Health inspection·March 1, 2019

F 0578 information had to provided. Level of Harm - Minimal harm or potential for actual harm The facility's policy titled, Advance Directives dated December 2016, indicated, Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555227 If continuation sheet Page 2 of 15 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 555227 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Marin 100 Thorndale Drive San Rafael, CA 94903 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review, the facility failed to include a level of supervision on the care plan of one of eight sampled residents (Resident 3) who had fallen repeatedly. This failure could potentially lead to future falls, fractures, or hospitalization when staff had not established how often Resident 3 needed safety checks to prevent him from falling. Findings: During an interview on 2/27/19 at 10:19 a.m., Resident 3 stated he had had a couple of falls when he had gotten up and lost his balance. During a medical record review on 2/28/19 at 9:12 a.m., Resident 3's nurses notes revealed Resident 3 was found by staff in his room on the floor on 10/30/18, 12/20/18, and 2/1/19. Resident 3's nurses notes indicated during all three falls Resident 3 had gotten up by himself without calling for assistance. Review of Resident 3's care plan titled CAA 11 Falls Care Plan, dated 2/1/19, revealed no indication of a level of supervision for Resident 3. During a record review and concurrent interview on 3/1/19 at 11:55 a.m., MDS Coordinator stated she participated in the development of care plans for residents. MDS Coordinator confirmed the care plan titled CAA 11 Falls Care Plan, dated 2/1/19, was Resident 3's long-term care plan for falls. MDS Coordinator confirmed the long-term care plan for falls did not indicate a level of supervision and it should include a level of supervision. During a record review and concurrent interview on 3/1/19 at 1:15 p.m., Director of Nursing confirmed the level of supervision should be included on Resident 3's long-term care plan for falls. When asked how she increased the level of supervision a resident needed if a timeframe had not been established on the care plan, Director of Nursing did not answer. Director of Staff Development (DSD) stated he had communicated to the certified nursing assistants (CNAs) that they needed to increase how often they checked on Resident 3. DSD stated his expectation was for CNAs to check on Resident 3 at least every hour and a half to two hours, but stated he had not told the CNAs a specific timeframe to check on him. DSD confirmed if the level of supervision was specific on the care plan it would be more effective in determining how Resident 3's supervision could be increased if he kept falling. Review of facility policy titled Care Plans, Comprehensive Person-Centered, dated 12/2016, revealed, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Review of facility policy titled Falls and Fall Risk, Managing, dated 3/2018, revealed, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific resks and causes to try to prevent the resident from falling and to try to minimize complications from falling. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555227 If continuation sheet Page 3 of 15 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 555227 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Marin 100 Thorndale Drive San Rafael, CA 94903 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to revise Nursing Plans of Care and attempt new interventions to prevent falls for 2 of 2 sampled residents at risk for falls. This had the potential to cause severe injuries or death to Resident 6 and Resident 13 during new incidences of falls. Findings: Resident 6 Resident 6, an [AGE] year-old female, was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Mild Cognitive Impairment, Age-related Osteoporosis, and History of Falling according to Resident 6's Facility Face Sheet. Resident 6's MDS (Minimum Data Set-part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) dated 2/26/2019 indicated her BIMS (Brief Interview of Mental Status-A required screening tool used in nursing homes to assess cognition, 13 to 15 points: intact cognition, 8 to 12 points: moderately impaired cognition, 0-7 points: severely impaired cognition) score was 15 which indicated Resident 22 had intact condition. Resident 6's MDS dated [DATE] also indicated she needed limited assistance with transfers, toilet use and locomotion in the unit. Resident 6 needed one-person physical assistance with all the above tasks. A Nursing Plan of Care for falls dated 12/5/18 indicated, 1) Keep environment free of hazards, clutter free, call light within reach, 2) Keep personal items within reach, 3) Encourage/remind resident to ask for help when needed if able, 4) Provide assistance as identified in transfers and mobility, 5) Visual ? [checks] Q2H (every two hours), when up, place in areas where staff can monitor whereabouts. First Fall: The facility post-fall assessment