Health inspection·April 17, 2025

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 meet professional standards of nursing care for one resident (Resident 1) of three sampled residents when laboratory tests were not completed per physican orders. Residents Affected - Few This failure had the potential to delay treatment for Resident 1. Findings: A review of Resident 1 ' s admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of multiple fractures (broken bones), diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypokalemia (a low level of potassium (an important mineral) in the blood), hypertension (HTN-high blood pressure), and atherosclerotic heart disease (a narrowing of the vessels in the heart, causing obstruction of blood flow). A review of Resident 1 ' s progress note, dated 3/12/25 at 11:49 a.m., indicated Licensed Nurse K (LN K) documented a telephone order from the Medical Director (MD, a physician) to Test norovirus [a virus that affects the digestive tract], C. diff. [inflammation of the digestive tract caused by the bacteria Clostridium difficile], COVID [Coronavirus Disease- an infectious disease caused by a virus], KUB [an x-ray of body structures responsible for processing urine]. LN K documented in the progress note the order was noted (the doctor ' s instructions were recorded in the patient ' s medical record) and carried out. A review of Resident 1 ' s Care Plan (CP) indicated Resident 1 had a plan for loose stools, initiated on 3/12/25. The interventions included, Test norovirus, c. diff. covid, KUB. A record review of a document titled, Lab Administration History indicated Resident 1 had an order for Other Tests: C. diff panel, norovirus, and covid. Special instructions indicated discontinue the order once results available, and MD notified. The start date for the order was 3/12/25 and the end date was 3/14/25. During a concurrent interview and record review of Resident 1 ' s CP on 4/17/25 at 12 p.m., LN L confirmed an order for norovirus lab was noted but the norovirus test was not completed, and the MD was aware. During a concurrent interview and record review of Resident 1 ' s progress note on 4/17/25 at 12:45 p.m., LN K confirmed the progress note indicated orders for lab tests for c. diff., covid, norovirus, and KUB were noted and carried out. LN K also stated she recalled a discussion with the MD and norovirus lab was not completed. Page 1 of 7 055850 055850 04/17/2025 Pine Ridge Care Center 45 Professional Center Pkwy San Rafael, CA 94903

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few A record review of all laboratory reports for Resident 1 indicated a test for C. Diff. was collected on 3/12/25 and reported to the facility on 3/14/25 as negative (the C. Diff. bacteria was not present). The facility did not have a laboratory report for norovirus. During a concurrent interview and record review of Resident 1 ' s Lab Administration History on 4/17/25 at 3:42 p.m., LN M confirmed Resident 1 had an order for tests for c diff, norovirus, covid, and KUB. LN M stated the order was for four tests and all four of the tests should have been completed. A review of Resident 1 ' s progress note, dated 3/13/25 at 8:05 p.m., indicated LN G received a phone call from the facility laboratory services which indicated Resident 1 had a critical low value (a laboratory test result that was significantly lower than the normal range and indicates a potential life-threatening condition) for potassium (a crucial mineral for the body). LN G notified the MD and received a telephone order for administration of potassium and magnesium. The order also indicated check Resident 1 ' s magnesium (a crucial mineral for the body) and CMP (a blood test that measures 14 different substances in your body) in 2 days. LN G documented the order was noted and carried out. A review of Resident 1 ' s CP indicated Resident 1 had a plan for dehydration/fluid maintenance/low potassium levels, initiated on 3/14/25. The interventions included, lab test as ordered: magnesium CMP in 2 days. During an interview on 4/17/25 at 3:30 p.m., the MD stated if he had written an order for labs, he would have expected all the labs were completed. The MD stated if he ordered a norovirus lab it should have been done and he didn ' t know why it wasn ' t. The MD also stated when he ordered a lab to be rechecked in two days it should have been rechecked in two days. During a concurrent interview and record review of Resident 1 ' s CP on 4/17/25 at 3:42 p.m., LN M confirmed CP indicated, lab tests as ordered: magnesium, CMP in 2 days with approach start date of 3/14/25. LN M stated 2 days would be 3/16/25. During a concurrent interview and record review of Resident 1 ' s Progress Notes on 4/17/25 at 4:05 p.m., LN B stated the MD order on 3/13/25 indicated repeat labs for magnesium and CMP in two days. LN B stated the order was due on 3/15/25. A record review of a document titled, Lab Administration History indicated Resident 1 had an order for CMP and Magnesium with instructions to inform MD once resulted, upload to Matrix (EHR- electronic health record) and may discontinue. The order start date was 3/17/25 and the end date was 3/17/25. A chart note was entered in the EHR on 3/17/25 at 3:58 p.m. with comments indicating the order administration was late and LN D received instructions from the lab to rebook. Review of a facility policy titled, Physician Orders indicated, Physician orders are obtained to provide a clear direction in the care of the resident. The policy further indicated, A physician ' s order is required prior to the discontinuation of any current order. 055850 Page 2 of 7 055850 04/17/2025 Pine Ridge Care Center 45 Professional Center Pkwy San Rafael, CA 94903

