Inspection·December 8, 2023

F 0637 Assess the resident when there is a significant change in condition Level of Harm - Minimal harm or potential for actual harm Based on record review, interviews, facility policy review, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure a significant change in status comprehensive assessment was completed within 14 days of hospice services election for one (Resident #24) of one sampled resident reviewed for hospice services. Residents Affected - Few Findings included: A review of a facility policy titled Hospice Care, revised in May 2021, revealed, 5. If appropriate a change of condition Minimum Data Set (MDS) shall be completed per RAI guidelines. A review of the CMS Long-Term Care RAI 3.0 User's Manual, Version 1.18.11, dated October 2023, Chapter 2: Assessments for the RAI revealed, 03. Significant Change in Status Assessment (SCSA) (A0310A = 4) The SCSA is a comprehensive assessment for a resident that must be completed when the IDT [interdisciplinary team] has determined that a resident meets the significant change guidelines for either major improvement or decline. The user's manual further specified, An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home. The ARD [Assessment Reference Date] must be within 14 days from the effective date of the hospice election. A review of Resident #24's Profile Face Sheet revealed the facility most recently admitted the resident on 10/06/2023 with diagnoses that included encephalopathy (A broad term for any brain disease that alters brain function or structure) and acute respiratory distress (a condition in which fluid collects in the lungs' air sacs, depriving organs of oxygen). A review of Resident #24's admission MDS, with an ARD of 10/12/2023, revealed Resident #24 had not received hospice services while a resident of the facility. A review of Resident #24's Transdisciplinary Notes revealed a note dated 11/07/2023 that indicated Resident #24 was admitted to hospice. A review of Resident #24's hospice record revealed the resident's hospice benefit period started on 11/07/2023. A review of Resident #24's MDS history revealed a SCSA MDS with an ARD of 12/04/2023 and a completion date of 12/05/2023. The MDS assessment history reflected there was no other SCSA MDS completed following Resident #24's admission to hospice services. During an interview on 12/07/2023 at 1:30 PM, the MDS Consultant confirmed Resident #24's SCSA MDS was not completed within the timeframe it should have been. The MDS Consultant said the SCSA MDS should have been completed within 14 days of Resident #24's admission to hospice. During an interview on 12/07/2023 at 1:44 PM, the Administrator stated Resident #24's SCSA MDS should have been completed within 14 days of the resident's admission to hospice. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056077 If continuation sheet Page 2 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056077 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Tamalpais 501 via Casitas Greenbrae, CA 94904 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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 record review and interviews, the facility failed to ensure a pro re nata (PRN, as needed) psychotropic medication (medications that affect the mind, emotions, and behavior) order specified the duration of use or stop date for one (Resident #20) of five sampled residents reviewed for unnecessary medications. Findings included: A review of Resident #20's Profile Face Sheet revealed the facility most recently admitted the resident on 03/30/2023 with diagnoses that included mild cognitive impairment (a condition in which people have more memory or thinking problems than other people their age) and unspecified disorientation. A review of Resident #20's Baseline & Comp [comprehensive] Care Plan, undated, revealed a Problem area that indicated Resident #20 required the use of psychotropic medications to manage their mood and/or behavior symptoms. The care plan specified the resident required antianxiety medication related to anxiety (Intense, excessive and/or persistent worry and fear) under hospice care. A review of Resident #20's physician's orders revealed orders dated 03/30/2023 for lorazepam (an antianxiety medication) 0.5 milligram (mg), one tablet every four hours PRN (as needed) for mild anxiety and lorazepam 0.5 mg, two tablets every four hours PRN for moderate to severe anxiety. Neither PRN order specified the duration of use or a stop date. A review of a Gradual Dose Reduction Tracking Report, dated 09/20/2023, revealed the interdisciplinary team (IDT) discussed Resident #20's PRN lorazepam order during an IDT meeting on 09/20/2023. According to the report, the resident was receiving lorazepam per hospice protocol, and the IDT discussed having the hospice physician document the continued need for the medication. A review of a Physician Psychotropic Chart Review, dated 11/01/2023, revealed Resident #20's orders for PRN lorazepam were reviewed. The physician documented a gradual dose reduction was clinically contraindicated due to hospice care; however, the duration of use or stop date for the orders was not specified. A review of Resident #20's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 11/10/2023, revealed Resident #20 had a Brief Interview for Mental Status (BIMS) score of 4, which indicated Resident #20 had severe cognitive impairment. According to the MDS, Resident #20 received an antianxiety medication during the seven days prior to the assessment. During an interview on 12/06/2023 at 1:37 PM, the Medical Director (MD) stated all psychotropic PRN medications should have a stop date. During an interview on 12/07/2023 at 12:26 PM, the Director of Nursing Services (DNS) stated she thought because they had documented the rationale for continued use of Resident #20's lorazepam, a stop date was not needed. During an interview on 12/07/2023 at 1:30 PM, the Administrator stated PRN medications should have (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056077 If continuation sheet Page 3 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056077 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Tamalpais 501 via Casitas Greenbrae, CA 94904 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 a stop date. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056077 If continuation sheet Page 4 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056077 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Tamalpais 501 via Casitas Greenbrae, CA 94904 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. Based on observations, interviews, record review, and facility policy review, the facility failed to ensure medications were not repackaged in one (third-floor medication cart) of two medication carts, and the facility failed to ensure an opened multi-dose vial was discarded in one (second-floor medication room) of one medication room observed. Findings included: During an interview on 12/08/2023 at 10:47 AM, the Director of Nursing Services (DNS) stated the facility did not have a policy that addressed repackaging medications. A review of a facility policy titled 5.3 Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, revised on 04/01/2022, revealed, Once any medication or biological package is opened, Facility [sic] should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. 1. Medication administration observation was conducted on 12/06/2023 at 7:59 AM with Licensed Vocational Nurse (LVN) #1. LVN #1 prepared Resident #12's medications, which included acetaminophen 325 milligrams (mg). LVN #1 removed one tablet from the bubble pack labeled #2 on the multi-dose medication card. The following bubble pack labeled #1 on the multi-dose medication card contained two tablets. Clear tape was observed on the back of the multi-dose medication card covering the bubble packs labeled numbers three through five. LVN #1 said it was okay to place medication tablets back in the open bubble packs on the multi-dose medication card. A review of the pharmacy label on the top of the medication card for Resident #12 revealed acetaminophen (a pain and fever medication) 325 mg tablet - take two tablets (650mg) by mouth every four hours as needed. A review of Resident #12's Physician's Orders dated 12/08/2023 revealed an order for Tylenol (acetaminophen) 325 mg tablet - two tablets by mouth every four hours PRN (pro re nata; as needed) for pain with an order date of 09/04/2017 and another order for acetaminophen 325 mg tablet - one tablet by mouth twice daily in addition to PRN with an order date of 05/22/2019. 2. An observation of the second-floor medication room was conducted on 12/06/2023 at 11:28 AM with LVN #1. An open multi-dose vial of Tuberculin Purified Protein Derivative (PPD) was observed in the refrigerator, which was dated as opened on 10/19/2023. LVN #1 said the multi-dose vial should have been used within 30 days of opening. A review of the undated, Aplisol (Tuberculin Purified Protein Derivative) package insert, provided by the facility, revealed, Vials in use more than 30 days should be discarded due to possible oxidation and degradation which may affect potency. During an interview on 12/08/2023 at 8:04 AM, the DNS said nurses should not tape medications back into the medication card and that a new card of acetaminophen should have been ordered. The DNS stated a multi-dose vial should be dated when opened and was good for 30 days after it was opened. The DNS said she expected multi-dose vials to be discarded after 30 days, and she expected medications (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056077 If continuation sheet Page 5 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056077 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Tamalpais 501 via Casitas Greenbrae, CA 94904 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 not to be repackaged or taped in the medication card. Level of Harm - Minimal harm or potential for actual harm During an interview on 12/08/2023 at 8:33 AM, the Administrator stated he expected multi-dose vials to be discarded if that was the policy. The Administrator said he expected the procedure to be followed regarding the repackaging of medications. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056077 If continuation sheet Page 6 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056077 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Tamalpais 501 via Casitas Greenbrae, CA 94904 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, record review, and facility policy review, the facility failed to ensure proper infection control practices during medication administration for three (Residents #8, #12, and #87) of nine residents observed during medication administration. Residents Affected - Some Findings included: A review of a facility policy titled Personal Protective Equipment - Gloves, revised in July 2009, revealed, Gloves must be worn when handling blood, body fluids, secretions, excretions, mucous membranes and/or non-intact skin. Further review of the policy revealed, 3. The use of gloves will vary according to the procedure involved. The use of disposable gloves is indicated: a. when it is likely that the employee's hands will come in contact with blood, body fluids, secretions, excretions, mucous membranes, and/or non-intact skin while performing the procedure. A review of a facility policy titled Handwashing/Hand Hygiene, revised in August 2019, revealed, This facility considers hand hygiene the primary means to prevent the spread of infections. The policy revealed, 7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: f. Before and after direct contact with residents; g. Before preparing or handling medications. Further review of the policy revealed, 8. Hand hygiene is the final step after removing and disposing of personal protective equipment. 9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections. 