dated [DATE] at 4:00 p.m. indicated, Landed on the floor while reaching for something, tripped on her shoes. The facility's Fall Risk Evaluation dated 10/26/18 indicated Resident 6 received a score of 10, which placed her at high risk for falls. Resident 6's Nursing Plan of Care to prevent falls titled CAA 11 FALLS CARE PLAN was revised on 12/5/18 with new effective interventions to prevent further falls. The facility also initiated a 72-hour short term care plan to monitor the resident after the fall. Despite the new interventions, Resident 6 suffered a fall on 10/29/18. Second Fall: The facility Post Fall assessment dated [DATE] at 7:30 p.m. indicated, [Resident 6] Landed on the floor-while, sitting on the chair. The facility's Fall Risk Evaluation dated 10/29/2018, indicated Resident 6 received a score of 10, which placed her at high risk for falls. The facility initiated a 72-hour short term care plan to prevent further falls. This short term care plan included the following new intervention, Encourage Resident to use w/er (wheelchair). Despite (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555227 If continuation sheet Page 4 of 15 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 555227 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Marin 100 Thorndale Drive San Rafael, CA 94903 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 0657 this new intervention, Resident 6 suffered another fall on 1/20/19. Level of Harm - Minimal harm or potential for actual harm Third Fall: Residents Affected - Some The facility's Post Fall assessment dated [DATE] at 8:45 p.m. indicated, Pt. [Resident 6] get out of bed uses her walker, let go her walker to check something in the wall, stumbled on the slippers she was wearing and lost her balance. The Fall Risk Evaluation dated 1/20/19 indicated Resident 6 received a score of 10, which placed her at high risk for falls. The Nursing Plan of Care dated 12/5/18, titled, CAA 11 FALLS CARE PLAN was not revised after this fall. There were no new interventions to prevent further falls. The facility started a 72-hour short term care plan with some new interventions such as, Visual/room visit more often, but did not specify how often Resident 6 was required to be monitored. The interventions in the short term care plan were not included in the long term Nursing Plan of Care dated 12/5/18. Resident 6 suffered another fall on 2/12/19. Fourth Fall: The facility's Post Fall assessment dated [DATE] at 8:45 p.m., indicated, RESIDENT FOUND SITTING ON THE FLOOR, STATED SHE WAS WALKING TO THE BATHROOM AND TRIPPED WITH HER SLIPPERS ON WALKER FOUND NEXT TO HER. The Fall Risk Evaluation dated 2/12/19 indicated Resident 6 received a score of 12, which placed her at high risk for falls. The Nursing Plan of Care to prevent falls titled CAA 11 FALLS CARE PLAN was not revised after the fall on 2/12/19, therefore there were no new interventions to prevent further falls. The facility started a 72-hour short term care plan to prevent further falls. One of the interventions in the short term care plan indicated, frequent room visits by staff (esp.[especially] at night) This intervention did not indicate how frequently Resident 6 was required to be monitored. Resident 13 Resident 13, an [AGE] year-old female was admitted to the facility on [DATE] with diagnoses including Muscle Weakness, Difficulty in Walking and History of Falling. Resident 13's MDS dated [DATE] indicated she had a BIMS score of 7, which indicated she was severely cognitively impaired. The MDS also indicated Resident 13 needed extensive assistance with transfers and was totally dependent on staff for locomotion on and off the unit. Resident 13's Nursing Plan of Care to prevent falls dated 12/28/18 had the following interventions to prevent falls: 1) Orient Resident to new room/environment, 2) Keep call light & personal items w/in reach, 3) Assist Resident to toilet per toileting schedule, 4) Keep bed at lowest position, lock wheels on bed/wheelchair when appropriate. Despite these interventions, Resident 13 suffered a fall on 2/26/19. First Fall: Resident 13's 72-hour short term care plan dated 2/15/19 indicated Resident 13 suffered a fall on 2/15/19. It indicated, PROBLEM Fall DATE IDENTIFIED 2/15/19 .Monitor VS & neuro check x 72 (hours). The Fall Risk assessment dated [DATE] indicated Resident 13 received a score of 12 which placed her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555227 If continuation sheet Page 5 of 15 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 555227 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Marin 100 Thorndale Drive San Rafael, CA 94903 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 0657 at high risk for falls. Level of Harm - Minimal harm or potential for actual harm The Nursing Plan of Care dated 12/28/18, titled, FALL RISK CARE PLAN was not revised after this fall. A 72-hour short term care plan was initiated for this fall. The short term care plan indicated, Non-skid socks to wear when OOB (out of bed). This