F 0678 Level of Harm - Minimal harm or potential for actual harm Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to: Residents Affected - Some 1. Ensure nursing staff were able to correctly state the facility ' s policy on how and when to perform Cardiopulmonary Resuscitation (CPR – an emergency procedure that combines chest compressions (the action of pushing hard and fast on the chest while performing CPR) and rescue breathing to restart a person ' s heartbeat and breathing) and Basic Life Support (BLS- a set of life-saving procedures performed on someone if/when their heart stops beating or the person has difficulty breathing until advanced medical help arrive) when four nursing staff (Certified Nursing Assistant A (CNA A), Licensed Nurse C (LN C), LN D, and LN G) of six nursing staff incorrectly stated the facility ' s policy; 2. Immediately perform CPR on one resident (Resident 1) of three sampled residents on [DATE] when she was found in bed not breathing and without a heartbeat; 3. Ensure an Automated External Defibrillator (AED- a portable medical device used to deliver an electric shock to a person experiencing an abnormal heart rhythm) was present for LNs to use as part of the CPR/BLS) procedure; and, 4. Ensure one LN of four LNs were currently certified to perform CPR/BLS for one resident (Resident 1) of three sampled residents when Resident 1 was found unresponsive, without a heartbeat and not breathing in her room. This failure decreased the facility ' s potential to provide successful resuscitation (to revive from unconsciousness or apparent death) efforts to Resident 1 and other residents who were identified as a Full Code (the resident ' s choice to receive all emergency treatment including CPR to resuscitate and maintain life). Findings: 1. A review of Resident 1 ' s Face Sheet (a summary of basic information about the resident) indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of multiple fractures (broken bones), diabetes (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), hypokalemia (a low level of potassium (an important mineral) in the blood), hypertension (HTN-high blood pressure), and atherosclerotic heart disease (a narrowing of the vessels in the heart, causing obstruction of blood flow). A review of Resident 1 ' s Physician Orders for Life-Sustaining Treatment (POLST – a form that contains written medical orders for healthcare professionals regarding specific medical treatments that can or cannot be done at the end-of life) signed by Resident 1 ' s Representative and dated [DATE], indicated Resident 1 selected, Attempt Resuscitation/CPR. During an interview on [DATE] at 10:20 a.m., CNA A stated the facility trained CNAs on CPR. During an interview on [DATE] at 10:50 a.m., LN C stated if a resident was found unresponsive by a CNA, the CNA is expected to go to one of the nurses ' stations to alert an LN. An LN then would 055850 Page 3 of 7 055850 04/17/2025 Pine Ridge Care Center 45 Professional Center Pkwy San Rafael, CA 94903

F 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some assess the resident. If the resident was unresponsive, the LN would call another LN to stay with the resident while the other LN checked the resident ' s POLST in the paper chart or in the EHR. If the resident was Full Code, an LN was expected to call 911 (a phone number used to call emergency services) and make an overhead announcement on the paging system to activate the Rapid Response Team (RRT- a designated group of nurses who respond to assist residents whose condition requires an immediate response). LN C stated the rapid response would be activated after the POLST was checked. LN C also stated the time CPR was provided mattered because if oxygen (a gas essential for human life) did not get to the brain quickly brain cells died. During an interview on [DATE] at 11:12 a.m., LN D stated if a CNA reported an unresponsive resident, the LN was expected to assess the resident and instruct the CNA to call for help. LN D stated help was summoned by using a call light in the resident ' s room so someone at the nurses ' station would respond. LN D stated she was unsure if the facility had a paging system and did not really know how to call for help. LN D stated she printed a daily census (a list of residents residing in the facility each calendar day) and wrote the code status of the residents she was assigned to. LN D confirmed she did not have the census on her person and kept it at the nurses ' station. LN D stated the time CPR was started was important because brain cells were affected by a lack of oxygen. During an interview on [DATE] at 2:12 p.m., the Director of Staff Development (DSD) stated CNAs were instructed to report to an LN when a resident was found unresponsive. The DSD stated CNAs did not provide CPR in the facility; only licensed staff (nurses who have the legal authority to practice nursing within a specific scope of practice as granted by a state or regulatory department) provided CPR. During an interview and record review on [DATE] at 10:47 a.m., the Director of Nursing (DON) stated she expected LNs to have residents ' code statuses easily accessible. The DON confirmed the RRT was made up of four people which included the Unit Manager (a nurse who supervises and manages staff in a specific unit) and the charge nurses from each of the three nurse ' s stations. The DON also stated there were phones in the hallways for staff to use to make an overhead Rapid Response announcement so everyone could hear it. During an interview on [DATE] at 4:28 p.m., LN G stated CNAs were CPR certified and could assist with CPR. A review of an undated facility policy titled, Emergency Procedure – Cardiopulmonary Resuscitation indicated, .General Guidelines .The chances of surviving SCA [Sudden Cardiac Arrest – when a person ' s heart stops] may be increased if CPR is initiated immediately upon collapse . If an individual .is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR .Instruct a staff member to activate the .[Rapid Response] code and call 911 .Verify or instruct a staff member to verify the DNR or code status .Initiate the .BLS sequence of events . When the AED arrives, assess for need and follow AED protocol as indicated. 2. A review of Resident 1 ' s progress note documented by Resident 1 ' s assigned LN (LN E) dated [DATE] at 9:40 p.m. indicated, During med [medication] pass; the [Resident 1] was observed eye closed with no chest rise and fall. Attempts to call the resident by her name three times yielded no response. Upon checking the resident ' s pulse, found it to be pulseless. The resident ' s skin was noted to be warm to touch; This writer promptly informed other LN ' s to verify the resident code status. Once the complete code status was confirmed, I commenced [started] CPR. Another nurse promptly dispatched 911. Subsequently, another nurse retrieved the crash cart [a wheeled container which stored 055850 Page 4 of 7 055850 04/17/2025 Pine Ridge Care Center 45 Professional Center Pkwy San Rafael, CA 94903