10. Single-use disposable gloves should be used: u. when anticipating contact with blood or body fluids. A review of Resident #8's Profile Face Sheet revealed the facility admitted Resident #8 on 03/10/2020 with a diagnosis of glaucoma (A group of eye conditions that can cause blindness). A review of Resident #8's physician orders revealed an order dated 03/10/2020, for Simbrinza (eye drop medication used to treat glaucoma) 1%-0.2% one drop to both eyes two times daily. Observation and interview during medication administration on 12/05/2023 at 9:10 AM revealed Licensed Vocational Nurse (LVN) #3 administered Simbrinza eye drops to Resident #8 by touching the resident's lower eyelid with their left hand and with their right hand administered one drop of medication to the resident's right eye. Continued observation showed LVN #3 touched the resident's left lower eyelid and administered one drop of medication to the left eye without performing hand hygiene or donning gloves before administration. During an interview with LVN #3 at the time of the observation, he confirmed he did not wear gloves when he administered the eye drops. LVN #3 stated he would have to check to see if he needed to wear gloves when administering eye drops. A review of Resident #12's Profile Face Sheet revealed the facility admitted Resident #12 on 08/31/2017 with a diagnosis of blepharitis (inflammation of the eyelid). A review of Resident #12's physician orders revealed an order dated 11/12/2022 for lubricating eye drops, one drop to both eyes daily for dry eye syndrome. Observation of medication administration on 12/06/2023 at 8:00 AM revealed LVN #1 administered eye drops to Resident #12. Resident #12's eyes were matted, and with gloved hands, LVN #1 held the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056077 If continuation sheet Page 7 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056077 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Tamalpais 501 via Casitas Greenbrae, CA 94904 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some bottle of eye drops in their left hand and administered one drop to the resident's right eye using their right hand to open the resident's right lower eyelid. Continued observation showed with the same gloved hands, LVN #1 placed the eye drop bottle in their right hand and administered one drop to the resident's left eye while using their left gloved hand to open the resident's left lower eyelid. LVN #1 then placed the lid on the eye drop bottle and, without removing the gloves, adjusted the head of the resident's bed, pillow, and meal tray. LVN #1 removed the gloves and performed hand hygiene. A review of Resident #87's Profile Face Sheet revealed the facility admitted Resident #87 on 12/04/2023 with a diagnosis of right artificial hip joint. A review of Resident #87's physician orders revealed an order dated 12/04/2023 for ibuprofen (anti-inflammatory and pain medication) 400 milligrams (mg) two times a day and Lidocaine 4% (numbing medication used to decrease pain) topical patch to right hip. During observation of medication administration on 12/06/2023 at 8:15 AM, LVN #1 donned gloves and prepared and gathered Resident #87's medications. LVN #1 touched the medication cards for acetaminophen (non-narcotic pain medication), multivitamins, Vitamin D3, and Vitamin B12, the box that contained a blood thinner medication, the box for the lidocaine patch, and three bottles of Miralax (stool softener medication) while preparing the medications. Continued observation showed LVN #1, with the same gloved hands, removed two ibuprofen tablets from the blister pack by popping the pills from the blister pack into her gloved right hand and placed the pills in a medication cup for administration to Resident #87. During an interview with LVN #1, at the time of the observation, LVN #1 stated she wore gloves to prevent infection and stated the palm of her hand was clean. Further observation of medication administration with LVN #1 showed after administration of the oral medications, LVN #1, with gloved hands, removed a lidocaine patch from Resident #87's right hip area and wadded the removed patch with the covering of the new lidocaine patch into her hand, and with the same gloved hands applied the new patch to the resident's right hip. With the same gloves and the old dressing in her hand, LVN #1 retrieved a pen from her pocket, signed the new patch, and then placed the pen back in her pocket. LVN #1 then removed the gloves and performed hand hygiene. During an interview with the Infection Preventionist (IP) on 12/07/2023 at 3:15 PM, the Infection Preventionist (IP) stated staff should wear gloves when in contact with blood, body fluids, or mucous membranes. The IP stated it was best practice to wear gloves when administering eye drops and confirmed the nurse placing the pen back in her pocket after touching the old lidocaine patch was an infection control issue. During an interview on 12/08/2023 at 8:04 AM, the Director of Nursing Services (DNS) stated facility policy did not instruct staff to don gloves for eye drop administration; however, staff were trained to wear gloves when administering eye drops. The DNS confirmed there were cross-contamination issues when LVN #1 was observed touching other items with gloved hands and placing the ibuprofen pills into her gloved hand. The DNS stated she expected gloves to be changed after removing an old patch and before applying a new patch, and if staff anticipated touching mucous membranes or drainage, gloves should be worn. During an interview on 12/08/2023 at 8:33 AM, the Administrator stated he expected staff to follow procedures for infection prevention. During an interview on 12/08/2023 at 10:20 AM, LVN #1 stated she should not have touched Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056077 If continuation sheet Page 8 of 9 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056077 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Tamalpais 501 via Casitas Greenbrae, CA 94904 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 #12's bed control, pillow, and meal tray with gloved hands due to the risk of contamination. Level of Harm - Minimal harm or potential for actual harm During an interview with the DNS, in the presence of the Administrator, on 12/08/2023 at 10:47 AM, the DNS stated the facility did not have an infection control policy that specifically addressed cross-contamination. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056077 If continuation sheet Page 9 of 9