new intervention would not have been appropriate for Resident 13, who, according to her MDS dated [DATE], was totally dependent on staff for locomotion on and off the unit. Residents Affected - Some Second Fall: The facility's Post Fall assessment dated [DATE] at 6:00 p.m. indicated, Resident felt an urgency to have a BM (bowel movement), was sitting in her w/c (wheelchair) eating dinner, got up and walked to the BR (bathroom) not using her walker (or call light). According to Resident 13's short term care plan dated 2/26/19, she suffered a fall. The Falls Risk assessment dated [DATE] indicated Resident 13 received a score of 12 which placed her at high risk for falls. The Nursing Plan of Care dated 12/28/18, titled, FALL RISK CARE PLAN was not revised after this fall. A 72-hour short term care plan was initiated for this fall. The short term care plan did not indicate how often Resident 13 was expected to be monitored by level of care staff. The short term care plan indicated, Call light within reach and reminded to use, which was already part of the initial Falls Risk Care Plan, and was not effective in reducing the incidence of falls. During an interview on 2/28/19 at 12:16 p.m., the DON confirmed that the long term care plans to reduce new incidences of falls did not get revised after every fall. The DON stated that the short term care plans were active for 72 hours. She also stated that Resident 6 was monitored by staff every 15 to 20 minutes but there was no log to keep track of visual checks. In addition, while reviewing the Falls Plan of Care for Resident 6 the DON stated that the interventions from the short care plan for falls should have been added to the long term care plan. During an interview on 2/28/19 at 11:54 a.m., Unlicensed Staff C stated that she checked on Resident 6 every 10 to 15 minutes. During an interview on 2/28/19 at 11:48 a.m., Licensed Staff B stated that she checked on Resident 6 every hour, and confirmed that Resident 6 was at risk for falls. The facility's protocol titled, Falls-Clinical Protocol, last revised in March of 2018, indicated, If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops .The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling .If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions. The facility's policy titled, Falls and Fall Risk, Managing, last revised in March of 2018 indicated, If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant .In conjunction with the attending physician, staff will identify and implement relevant interventions. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555227 If continuation sheet Page 6 of 15 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 555227 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Marin 100 Thorndale Drive San Rafael, CA 94903 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The facility's policy titled, Care Planning-Interdisciplinary Team, last revised in September of 2013 indicated, Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. The facility's policy titled, Care Plans, Comprehensive Person-Centered, last revised in December of 2016 indicated, Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change .The interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met. The facility violated its own policies by failing to update and revise the Nursing Plans of Care after every fall for Resident 6 and Resident 13. The facility violated the regulations by failing to ensure that Resident 6 and Resident 13, who were at risk for falls, had effective revisions in the Nursing Plans of Care after every fall to prevent further falls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555227 If continuation sheet Page 7 of 15 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 555227 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Marin 100 Thorndale Drive San Rafael, CA 94903 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to attempt new interventions to prevent falls for 2 of 2 sampled residents at risk for falls. This had the potential to cause severe injuries or death to Resident 6 and Resident 13 during new incidences of falls. Findings: Resident 6 Resident 6, an [AGE] year-old female, was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease, Mild Cognitive Impairment, Age-related Osteoporosis, and History of Falling according to Resident 6's Facility Face Sheet. Resident 6's MDS (Minimum Data Set-part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes) dated 2/26/2019 indicated her BIMS (Brief Interview of Mental Status-A required screening tool used in nursing homes to assess cognition, 13 to 15 points: intact cognition, 8 to 12 points: moderately impaired cognition, 0-7 points: severely impaired cognition) score was 15 which indicated Resident 22 had intact condition. Resident 6's MDS dated [DATE] also indicated she needed limited assistance with transfers, toilet use and locomotion in the unit. Resident 6 needed one-person physical assistance with all the above tasks. A Nursing Plan of Care for falls