Health inspection·August 13, 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 interview and record review, the facility failed to allow one resident (Resident 1) to retain her personal recliner chair which assisted in supporting Resident 1's lower back and venous insufficiency (a condition where the veins in the legs have difficulty in returning blood to the heart, often causing swelling and pain).This failure resulted in Resident 1 enduring back and leg pain. Cross reference F689.Findings:A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of venous insufficiency (a condition where the veins in the legs have difficulty in returning blood to the heart, often causing swelling and pain), morbid obesity (a disorder that involves having too much body fat, which increases the risk of serious health problems such as joint pain from excess weight), and personality disorder (a mental health condition characterized where people have a pattern of seeing themselves and reacting to other others in ways that cause problems). This document also indicated Resident 1 was her own responsible party.A review of Resident 1's multidisciplinary care conference notes indicated the following:-On 4/18/24 at 1:49 p.m. indicated, Resident is able to verbalize her needs and is a strong advocate for herself.-On 7/15/24 at 5:04 p.m. indicated, .her recliner chair needs to be replaced due to her incontinence as the order [sic] is very unpleasant.SSD [Social Service Director]: we have requested that she replace her electric recliner with a new one, but she has not been too receptive to this. She says she will think about it but is not sure she wants to as this chair is comfortable. Per family they will be bringing her a new recliner chair.A review of Resident 1's care plans indicated the following:-On 4/22/25 a care plan was initiated regarding Resident 1's preference for self-directed room activities indicated it was Very important [for staff] to take care of [Resident 1's] personal belongings/ things.-On 7/1/25 a care plan regarding Resident 1's potential to demonstrate verbally abusive behaviors related to poor impulse control was revised to include [Resident 1's] preference to use old personal reclining chair (with foul odor and is dirty) oppose to a new one. She verbalizes being upset with staff due to [the] replacement.A review of a Resident Council Meeting dated 4/23/25 indicated, Has [sic] issues been resolved to Resident/ Family Councils reasonable satisfaction? Yes [check marked].Spoke to [Family Member 1 (FM 1)] as well [as] patient.[FM 1] said he would look into hiring professionals to clean chair and follow back up w/ [with] facility. Facility will keep chair stored until we hear back from [FM 1]. A review of the Resident Council Meetings dated May 2025 documented no continuing complaints regarding odor from Resident 1's chair.A review of Resident 1's progress note dated 6/5/25 at 11:11 a.m. indicated, The resident's son informed the facility that he approves replacing the resident's current reclining chair with a new one, as the existing chair is very old and emits a strong, unpleasant odor. The facility has received multiple complaints regarding offensive odors originating from the chairs.A review of Resident 1's progress note dated 6/5/25 at 4:35 p.m., documented by the SSD indicated, The facility had to replace residents [sic] chair with another reclining chair due Page 1 of 8 555214 555214 08/13/2025 Professional Post Acute Center 81 Professional Center Parkway San Rafael, CA 94903

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few to infection control issues. Her chair was cloth and over time had become soiled. We replaced it with a faux leather recliner. Her previous chair is being stored in the garage for now. She [Resident 1] is unhappy with the current chair.A review of Resident 1's progress note dated 6/18/25 at 12:39 p.m., the SSD indicated, Resident believes that by professionally cleaning her old chair it will be sufficient but due to how far the smell is deep in the cushions we believe it will not work.Facility replaced her old one with one that was donated to the facility, but she [Resident 1] does not like the footrest as it does not elevate high enough.A review of the facility's post-fall review of Resident 1's fall dated 6/28/25 at 7:49 p.m. indicated, Date and Time of Fall.6/28/25 at [7:10 p.m.].[Resident 1] fell on both knees, both legs folded underneath her.