Health inspection·March 28, 2025

F 0572 Give residents a notice of rights, rules, services and charges. 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 notify one of two sampled residents (Resident 1) of their responsibilities as a resident when Resident 1 ' s daily rate for room and board increased twice (on 1/1/24 and 1/1/25) with no advanced written notice and required a security deposit with no advanced written notice. These failures caused financial hardship to Resident 1 who stated, It ' s really ruined my life, and stated she felt poor. Residents Affected - Few Finding: During an observation on 2/5/25 at 9:57 a.m., a sign posted in the facility hallway indicated the private pay daily rate was $525 for a two-bed room. During an electronic medical record review on 2/5/25 at 11:42 a.m., Resident 1 ' s face sheet indicated she was admitted [DATE], payor information indicated Private Pay, and Resident 1 ' s power of attorney for healthcare was Family Member (FM) 4. Review of Resident 1 ' s Minimum Data Set (an assessment tool) dated 12/8/24 indicated a BIMS score of 13 (Brief Interview for Mental Status, a score of 13 to 15 indicates no cognitive impairment). During an interview on 2/6/25 at 3:29 p.m., Medical Records Director stated Resident 1 did not have an admission agreement. During an observation and concurrent interview on 3/24/25 at 12:50 p.m., Resident 1 was sitting in her wheelchair in the room where she resided, which was a two-bed room. When queried, Resident 1 stated she did not get an admission agreement when she was first admitted but had just signed one recently. Resident 1 stated she had not been given a copy so she could not provide information on the daily room rate or the security deposit amount that were in the agreement. Resident 1 verified she had had her daily room rate increased during her stay at the facility. Resident 1 stated she was paying $525 per day and then in January the rate increased it to $680 day, which is a lot of money for a place like this. Resident 1 denied she was given 30-days ' written notice of the rate increase. Resident 1 verified the security deposit and the daily rate increase were a financial hardship for her, and stated, It ' s really ruined my life. It makes me feel poor. During a phone interview on 3/24/25 at 1:55 p.m., FM 4 stated Resident 1 had been at the facility for two years now. FM 4 stated the facility took two payments from Resident 1 for January (2025). FM 4 stated the facility staff said one of the payments was being considered a security deposit. FM 4 stated she had handled Resident 1 ' s finances up until June of 2024, and then Resident 1 took over her own finances. FM 4 looked through some documents, and then read from an invoice, Private room and board 6/1/24 to 6/30/24 $15,750, May 2024 was $16,275. FM 4 stated that on 4/23/23 she got a Page 1 of 6 056430 056430 03/28/2025 Northgate Postacute Care 40 Professional Center Parkway San Rafael, CA 94903

F 0572 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few statement that indicated a daily room rate of $412 per day and the January 2024 statement indicated $525 per day. FM 4 stated she got no notification that the rate was going up. FM 4 stated the facility did not send her (FM 4) an admission agreement. During a record review on 3/24/25 at 4:45 p.m., Resident 1 ' s admission agreement indicated an admission date of 3/6/23 and had an electronic signature for Resident 1 dated 2/14/25. Further review of Resident 1 ' s admission agreement indicated a section for private pay daily room rate amounts with these spaces blank, no dollar amounts were listed. Further review of Resident 1 ' s admission agreement indicated a section for security deposits for private pay residents with N/A indicated in the space for the security deposit amount. Continuing the record review on 3/24/25 at 4:45 p.m., Resident 1 ' s billing statements for December 2024, January 2025, February 2025, and March 2025 indicated no bill for a security deposit. Review of Resident 1 ' s statement dated 2/1/25 indicated two checks were received in the amount of $15,079.16, with effective dates of 12/31/24 and 1/8/25. Continuing the record review on 3/24/25 at 4:45 p.m., review of Resident 1 ' s billing statements dated 1/1/24 and 2/1/24 revealed Resident 1 was charged a daily room rate of $412 per day for January and February 2024. Review of Resident 1 ' s billing statement dated 3/1/24 revealed Resident 1 was charged a daily room rate of $525 per day for March 2024 and was retroactively charged $525 per day for the two previous months (January and February 2024) and billed for the difference (an additional $6,780). Review of Resident 1 ' s billing statement dated 1/1/25 revealed Resident 1 was charged a daily room rate of $525 per day for January 2025. Review of Resident 1 ' s billing statement dated 2/1/25 revealed Resident 1 was charged a daily room rate of $680 per day and was retroactively charged $680 per day for the previous month (January 2025) and billed for the difference (an additional $4,805). During a phone interview on 3/25/25 at 1:33 p.m., Accounts Receivable Director (ARD) A verified Resident 1 ' s daily room rate increased from $412 per day to $525 per day in January 2024. When queried, ARD A stated Resident 1 was verbally informed of the increase. ARD A stated the reason the rate went up was because it was time for the rate to go up for everyone. ARD A verified Resident 1 ' s daily room rate increased from $525 per day to $680 per day in January 2025. ARD A stated the company just decided the daily rate would go up again. ARD A stated Resident 1 was verbally informed of the increase. When queried, ARD A stated it was usually the administrator who would inform residents of room rate changes. During an interview on 3/25/25 at 2:10 p.m., Administrator stated she had not informed Resident 1 that her room rate increased because she was not aware Resident 1 ' s room rate increased. Administrator stated either she or her supervisor would be responsible for informing a resident of a room rate increase. Administrator stated this would normally be done months ahead of the increase in rate. Administrator stated she did not know where this would be documented if Resident 1 received notice of the room rate increases. During a record review and concurrent interview on 3/25/25 at 2:13 p.m., Admissions Coordinator (AC) B stated she handled the admission agreements for residents. AC B verified the admission agreement was how the rules, regulations, and resident responsibilities were communicated to the residents. AC B stated generally she did not give a copy to the resident when signed, she offered a copy to everyone, but most declined. AC B stated she had not been documenting that the admission agreement was offered to residents. AC B verified that for private pay residents, paying the daily rate and the 056430 Page 2 of 6 056430 03/28/2025 Northgate Postacute Care 40 Professional Center Parkway San Rafael, CA 94903