dated 12/5/18 indicated, 1) Keep environment free of hazards, clutter free, call light within reach, 2) Keep personal items within reach, 3) Encourage/remind resident to ask for help when needed if able, 4) Provide assistance as identified in transfers and mobility, 5) Visual ? [checks] Q2H (every two hours), when up, place in areas where staff can monitor whereabouts. First Fall: The facility post-fall assessment dated [DATE] at 4:00 p.m. indicated, Landed on the floor while reaching for something, tripped on her shoes. The facility's Fall Risk Evaluation dated 10/26/18 indicated Resident 6 received a score of 10, which placed her at high risk for falls. There was no documentation that an interdisciplinary team meeting was held to discuss the fall that occurred on 10/26/18. Resident 6's Nursing Plan of Care to prevent falls titled CAA 11 FALLS CARE PLAN was revised on 12/5/18 with new effective interventions to prevent further falls. The facility also initiated a 72-hour short term care plan to monitor the resident after the fall. Despite the new interventions, Resident 6 suffered a fall on 10/29/18. Second Fall: The facility Post Fall assessment dated [DATE] at 7:30 p.m. indicated, [Resident 6] Landed on the floor-while, sitting on the chair. The facility's Fall Risk Evaluation dated 10/29/2018, indicated Resident 6 received a score of 10, which placed her at high risk for falls. There was no documentation that an interdisciplinary team meeting was held to discuss the fall that occurred on 10/29/18. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555227 If continuation sheet Page 8 of 15 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 555227 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Marin 100 Thorndale Drive San Rafael, CA 94903 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 0689 Level of Harm - Minimal harm or potential for actual harm The facility initiated a 72-hour short term care plan to prevent further falls. This short term care plan included the following new intervention, Encourage Resident to use w/er (wheelchair). Despite this new intervention, Resident 6 suffered another fall on 1/20/19. Third Fall: Residents Affected - Some The facility's Post Fall assessment dated [DATE] at 8:45 p.m. indicated, Pt. [Resident 6] get out of bed uses her walker, let go her walker to check something in the wall, stumbled on the slippers she was wearing and lost her balance. The Fall Risk Evaluation dated 1/20/19 indicated Resident 6 received a score of 10, which placed her at high risk for falls. There was no documentation indicating that an interdisciplinary team meeting was held to discuss the fall that occurred on 1/20/19. The Nursing Plan of Care dated 12/5/18, titled, CAA 11 FALLS CARE PLAN was not revised after this fall. There were no new interventions to prevent further falls. The facility started a 72-hour short term care plan with some new interventions including, Visual/room visit more often, but did not specify how often Resident 6 was required to be monitored. The interventions in the short term care plan were not included in the long term Nursing Plan of Care dated 12/5/18. Resident 6 suffered another fall on 2/12/19. Fourth Fall: The facility's Post Fall assessment dated [DATE] at 8:45 p.m., indicated, RESIDENT FOUND SITTING ON THE FLOOR, STATED SHE WAS WALKING TO THE BATHROOM AND TRIPPED WITH HER SLIPPERS ON WALKER FOUND NEXT TO HER. The Fall Risk Evaluation dated 2/12/19 indicated Resident 6 received a score of 12, which placed her at high risk for falls. An interdisciplinary meeting was documented on 2/26/19 but indicated, Scheduled Care Conference and was not conducted specifically to discuss the fall that occurred on 2/12/19. The Nursing Plan of Care to prevent falls titled CAA 11 FALLS CARE PLAN was not revised after the fall on 2/12/19, therefore there were no new interventions to prevent further falls. The facility started a 72-hour short term care plan to prevent further falls. One of the interventions in the short term care plan indicated, frequent room visits by staff (esp.[especially] at night). This intervention did not indicate how frequently Resident 6 was required to be monitored. Resident 13 Resident 13, an [AGE] year-old female was admitted to the facility on [DATE] with diagnoses including Muscle Weakness, Difficulty in Walking and History of Falling. Resident 13's MDS dated [DATE] indicated she had a BIMS score of 7, which indicated she was severely cognitively impaired. The MDS also indicated Resident 13 needed extensive assistance with transfers and was totally dependent on staff for locomotion on and off the unit. Resident 13's Nursing Plan of Care to prevent falls dated 12/28/18 had the following interventions to prevent falls: 1) Orient Resident to new room/environment, 2) Keep call light & personal items w/in reach, 3) Assist Resident to toilet per toileting schedule, 4) Keep bed at lowest position, lock wheels on bed/wheelchair when appropriate. Despite these interventions, Resident 13 suffered a fall on 2/26/19. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555227 If continuation sheet Page 9 of 15 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 555227 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Marin 100 Thorndale Drive San Rafael, CA 94903 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 0689 First Fall: Level of Harm - Minimal harm or potential for actual harm Resident 13's 72-hour short term care plan dated 2/15/19 indicated Resident 13 suffered a fall on 2/15/19. It indicated, PROBLEM Fall DATE IDENTIFIED 2/15/19 .Monitor VS & neuro check x 72 (hours). The Fall Risk assessment dated [DATE] indicated Resident 13 received a score of 12 which placed her at high risk for falls. There was no documentation indicating that an interdisciplinary team meeting was held to discuss the fall that occurred on 2/15/19. Residents Affected - Some The Nursing Plan of Care dated 12/28/18, titled, FALL RISK CARE PLAN was not revised after this fall. A 72-hour short term care plan was initiated for this fall. The short term care plan indicated, Non-skid socks to wear when OOB (out of bed). This new intervention would not have been appropriate for Resident 13, who, according to her MDS dated [DATE], was totally dependent on staff for locomotion on and off the unit. Second Fall: The facility's Post Fall assessment dated [DATE] at 6:00 p.m. indicated, Resident felt an urgency to have a BM (bowel movement), was sitting in her w/c (wheelchair) eating dinner, got up and walked to the BR (bathroom) not using her walker (or call light). According to Resident 13's short term care plan dated 2/26/19, she suffered a fall that same day (2/26/19). The Falls Risk assessment dated [DATE] indicated Resident 13 received a score of 12 which placed her at high risk for falls. There was no documentation indicating that an interdisciplinary team meeting was held to discuss the fall that occurred on 2/26/19. The Nursing Plan of Care dated 12/28/18, titled, FALL RISK CARE PLAN was not revised after the fall on 2/26/19. A 72-hour short term care plan was initiated for this fall. The short term care plan did not indicate how often Resident 13 was required to be monitored by level of care staff. The short term care plan indicated, Call light within reach and reminded to use, which was already part of the initial Falls Risk Care Plan, and was not effective in reducing the incidence of falls. During an interview on 2/28/19 at 12:16 p.m., the DON confirmed that the long term care plans to reduce new incidences of falls did not get revised after every fall. The DON stated that the short term care plans were active for 72 hours. She also stated that Resident 6 was monitored by staff every 15 to 20 minutes but there was no log to keep track of visual checks. In addition, while reviewing the Falls Plan of Care for Resident 6 the DON stated that the interventions from the short care plan for falls should have been added to the long term care plan. During an interview on 2/28/19 at 11:54 a.m., Unlicensed Staff C stated that she checked on Resident 6 every 10 to 15 minutes. During an interview on 2/28/19 at 11:48 a.m., Licensed Staff B stated that she checked on Resident 6 every hour, and confirmed that Resident 6 was at risk for falls. The facility's protocol titled, Falls-Clinical Protocol, last revised in March of 2018, indicated, If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling, until falling reduces or stops .The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling .If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555227 If continuation sheet Page 10 of 15 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 555227 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Marin 100 Thorndale Drive San Rafael, CA 94903 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions. The facility's policy titled, Falls and Fall Risk, Managing, last revised in March of 2018 indicated, If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant .In conjunction with the attending physician, staff will identify and implement relevant interventions. The facility's policy titled, Care Planning-Interdisciplinary Team, last revised in September of 2013 indicated, Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. The facility's policy titled, Care Plans, Comprehensive Person-Centered, last revised in December of 2016 indicated, Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change .The interdisciplinary Team must review and update the care plan: a. When there has been a significant change in the resident's condition; b. When the desired outcome is not met. The facility violated its own policies by failing to update and revise the Nursing Plans of Care after every fall for Resident 6 and Resident 13. The facility violated the regulations by failing to ensure that Resident 6 and Resident 13, who were at risk for falls, were provided adequate supervision by direct care staff and had effective revisions in the Nursing Plans of Care to prevent further falls. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555227 If continuation sheet Page 11 of 15 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 555227 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Marin 100 Thorndale Drive San Rafael, CA 94903 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to maintain accurate medical records for one of six sampled residents. This had the potential for overmedication, inaccurate medication reconciliation of controlled substances, inappropriate pain control for Resident 7 and diversion of controlled drugs. Findings: Resident 7, a [AGE] year-old female was admitted to the facility on [DATE], with diagnoses including hemiplegia (complete paralysis or loss of function of one-half of the body) and hemiparesis (weakness of one-half side of the body) following cerebral infarction (a brain lesion in which a cluster of brain cells die when they do not get enough blood) affecting left non-dominant side. Resident 7's MDS (Minimum Data Set-part of the federally mandated process for clinical assessment of all residents in Medicare and Medicaid certified nursing homes), dated 12/10/18 indicated she frequently experienced pain during the last five days (12/6/18-12/10/18), and the intensity on a scale from zero to ten, with zero being no pain and ten being as the worst pain imaginable, had been a seven within the same five-day period of the MDS assessment. According to Resident 7's Medication Administration Record for the month of February, 2019, Resident 7 had a physician's order indicating, OXYCODONE (an opioid medication for the treatment of moderate to severe pain) IR (immediate-release medication that starts to works within a few minutes of administration) (BBW) (Black Box Warning- the strictest warning put in the labeling of prescription drugs or drug products by the Food and Drug Administration when there is reasonable evidence of an association of a serious hazard with the drug) 5 mg(milligrams) ONE TAB PO(by mouth) Q4HRS(every four hours) PRN(as needed) FOR MODERATE PAIN. During record review on 3/1/19 at 10:30 a.m., it was noted that the controlled medication oxycodone 5 mg tablet was signed out on 2/9/19 in the controlled drug record for Resident 7 but not documented in her Medication Administration Record (MAR) as administered, on 2/9/19. This medication had been signed out by Licensed Staff B, in the controlled drug record log book for Resident 7. During an interview with the DSD on 3/1/19 at 10:32 a.m., the DSD confirmed that this medication had not been documented as administered in Resident 7's MAR, but was logged out in the controlled drug record on 2/9/19. The DSD stated that all the administered controlled medications were required to be documented in the medication administration record of the resident receiving the medication. The DSD indicated that Licensed Staff B probably forgot to document the administration of oxycodone 5 mg tablet in Resident 7's MAR. During an interview on 3/01/19 at 10:37 a.m., Licensed Staff B stated that she forgot to document oxycodone 5 mg tablet on Resident 7's MAR on 2/9/19. She also confirmed forgetting to document the pain level which prompted the administration of this medication, and the effectiveness of the medication in alleviating pain. She stated that she was probably very busy. She stated that she would write a late entry documenting the administration of oxycodone 5 mg tab on 2/9/19, on Resident 7's MAR and proceeded to document the administration of this medication on 2/9/19. In another area of the MAR she wrote a note indicating, LE (late entry) 3/1/19 0900 (9:00 a.m.) oxycodone 5 mg given for L (left) arm pain-effective. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555227 If continuation sheet Page 12 of 15 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 555227 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Marin 100 Thorndale Drive San Rafael, CA 94903 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 3/01/19 at 11:55 a.m., Unlicensed Staff D, Resident 7's caregiver, stated that Resident 7 had pain on her left arm, so she needed oxycodone when showering and participating in physical therapy. Unlicensed Staff C stated that other, non-narcotic analgesics did not alleviate Resident 7's pain. Unlicensed Staff C stated that only oxycodone was effective in controlling Resident 7's pain. Resident 7 was hard of hearing and was unable to answer any questions. Resident 7 was observed with a contracted left hand bent at the level of the elbow. The facility's policy titled, Administering Medications last revised in December of 2012, indicated, As required or indicated for a medication, the individual administering the medication will record in the resident's medical record: a. The date and time the medication was administered; b. The dosage; c. The route of administration; d. The injection site (if applicable); e. Any complaints or symptoms for which the drug was administered; f. Any results achieved and when those results were observed; and g. The signature and title of the person administering the drug. The facility's policy titled, Documentation of Medication Administration last revised in April of 2007 indicated, A Nurse or Certified Medication Aide (where applicable) shall document all medications administered to each resident on the resident's medication administration record (MAR) . 