[Resident 1 was] Receiving staff assistance with transfer to bedside commode.Was resident using assistive device for ambulation or transfer? No.Resident's footwear at time of fall.Slippers.Resident's behavior last observed prior to fall (Check all that apply).Excited, Agitated, Anxious/Nervous Appearance.Medications given in last 4 hours prior to fall.Diuretic.Has the resident received new medications in the past 7 days that may add to fall risk? Yes.Lasix(R) [furosemide].IDT Review Summary and Recommendations.Resident stated she fell because she wanted her old chair back. Resident with Hx [history] of personality disorder Root cause: Resident without apparent injuries, does have left lower leg redness to which the resident was refusing care/treatment to her leg and refused pillows or elevation. Resident requests to be in a chair/recliner.Resident has requested her old recliner [the one her son purchased for her] chair back multiple times- it is in extreme disrepair as evidence by a deep smell that affects other residents and staff.Resident stands and pivots to her bedside commode and fell.[document was signed on] 6/30/2025.During an interview on 8/13/25 at 8:33 a.m., FM 1 stated, This whole mess started when [the facility] took away [Resident 1's personal] recliner that I had purchased because it smelled. This chair was a medical necessity [for Resident 1] as much as a wheelchair would be to a quad [referring to paralysis in all 4 limbs] or a para [referring to paralysis in lower limbs]. FM 1 stated Resident 1 had a fused lower vertebra (a series of small bones that make up the spine) causing Resident 1 chronic back pain. Because of Resident 1's venous insufficiency, Resident 1 needed to elevate her feet as often as possible. FM 1 stated Resident 1 had the. recliner for many years, and it did not cause Resident 1 any problems. FM 1 stated he offered to have the chair deep cleaned by a professional company. An appointment was scheduled but was shut down by the Administrator [ADM]. FM 1 stated the replacement chair was causing Resident 1 significant pain in her lower back. FM 1 also reported the footrest on the chair dug into the back of her legs, causing further pain and it did not elevate high enough to drain her legs for her venous insufficiency. FM 1 stated since the facility took Resident 1's personal recliner chair on 6/5/25, Resident 1 suffered and diligently tried to get it back.During an interview on 8/15/25at 11:22 a.m., the SSD stated Resident 1 did not like the replacement chair because it did not recline back far enough and nor raise her legs high enough. The older chair needed to be replaced because it had years of urine soaked into the cushions. The SSD further stated, I know the family offered to have it deep cleaned but we didn't think it would get rid of the smell or get clean enough. The SSD stated this was the decision of the ADM.During an interview on 8/19/25 at 8:33 a.m., the DON stated she understood Resident 1 was uncomfortable in the replacement chair and further stated, If I were [Resident 1], I would want my chair back too. During an interview on 8/19/25 at 8:48 a.m., the ADM stated the odor from Resident 1's chair was frequently a topic of discussion at Resident Council.During an interview on 8/19/25 at 9:24 a.m., the Resident Council President (RCP) stated there was never a mention of Resident 1's chair or any odor emitted from it during the meetings.During an interview on 8/19/25 at 9:41 a.m., the Activities Director (AD) stated he was present 555214 Page 2 of 8 555214 08/13/2025 Professional Post Acute Center 81 Professional Center Parkway San Rafael, CA 94903

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few at all the Resident Council meetings and did not recall any discussion about Resident 1's chair or any odor emitted from it.During an interview on 8/19/25at 10:02 a.m., FM 2 stated she made an appointment with a professional cleaning company to deep clean Resident 1's chair on 6/20/25 between 11 a.m. and 2 p.m.; however, FM 2 stated the Housekeeping Services Supervisor (HSS) informed her that the ADM would not approve of the Resident 1's recliner to be cleaned and any new chair purchased for Resident 1's use needed to be approved by the ADM first.During an interview on 8/19/25 at 10:32 a.m., the HSS stated the ADM instructed him to remove Resident 1's recliner chair from Resident 1's room on 6/5/25.During an interview on 8/20/25at 9:15 a.m., the Operations Manager of the cleaning company FM 2 hired confirmed an appointment had been made to deep clean an upholstered recliner chair at the facility on 6/20/25. The Operations Manager stated the appointment was cancelled on 6/19/25.During an interview on 8/20/25 at 12:37 p.m., the ADM stated the family of Resident 1 never followed up with deep cleaning Resident 1's chair. The ADM stated she spoke with Resident 1 all the time and [Resident 1] didn't like the replacement chair because [Resident 1] hated change.During an interview on 8/21/25at 11:45 a.m., the HSS confirmed he spoke with FM 2 to cancel the appointment for Resident 1's reclining chair because the ADM would not approve of having Resident 1's chair deep cleaned. The HSS stated the ADM wanted to approve of any chairs purchased by the family for Resident 1.A review of the facility's policy titled Personal Property, revised August 2022 indicated, Residents are encouraged to use personal belongings to maintain a homelike environment and foster independence. Residents are permitted to bring room furnishings if.the room is large enough to accommodate the furniture.the furniture does not infringe upon the rights of others.and the furniture does not violate current life safety code requirements.A review of the facility's policy titled Resident Rights, revised February 2021 indicated, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to.self-determination.be supported by the facility in exercising .her rights.retain and use personal possessions to the maximum extent that space and safety permit. 