. Toothbrushes found in a shared bathroom were not labeled with the resident names, and 2. Resident's foley catheter (FC, a hollow tube inserted into the bladder to drain or collect urine) tubing (a thin, flexible tube connected to a catheter that drains urine from the bladder into a collection bag) was on a contaminated surface. These failures put the residents at risk for the transmission of infections. Findings: 1.During a concurrent observation and interview on 6/3/25 at 12:19 p.m., Licensed Nurse (LN) B in Resident 3's and Resident 6's room, verified Resident 3 did not have a toothbrush on or in the bedside table/bedside drawer. During a concurrent observation and interview on 6/3/25 at 12:49 p.m., in the shared bathroom for Resident 3 and Resident 6, Unlicensed Staff D verified there were 2 toothbrushes in the bathroom that were not labeled with names. Unlicensed Staff D stated if the toothbrushes were not labeled with the residents' name it meant the facility policy was not followed. Unlicensed Staff D stated, I'm not sure which toothbrush belonged to which resident since they were unlabeled. Unlicensed Staff D stated staff should put the resident names on their toothbrush and toothpaste to prevent confusion and accidental use of a toothbrush that does not belong to the resident. During an interview on 6/3/25 at 1:45 p.m., the Director of Staff Development (DSD) verified residents' toothbrushes, especially when kept in the bathroom that was shared with a roommate, should be labeled with their names. The DSD added, toothbrushes labeled with each resident's name was important for infection control and to ensure each resident used their own toothbrush. A review of the facility's policy and procedure (P&P) titled Oral Care, revised 1/1/12, the P&P indicated, .each toothbrush of a resident must be labeled with resident's name, unless kept in the resident's bedside drawer 2. During an observation on 6/3/25 at 11:23 a.m., Resident 1 had a FC hanging on the right side of her bed while the FC tubing was touching a fall mattress (mat placed on the floor that decreases the impact of a fall and reduces the risk of fall-related injuries). During a concurrent observation and interview on 6/3/25 at 11:32 a.m., LN B verified Resident 1's FC tubing was touching the fall mattress and added, the FC tubing should not touch the floor or the fall mattress because those were dirty/contaminated surfaces. LN B stated allowing the FC tubing to touch the fall mattress was unsanitary and could result in resident getting sick with an infection. During an interview on 6/3/25 at 11:44 a.m., Unlicensed Staff C stated it was the facility's policy to ensure FC tubing did not touch the floor or the fall mattress because these surfaces are dirty and contaminated. Unlicensed Staff C stated allowing the FC tubing to touch the floor or fall mattress could result in the resident getting an infection. 055331 Page 5 of 6 055331 06/03/2025 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 During an interview on 6/3/25 at 1:30 p.m., the DSD stated the FC tubing should not touch the floor or the fall mattress because these were considered dirty surfaces. The DSD stated if the FC tubing lays on the floor or fall mattress, it could cause an infection. A review of the facility P&P titled Catheter- Care of, revised 6/10/21, the P&P indicated, . the catheter tubing, bag or spigot will be anchored to not touch the floor . A review of the facility's P&P titled Infection Control- Policies and Procedures dated 1/1/12, the P&P indicated, . to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of disease and infections . 055331 Page 6 of 6