2. Administration of medication must be documented immediately after (never before) it is given. This lack of documentation in the facility's MAR had the potential to cause overmedication of controlled substances to Resident 7, diversion of drugs, inability to reconcile controlled substances from the controlled drug record, and inappropriate pain control for Resident 7. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555227 If continuation sheet Page 13 of 15 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 555227 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Marin 100 Thorndale Drive San Rafael, CA 94903 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review the facility failed to ensure: 1. One cook was able to correctly describe the cool down process for food and 2. The kitchen maintained an air gap for kitchen appliances. This failure could potentially lead to food borne illness in a vulnerable population. Findings: 1. During an interview and concurrent record review on 3/1/19 at 10 a.m., [NAME] A stated the total time for cooling down cooked food was seven hours from start to finish. When asked if she used a cool down log, [NAME] A stated yes and got a binder that contained the log. Review of the log revealed a description of the cool down process at the top and then columns to record data, including temperatures, throughout the process. One of the columns indicated at the top Final [temperature] after 6 hours. When asked again how long the cool down process takes from start to finish, [NAME] A stated seven hours. When asked what she would do if a food was above 40 degrees after cooling for six hours, [NAME] A stated, I would add more time. Review of facility document titled HACCP Cooling and Reheating Chart, dated 9/2014, revealed, Cool food quickly from 140º F (degrees Fahrenheit) (60º C (Celsius)) to 70º F (21º C) . within 2 hours and then to 40º F (4º C) or below within an additional 4 hours (total cooling time 6 hours). Products that do not reach 40º F (4º C) within 6 hours must be discarded. 2. During an observation and concurrent interview on 2/28/19 at 10:46 a.m., a floor sink under the dishwasher had several pipes leading down into it: A black plastic pipe approximately three inches in diameter was approximately two inches below floor level. A copper pipe approximately one inch in diameter was approximately four inches below floor level. Two clear plastic pipes approximately 3/4 inch in diameter were approximately six inches below floor level. When queried, Registered Dietician confirmed the pipes were below floor level and stated maintenance needed to come cut off the pipes. During an observation and concurrent interview on 2/28/19 at 11 a.m., Assistant Maintenance Director stated the black plastic pipe was the drainage pipe from the dishwasher, the copper pipe released steam from the heat blaster that heated the water for the dishwasher, and the two clear plastic pipes came from the water softener and the backup sanitizer that sanitized the dishes if the heat blaster failed. Assistant Maintenance Director stated the pipes had been this way (below floor level) for 30 years. Registered Dietician stated the pipes needed to be cut, and Assistant Maintenance Director stated he would call and have a plumber come as soon as possible. In response to a request for an air gap policy, the facility produced an untitled document on facility letterhead that indicated, A. AIR GAP SEPARATION (AG) The term 'air gap separation' shall mean a physical separation between the free flowing discharge end of a potable water supply pipeline and an open or non pressure receiving vessel. An approved Air Gap shall be at least double the diameter of the supply pipe measured vertically above the overflow rim of the vessel - in no case less than 1 inch . All piping from the service connection to the receiving tank shall be above grade level and be entirely visible . Review of Federal Food Code 2017, section 5-202.13 titled Backflow Prevention, Air Gap revealed An (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555227 If continuation sheet Page 14 of 15 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 555227 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Villa Marin 100 Thorndale Drive San Rafael, CA 94903 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 0812 Level of Harm - Minimal harm or potential for actual harm air gap between the water supply inlet and the flood level rim of the PLUMBING FIXTURE, EQUIPMENT, or nonFOOD EQUIPMENT shall be at least twice the diameter of the water supply inlet and may not be less than 25 mm (1 inch). Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555227 If continuation sheet Page 15 of 15