F 0572 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few security deposit were considered part of the resident ' s responsibilities, and they were included in the admission agreement. AC B verified the admission agreement was the agreement to pay the daily room rate if a resident became private pay later in their stay. AC B stated the reason the admission agreement was important was so that the resident understood the rules and regulations and so the facility staff understood how the resident expected to be treated by staff. AC B reviewed Resident 1 ' s admission agreement. AC B verified Resident 1 ' s admission agreement indicated Resident 1 was admitted [DATE] and was signed by Resident 1 on 2/14/25. AC B verified she signed the admission agreement as witness. AC B stated corporate asked her to have Resident 1 sign it, but she did not know the reason they asked her to get it signed. AC B verified the daily room rates were blank on Resident 1 ' s admission agreement and stated the room rates were normally prefilled by the business office before she had a resident sign one. AC B stated she was not aware Resident 1 ' s room rates were blank, and stated she did not get into the financial aspects of resident ' s agreements. AC B verified that if the daily room rates were blank on the admission agreement, then the resident had not agreed to a particular rate when they signed. During a record review and concurrent interview on 3/25/25 at 2:32 p.m., Administrator stated she instructed AC B to audit all the residents to make sure they each had an admission agreement after this surveyor asked for Resident 1 ' s admission agreement on 2/6/25 and it could not be found. Administrator stated the whole leadership at the facility had a turnover so no one was there who would know if Resident 1 signed an agreement when Resident 1 was admitted (in March 2023). Administrator reviewed Resident 1 ' s admission agreement and verified the admission agreement indicated, We will provide you with a 30-day written notice before increasing the basic daily rate, and stated that was standard in skilled nursing facilities. Administrator stated she would have medical records review Resident 1 ' s chart for any documentation of this notification. During a record review and concurrent interview on 3/25/25 at 3:56 p.m., Administrator reviewed Resident 1 ' s billing statement dated 2/1/24 and verified Resident 1 ' s daily room rate increased. Administrator called Medical Records Director into her office. Medical Records Director entered Administrator ' s office and stated she could not find any documentation that Resident 1 had ever been notified of a room rate increase. Administrator stated Resident 1 should have been notified in writing with 30-days ' notice of the increase, and she will make sure that happened going forward. During a phone interview on 3/27/25 at 10:12 a.m., ARD A stated the second check collected from Resident 1 for January 2025 was a security deposit. ARD A stated it was the policy of the company to get a deposit for private pay residents, so the second check was for Resident 1 ' s deposit. ARD A stated, We never got it at the beginning (of Resident 1 ' s status as private pay), so we were asking for it now. ARD A stated she could just apply the deposit to next month ' s room and board, but was unable to state where it was documented that Resident 1 owed a security deposit to the facility or the amount of the deposit. During a phone interview on 3/28/25 at 10:49 a.m., ARD A stated that if a resident was required to pay a security deposit it should be itemized on the billing statement. ARD A verified Resident 1 ' s billing statements for December 2024 and January 2025 did not indicate she owed or was paying a security deposit. ARD A stated the amount of the deposit was one month room and board, but was not able to explain the reason Resident 1 ' s security deposit was for more than the amount of one month ' s room and board she was paying in 2023 when she became private pay. When asked for a policy for collecting security deposits, ARD A stated, We follow the admission agreement. During a record review and concurrent interview on 3/28/25 at 11:35 a.m., Administrator reviewed 056430 Page 3 of 6 056430 03/28/2025 Northgate Postacute Care 40 Professional Center Parkway San Rafael, CA 94903