555214 Page 3 of 8 555214 08/13/2025 Professional Post Acute Center 81 Professional Center Parkway San Rafael, CA 94903

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an environment free of falls for one resident (Resident 1) of three sampled residents when the facility:1. Did not initiate a person-centered care plan for Resident 1's fall risk prior to [DATE]; and,2. Did not analyze Resident 1's risk for a fall after worsening edema (swelling from an accumulation of fluid in the body's tissues) and possible deep vein thrombosis (DVT, a blood clot in a deep vein which can cause pain and swelling) in her lower legs.These failures contributed to Resident 1 sustaining a left fibula (one of the two bones in the calf) [NAME] fracture (a break of the upper fibula usually caused by twisting or forceful rotation of the ankle) from a fall. Cross reference

F557.Findings:1. A review of Resident 1's admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses of venous insufficiency (a condition where the veins in the legs have difficulty in returning blood to the heart, often causing swelling and pain), morbid obesity (a disorder that involves having too much body fat, which increases the risk of serious health problems such as joint pain from excess weight), and personality disorder (a mental health condition characterized where people have a pattern of seeing themselves and reacting to other others in ways that cause problems). A review of Resident 1's care plans on [DATE] indicated the following:-On [DATE] a care plan was initiated for Resident 1's limited ability to perform Activities of Daily Living (ADL, basic tasks performed by individuals to maintain their daily life) related to her limited mobility and morbid obesity. Resident 1's goal was to demonstrate the appropriate use of adaptive devices (equipment used to help people perform daily activities, such as a cane or walker) to increase her ability with transfers or toilet use; however, no specific adaptive device was indicated. The interventions listed to assist Resident 1 to meet this goal included, TRANSFER: The resident has requires [sic] 1 staff assistance with transfers.[Revised] on [DATE].[and] TOILET USE: The resident has requires [sic] 1 staff participation to use toilet.[Revised] on [DATE].-On [DATE] a care plan was initiated for Resident 1's moderate risk for falls related to gait and balance problems. Resident 1's goal was to be free of serious injury through the review date of [DATE]. The last time this care plan was updated was on [DATE].-On [DATE] a care plan was initiated for Resident 1's risk for breakdown immobility related to an alteration in peripheral tissue perfusion (a reduction or impairment in blood flow to the tissues of the arms and legs, preventing them from receiving enough oxygen) due to chronic venous insufficiency. Staff were expected to implement interventions which included checking the lower extremities for pain, cramping, and weakness in one or both legs. This care plan was revised on [DATE].- On [DATE] a care plan was initiated for Resident 1's potential to demonstrate.behaviors r/t [related to] poor impulse control which indicated staff was expected to Assess and anticipate resident's needs.toileting needs, comfort level, body positioning, pain etc.-There was no documented evidence that a care plan for Resident 1's risk of falls was updated between [DATE] and [DATE].A review of Resident 1's quarterly risk data collection tool dated [DATE] at 6:37 p.m., [DATE] at 11:51 a.m., [DATE] at 11:23 a.m., and [DATE] at 5:33 p.m. indicated, .is resident at risk for falls? Yes.A review of Resident 1's Minimum Data Set (MDS-a federally mandated resident assessment tool) dated [DATE] indicated:-Resident 1 had a Brief Interview for Mental Status (BIMS, an assessment used to measure cognition (a person's ability to process information and understanding)) score of 15 which indicated Resident 1's cognition was intact;-Resident 1 normally used a walker as a mobility device; and,-Resident 1 required setup or clean-up assistance (meaning the helper assisted only prior to or following the activity) when transferring from a sitting to standing position and during toilet transfers.During an interview on [DATE] at 12:43 p.m., the 555214 Page 4 of 8 555214 08/13/2025 Professional Post Acute Center 81 Professional Center Parkway San Rafael, CA 94903