F 0678 equipment used in emergency resuscitations]. Level of Harm - Minimal harm or potential for actual harm A review of Resident 1 ' s progress note documented by the UM of Resident 1 ' s nurse ' s station dated [DATE] at 9:43 p.m. indicated, This writer informed to help asses [Resident 1]. Resident is warm to touch. No chest rise and fall noted. Pupillary reflex [the automatic change in the size of a person ' s pupils, which are the openings in the center of the eye, in response to light] checked and bilaterally [both eyes] unreactive to light and accommodation. Residents Affected - Some A review of Resident 1 ' s progress note dated [DATE] at 10:57 p.m. indicated, Paramedics terminated CPR. Death pronounced at 10:55 p.m. During an interview on [DATE] at 3:55 p.m., LN F stated on the evening of [DATE] she heard shouting and went to Resident 1 ' s room. LN F called 911. LN F stated she did not know why LN H had not called 911 or why LN H had left Resident 1 ' s room and later returned. During a concurrent interview and record review on [DATE] at 10:42 a.m., the DON confirmed a document titled, .County EMS [Emergency Medical Services] Field Determination of Death indicated emergency personnel from the local Fire Department arrived on the scene at 10:25 p.m. on [DATE]. During a concurrent interview and review of Resident 1 ' s progress note on [DATE] at 10:47 a.m., the DON stated she expected CPR should be done immediately and LNs should have code statuses easily accessible. The DON confirmed Resident 1 ' s nurse progress notes dated [DATE], indicated at 9:40 p.m. LN E found Resident 1 unresponsive, not breathing, without a pulse and other LNs were asked to verify Resident 1 ' s code status prior to starting CPR. The DON also confirmed Resident ' s progress note dated [DATE] indicated at 9:43 p.m. LN G went to Resident 1 ' s room and checked Resident 1 ' s skin temperature, apical pulse (a pulse point on a chest at the bottom tip of the heart), respiratory status, and pupillary response. After LN G confirmed Resident 1 did not have a pulse, was not breathing, and Resident 1 ' s code status was confirmed, LN E then started CPR. The DON stated LNs had residents ' code status written on the daily census and was in the EHR system on the medication cart. The DON stated she was unaware if the RRT used the paging system when Resident 1 required CPR on [DATE]. During an interview on [DATE] at 2:08 p.m., LN H stated on the evening of [DATE] he was documenting on resident charts at the nurse ' s station when LN E walked to the nurse ' s station and said he needed help. LN H did not recall who checked Resident 1 ' s code status. LN H stated he finished typing his documentation and went to Resident 1 ' s room. LN H stated he saw LN E was performing chest compressions on Resident 1. LN H stated LN F called 911. LN H took over chest compressions on Resident 1 while the EMS dispatcher coached the team over the phone. During an interview on [DATE] at 4:28 p.m., LN G confirmed she was the UM on the evening of [DATE]. LN G stated LN E came to the nurse ' s station and requested an assessment of Resident 1. LN G got her stethoscope (a medical instrument used for listening to a person ' s heart and/or breathing) and pen light (a small flashlight). LN G stated Resident 1 was in her bed and warm to the touch. LN G stated she listened to Resident 1 ' s apical pulse and four quadrants of her lungs and heard no heartbeat or breath sounds. LN G also stated Resident 1 ' s pupils were fixed (not reacting/moving) to light and dilated (enlarged). LN G told LN E to make sure Resident 1 was a full code and then LN G ran out of the room to get the crash cart. LN G then paged all nurses to go to Resident 1 ' s room. LN G stated LN E started chest compressions and she used the Ambu bag. LN H entered the room and then left. LN F came to the room and was told to call 911. LN H later returned to Resident 1 ' s room and 055850 Page 5 of 7 055850 04/17/2025 Pine Ridge Care Center 45 Professional Center Pkwy San Rafael, CA 94903