F 0572 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident 1 ' s admission agreement, and verified the admission agreement indicated N/A in the security deposit section where the amount of the security deposit should have been indicated. Administrator stated, N/A means not applicable. Administrator stated the amount of the deposit was one month room and board, but did not know who was responsible for entering the amount. Administrator denied that there was any other method of communicating the deposit amount to the resident even if they were not private pay on admission and became private pay later in their stay. Administrator verified Resident 1 ' s billing statement should have had the security deposit itemized. Administrator verified that without the itemized statement the purpose of the check collected on 1/8/25 was not clear. Administrator denied there was any documentation that Resident 1 agreed to pay the security deposit or the amount of the security deposit. When queried, Administrator stated the rationale for giving 30-days ' notice of changes in the residents ' bill was, So we know what we are going to pay next. The policy and procedure for collecting security deposits requested from ARD A on 3/28/25 at 10: 49 a.m., was not provided. Review of the facility policy and procedure, Billings, dated 4/2018, indicated, Each resident will receive an itemized statement for services rendered during the billing cycle. The resident will be notified in writing at least 30 days prior to a change in his/her billing. Review of facility policy and procedure Exercise of Resident Rights, dated 11/2017, indicates, 1. Upon admission, a designated staff member will be responsible for providing the resident with an oral review of his or her rights and responsibilities prior to . or within 5 working days after the admission . 2. The resident or their representative will be required to sign a statement acknowledging his or her receipt of a written copy of resident rights and responsibilities . Review of facility policy and procedure admission to the Facility, dated 1/2023, indicated, Procedure: admission: . 4. An admission and Financial Agreement must be signed for every resident admitted regardless of the payer source. A copy of the admission and Financial Agreement is provided to the resident, and a copy is placed in the resident ' s permanent financial records. 056430 Page 4 of 6 056430 03/28/2025 Northgate Postacute Care 40 Professional Center Parkway San Rafael, CA 94903

F 0620 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain signed admission agreements for three of five sampled residents (Residents 1, 2, and 3), and failed to give one of five sampled residents (Resident 1) a copy of the admission agreement. This failure resulted in Resident 1 having no documentation of what daily room rate or security deposit she had agreed to pay on admission, and had the potential to result in Resident 2 or 3 having no document for reference when they need information about the terms of their admission. Finding: During an electronic medical record review on 2/5/25 at 11:42 a.m., Resident 1 ' s face sheet indicated she was admitted [DATE], payor information indicated Private Pay, and Resident 1 ' s power of attorney for healthcare was Family Member (FM) 2. Review of Resident 1 ' s Minimum Data Set (an assessment tool) dated 12/8/24 indicated a BIMS score of 13 (Brief Interview for Mental Status, a score of 13 to 15 indicates no cognitive impairment). During an interview on 2/5/25 at 1:22 p.m., Resident 1 stated she was having trouble with paying her bill at the facility. Resident 1 stated the staff kept telling her she owed a security deposit, but she had never been told she needed to pay a security deposit and she had already been at the facility for over a year. Resident 1 stated a staff member in accounts payable had been asking for the security deposit for about two weeks, and that when she asked questions about the deposit she did not get an answer. During an interview on 2/6/25 at 3:29 p.m., Medical Records Director stated Resident 1 did not have an admission agreement. During an interview on 3/24/25 at 12:50 p.m., When queried, Resident 1 stated she did not get an admission agreement when she was first admitted but had just signed one recently. Resident 1 stated she had not been given a copy so she could not provide information on the daily room rate or the security deposit amount that were in the agreement. Resident 1 verified she had had her daily room rate increased during her stay at the facility. Resident 1 stated she was paying $525 per day and then in January the rate increased it to $680 day. During a record review and concurrent interview on 3/25/25 at 2:13 p.m., Admissions Coordinator (AC) B stated she handled the admission agreements for residents. AC B stated she did not give a copy to the residents, she offered a copy to everyone, but most declined. AC B stated she had not been documenting that the admission agreement was offered to residents. AC B verified that for private pay residents, paying the daily rate and the security deposit were included in the admission agreement. AC B stated the reason the admission agreement was important was so that the resident understood the rules and regulations and so the facility staff understood how the resident expected to be treated by staff. AC B reviewed Resident 1 ' s admission agreement. AC B verified Resident 1 ' s admission agreement indicated Resident 1 was admitted [DATE] and was signed by Resident 1 on 2/14/25. AC B verified Resident 2 ' s admission agreement indicated Resident 2 was admitted [DATE] and was signed by Resident 2 on 2/21/25. AC B verified she signed both the admission agreements as witness. During a record review and concurrent interview on 3/25/25 at 2:32 p.m., Administrator stated the 056430 Page 5 of 6 056430 03/28/2025 Northgate Postacute Care 40 Professional Center Parkway San Rafael, CA 94903

F 0620 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few reason Resident 1 and Resident 2 had admission agreements that were signed last month in February (years after their admissions) was because she instructed AC B to audit all the residents to make sure they each had an admission agreement after this surveyor asked for Resident 1 ' s admission agreement on 2/6/25 and it could not be found. During an interview on 3/25/25 at 3:56 p.m., Director of Nursing stated the facility did not have an admission agreement on file for Resident 3 and she did not know the reason. Review of facility policy and procedure admission to the Facility, dated 1/2023, indicated, Procedure: admission: . 4. An admission and Financial Agreement must be signed for every resident admitted regardless of the payer source. A copy of the admission and Financial Agreement is provided to the resident, and a copy is placed in the resident ' s permanent financial records. 056430 Page 6 of 6