F 0689 Level of Harm - Actual harm Residents Affected - Few Director of Nursing (DON) stated nursing staff did not consider Resident 1 at risk of falls prior to [DATE] and acknowledged Resident 1's care plan regarding her fall risk was initiated on the same day Resident 1 fell on [DATE].2. A review of Resident 1's order summary report dated [DATE] to [DATE] indicated the following physician's orders:-On [DATE] an order was placed for staff to encourage Resident 1 to elevate her legs using the recliner every shift for swelling; and,-On [DATE] an order was placed for a Left Duplex Scan (a non-invasive ultrasound test that uses sound waves to create images of blood vessels and assess blood flow) for veins in extremity unilateral (one side) one time only related to morbid obesity;A review of Resident 1's physician progress note dated [DATE] indicated, Assessment & Plan.Venous Stasis Edema W [with] Inflammation [the reddening and swelling of a body part as a reaction to injury or infection] of Bilat [both] Legs (primary encounter diagnosis) Note: Severe edematous leg edema with chronic inflammation changes. Left more than right leg, Patient is not compliant with leg elevation, which can be uncomfortable for patient.Patient does not walk tends to be sitting most of the day. She is at risk of DVT [deep vein thrombosis, a blood clot in a deep vein, usually in the leg or pelvis, which can cause pain, swelling, and skin changes] given that his [sic] unilateral more affected on the left leg.Hold off on antibiotics until ultrasound is done and or see any improvement with above intervention, patient is afebrile [without fever].A review of Resident 1's care plan initiated on [DATE] indicated a focus on Resident 1's left lower leg edema related to venous insufficiency; however, it did not indicate interventions staff were expected to implement regarding how the left lower leg edema could change Resident 1's mobility or what specific safety measures to implement.A review of all of Resident 1's care plans initiated between [DATE] and [DATE] showed no documented evidence of any use of furosemide, its side effects, and how it related to Resident 1's risk of falls.A review of Resident 1's care plan regarding her left lower leg edema related to venous insufficiency was revised on [DATE] to include .has increased swelling and erythema to LLE [left lower extremity]; pain, ‘achy,' and ‘hot'. but was not revised to include interventions staff were expected to implement regarding how the change in condition could change her mobility or what specific safety measures to implement.A review of Resident 1's Change in Condition Evaluation dated [DATE] at 7:36 p.m., indicated, [Resident 1] had several staff assisting her, 2 on her right side and one on her left side supporting her and attempting to pivot her to the bedside commode when she had an assisted fall to the floor.Most recent weight.307.4 [no unit of measure indicated] Date [weight was obtained] [DATE] at 4:44 p.m. [using a] Scale: Wheelchair.Is a behavioral assessment relevant to the change in condition been reported? Not clinically applicable to the change in condition being reported.List any medication changes made in the past week.Furosemide 20 mg.A review of a hospital Emergency Department (ED) admission information form, dated [DATE], indicated Resident 1 arrived to the ED on via ambulance at 7:45 p.m. with a primary diagnosis of left leg cellulitis (skin infection causing redness, swelling and pain to affected area) and a secondary diagnosis of left fibula [NAME] nondisplaced fracture. Resident 1's chief complaint indicated, Accident from [Facility], staff was attempting to help patient to commode and she slid to the floor.A review of the facility's post-fall review of Resident 1's fall dated [DATE] at 7:49 p.m. indicated, Date and Time of Fall.XXX[DATE] at [7:10 p.m.].[Resident 1] fell on both knees, both legs folded underneath her.[Resident 1 was] Receiving staff assistance with transfer to bedside commode.Was resident using assistive device for ambulation or transfer? No.Resident's footwear at time of fall.Slippers.Resident's behavior last observed prior to fall (Check all that apply).Excited, Agitated, Anxious/Nervous Appearance.Medications given in last 4 hours prior to fall .Diuretic.Has the resident received new medications in the past 7 days that may add to fall risk? Yes.Lasix(R) [furosemide].IDT Review Summary and 555214 Page 5 of 8 555214 08/13/2025 Professional Post Acute Center 81 Professional Center Parkway San Rafael, CA 94903