F 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some assisted with chest compressions. LN G confirmed there was a paging system at the nurse ' s station. LN G stated the paging system was used for emergencies after 9 p.m. LN G stated the RRT team members were expected to respond to the RRT overhead announcement. A review of an email and records received from the facility Administrator (ADM) on [DATE] at 12:18 p.m. indicated: - A Medication Administration Record dated [DATE] at 9:54 p.m., LN E had passed medication to a resident in another room which did not align with the LN E ' s progress note documented on [DATE] at 9:40 p.m. which indicated LN E discovered Resident 1 unresponsive and promptly initiated CPR. - According to a screen shot of a phone log, LN H called the DON at 10:10 p.m. on [DATE]. - According to a screen shot of a phone log, a call was placed to 911 was placed at 10:11 p.m. on [DATE]. - According to a screen shot of a phone log, a call was made to the DON a second time to notify her Resident 1 was found unresponsive, CPR was initiated, and 911 had been called at 10:11 p.m. A review of an undated facility policy titled, Emergency Procedure – Cardiopulmonary Resuscitation indicated, .If an individual .is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR/BLS shall initiate CPR . If the resident ' s DNR [DNR- a medical order instructing healthcare providers not to perform CPR or other life-saving measures if a person ' s heart or breathing stop] status is unclear, CPR to be initiated until it is determined that there is a DNR or a physician ' s order not to administer CPR . Instruct a staff member to activate the .[Rapid Response] code and call 911 . A review of the 2020 American Heart Association ' s Adult Basic Life Support [BLS] Algorithm for Healthcare Providers indicated, .Look for no breathing .and check pulse (simultaneously). Is pulse definitely felt within 10 seconds? .[If] No breathing .pulse not felt .By this time in all scenarios, emergency response system or backup is activated, and AED [automatic external defibrillator] and emergency equipment are retrieved or someone is retrieving them .Start CPR .Use AED as soon as it is available .AED arrives. Check rhythm. Shockable rhythm [the pattern or timing of the heart beats]? Yes, shockable .Give 1 shock [an electric shock to a person experiencing an abnormal heart rhythm]. Resume CPR immediately . 3. During a concurrent interview and policy review on [DATE] at 10:47 a.m., the DON confirmed the facility policy, Emergency Procedure – Cardiopulmonary Resuscitation indicated, .Instruct a staff member to retrieve the automatic external defibrillator [AED]. The DON stated the facility did not have an AED to be used to provide BLS to a resident who needed it. During an interview on [DATE] at 3:30 p.m., the Medical Director (MD) stated he expected nursing staff to follow the CPR policy. The MD also stated the use of an AED was expected as part of the BLS process. A review of an undated facility policy titled, Emergency Procedure – Cardiopulmonary Resuscitation indicated, Purpose .Personnel have completed training on the initiation of .CPR and .BLS, including defibrillation for victims of .SCA. Early delivery of a shock with a defibrillator plus CPR within 3-5 minutes of collapse can further increase chances of survival . Maintain equipment and 055850 Page 6 of 7 055850 04/17/2025 Pine Ridge Care Center 45 Professional Center Pkwy San Rafael, CA 94903

F 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some supplies necessary for CPR/BLS in the facility at all times .Initiate the .BLS sequence of events . When the AED arrives, assess for need and follow AED protocol as indicated. 4. A review of an email received from the DON on [DATE] at 12:31 p.m. indicated, .Hereto attached are the CPR certs [certification] for [LN H], [LN G], and [LN E]. [LN F ' s] is expired. But she [LN F] did not perform CPR that day [[DATE] on Resident 1]. A review of an undated facility policy titled, Emergency Procedure – Cardiopulmonary Resuscitation indicated, Purpose .Personnel have completed training on the initiation of cardiopulmonary resuscitation (CPR) and basic life support (BLS), including defibrillation for victims of sudden cardiac arrest. CPR/BLS certifications are required for the Registered Nurses, Licensed Vocational Nurses .Preparation for [CPR] .Obtain and/or maintain American Red Cross or American Heart Association .certification in .BLS/CPR for key clinical staff members who will direct resuscitative efforts, including non-licensed personnel . 055850 Page 7 of 7