F 0689 Level of Harm - Actual harm Residents Affected - Few Recommendations.Resident stated she fell because she wanted her old chair back. Resident with Hx [history] of personality disorder Root cause: Resident without apparent injuries, does have left lower leg redness to which the resident was refusing care/treatment to her leg and refused pillows or elevation. Resident requests to be in a chair/recliner.Resident has requested her old recliner [the one her son purchased for her] chair back multiple times- it is in extreme disrepair as evidence by a deep smell that affects other residents and staff.Resident stands and pivots to her bedside commode and fell.[document was signed on] [DATE].A review of Resident 1's care plans initiated on [DATE] indicated the following:-A focus on Impaired Physical Mobility General indicated, Goal[s].Resident will be able to perform activity within physical limits.Resident will be free of complications of immobility.Resident will maintain normal muscle tone.Resident will maintain safe balance and coordination.Resident will participate in prescribed rehabilitation program.Resident will perform physical activity within prescribed mobility restrictions.Resident will use adaptive techniques to safely transfer and ambulate .[Interventions to assist Resident 1 to meet these goals included] Patient will be monitored for complication such as depression, suicidal thought due to immobility.Patient will be sent out to [hospital] for checking the muscle, bones.Patient will be provided with call light and help instead of walking herself.-A focus on a risk for falls r/t Gait/balance problems indicated, Goal.The resident will not sustain serious injury.[Interventions to assist Resident 1 to meet these goals included] Ensure that [Resident 1] is wearing appropriate footwear (slippers) when ambulating or mobilizing in w/c [wheelchair].A review of Resident 1's care plan with a focus on resident is/has potential to demonstrate.behaviors r/t [related to] poor impulse control was revised on [DATE] to include, [Resident 1] has a preference to use old reclining chair (with foul odor and is dirty) oppose to a new one. She verbalizes being upset with staff due to replacement indicated the following intervention for staff to implement Assess and anticipate resident's needs.toileting needs, comfort level, body positioning, pain etc.A review of a hospital's discharge summary note dated [DATE] at 9:07 p.m. indicated, .[Resident 1] had suffered a fall at skilled nursing facility. [Resident 1] was brought here for work-up and noted to have a left fibula fracture as well as a right lower extremity deep venous thrombosis. [Resident 1] was started on anticoagulation [medical treatment that prevents blood clots] but then developed severe soft tissue hemorrhage [heavy, uncontrolled bleeding] into the left lower extremity.[Resident 1] developed progressive septic shock [a life-threatening condition that occurs when the body's immune system overreacts to an infection, leading to a drop in blood pressure and organ failure] with acute renal [kidney] failure despite antibiotics for cellulitis.[Resident 1] on [DATE].died peacefully.During an interview on [DATE] at 12:43 p.m., the DON stated the reason there were so many staff in Resident 1's room was to place her on the commode because Resident 1 stated she had been having pain in her legs. The DON further stated, Knowing what [Resident 1's] pain level was that day, I would have used a [resident lift (a mechanical device used to safely transfer residents with limited mobility)].During an interview on [DATE], at 9:29 a.m., Certified Nursing Assistant 1 (CNA 1) stated Resident 1 had attempted to stand up from the new recliner (the one the facility gave her) chair to use the commode for 5-10 minutes. CNA 1 stated Resident 1 said she was unable to get off the new recliner chair and stand up. CNA 1 stated he went to seek assistance from his co-workers. The Nursing Supervisor (NS) and CNA 2 were available to assist. CNA 1 stated, Each of us put an arm under [Resident 1's] armpit and helped her to stand. It took a couple of times, but when [Resident 1] finally stood she went down.It happened so suddenly, and she was heavy. She fell and landed on her knees hard. CNA 1 stated Resident 1 did not use a walker or wheelchair and did not have one at the time of the fall.During an interview on [DATE] at 10:05 a.m., CNA 2 stated, When I walked in 555214 Page 6 of 8 555214 08/13/2025 Professional Post Acute Center 81 Professional Center Parkway San Rafael, CA 94903

F 0689 Level of Harm - Actual harm Residents Affected - Few the room on [DATE], [Resident 1] had a look on her face like she was in pain. We each took an arm, and [Resident 1] was finally able to stand. When she started to turn toward the commode, [Resident 1's] knees buckled. We tried to stop the fall, but she was too heavy. She landed on her knees.During an interview on [DATE] at 10:29 a.m., the Nurse Supervisor (NS) stated Resident 1 normally was able to get up on her own. LN 1 stated CNA 1 and CNA 2 needed more help to get Resident 1 off the new recliner, so LN 1 got behind Resident 1 and helped push her up from the recliner. LN 1 stated Resident 1 finally got up but quickly became weak. LN 1 stated, The CNAs tried to catch her, but she was too heavy, so she landed on her knees and cried out in pain.During an interview on [DATE] at 10:45 a.m., the Director of Staff Development (DSD) stated an order was not necessary to use the lift equipment on a resident; however, Physical Therapy normally evaluated each resident prior to use. The DSD also stated a Registered Nurse would also be able to evaluate whether a resident was able to transfer safely. The DSD further stated if three people were attempting to transfer a resident, a total lift (a mechanical device used to safely transfer residents who cannot support their own weight) should be used.During an interview on [DATE] at 12:54 p.m., CNA 1 stated Resident 1 was uncomfortable in the new recliner (the one the facility gave her) and needed help getting up to use the commode even before she fell on [DATE].During an interview on [DATE] at 8:33 a.m., the DON stated the administration of furosemide medication would place a resident at risk for falls due to its side effects of lowering blood pressure, possible dizziness and confusion combined with an urgency and frequency to void. The DON confirmed Resident 1 did not have a care plan for the use of furosemide and one should have been created with the implementation of furosemide on [DATE].During an interview on [DATE] at 8:51 a.m., Family Member 1 (FM 1) stated Resident 1's old recliner was purchased several years ago, and Resident 1 depended heavily on this chair to maintain her independence and to be free of pain. The features of Resident 1's old recliner included: lifted Resident 1 to a standing position, oversized for a bariatric (obese) user, elevated Resident 1's legs, fully reclined Resident 1 to a lying position, and was heated. FM 1 stated these features assisted Resident 1 to feel independent and live pain free. During an interview on [DATE] at 12:24 p.m., the DON stated the care plan created for Resident 1's left lower leg edema should have triggered a care plan to be created for fall risk. The DON further stated though [Resident 1] was independent in transferring to the commode, the pain she had in her leg was enough to make her fall.During a telephone interview and concurrent record review on [DATE] at 2 p.m., Physical Therapist 1 (PT 1) stated he was unable to find any documented evidence that Resident 1 had ever been evaluated by a PT for the safe use of either a walker or a wheelchair.A review of facility policy titled Falls and Fall Risk, Managing, dated 2001, indicated, Based on previous evaluations and current data, the nursing staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling.Resident conditions that may contribute to the risk of falls include.lower extremity weakness.medication side effects.functional impairments.Medical factors that contribute to the risk of falls include.heart failure.balance and gait disorders.Resident-Centered Approaches to Managing Falls and Fall Risk.Examples of initial approaches might include.a rearrangement of room furniture.improving footwear.etc.A review of the facility's policy titled Care Plans, Comprehensive Person-Centered revised [DATE] indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychological and functional needs is developed and implemented for each resident.The comprehensive, person-centered care plan.reflects currently recognized standards of practice for problem areas and conditions.Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the 555214 Page 7 of 8 555214 08/13/2025 Professional Post Acute Center 81 Professional Center Parkway San Rafael, CA 94903

F 0689 Level of Harm - Actual harm Residents Affected - Few relationship between the resident's problem areas and their causes, and relevant clinical decision making.Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.The interdisciplinary team reviews and updates the care plan.when there has been a significant change in the resident's condition.A review of the facility's policy titled Safe Lifting and Movement of Residents revised [DATE] indicated, .Manual lifting ((the activity involving the use of the human body to lift or support a load) of residents shall be eliminated when feasible. Nursing staff, in conjunction with rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. Such assessment shall include the following.Resident's mobility (degree of dependency); Resident's size; Weight-bearing ability.Whether the resident is usually cooperative with staff.Mechanical lifting devices shall be used for heavy lifting, including lifting and moving residents when necessary. 555214 Page 8 of 8