Health inspection·August 18, 2023

F 0679 Provide activities to meet all resident's needs. 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 provide a program supporting the residents choice of activities with activities supporting the residents physical, mental, and psychosocial well-being, and encouraging interaction with the community, for one of eight sampled residents (Resident 2), when the activities provided by the facility to Resident 2 were limited to having the TV turned on in her room, despite activity assessments which indicated Resident 2 enjoyed reading, listening to music, being around pets, and spending time outdoors. This failure resulted in Resident 2 not having her activities needs met. Residents Affected - Some Findings: A review of Resident 2's admission Record indicated she was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), hemiplegia (paralysis on one side of the body), hemiparesis (weakness in one side of the body), aphasia (loss of ability to understand or express speech due to brain damage), difficulty in walking, muscle weakness, osteoarthritis (joint disease) and need for assistance with personal care. A review of Resident 2's Activities Assessment, dated 12/20/22, indicated Resident 2 enjoyed group activities, pet visits, intellectual activities, music, spiritual activities, television, and radio. A review of Resident 2's Comprehensive Care Plan indicated an Activities Care Plan, created on 12/20/22, which indicated Resident 2's current interests and preferences for activities and daily routine included, family involvement/visits, reading/keeping up with the news, listening to music, being around animals such as pets, and spending time outdoors. A review of Resident 2's Minimum Data Set (MDS - a comprehensive, standardized and federally mandated resident assessment), dated 12/21/22, indicated, under Preferences for Customary Routine and Activities, that Resident 2 preferred family involvement, reading books, newspapers, or magazines, listening to music, being around animals such as pets, keeping up with the news, spending time outdoors and participating in religious activities or practices. During an observation on 8/14/23, at 2 p.m., Resident 2 was in her room. Resident 2 was lying in her bed, supine (face upward). The TV was turned on. During an attempted interview, Resident 2 opened her eyes but did not answer questions. During an observation on 8/14/23, at 4:10 p.m., Resident 2 was in her room, lying in her bed, supine, eyes closed. The TV was turned on. During an observation on 8/15/23, at 10:07 a.m., Resident 2 was in her room, lying in her bed, supine, eyes closed. The TV was turned on. During an observation on 8/15/23, at 11:50 a.m., Resident 2 was in her room, lying in her bed, supine, eyes closed. The TV was turned on. During an observation on 8/15/23, at 3:30 p.m., Resident 2 was in her room, lying in her bed, supine, eyes closed. The TV was turned on. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555227 If continuation sheet Page 2 of 14 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 08/18/2023 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 0679 Level of Harm - Minimal harm or potential for actual harm During an observation on 8/15/23, at 4:10 p.m., Resident 2 was in her room, lying in her bed, supine, eyes closed. The TV was turned on. During an observation on 8/16/23, at 10:10 a.m., Resident 2 was in her room, lying in her bed, supine, eyes closed. The TV was turned on. Residents Affected - Some During an observation on 8/16/23, at 11:20 a.m., Resident 2 was in her room, lying in her bed, supine, eyes closed. The TV was turned on. During an observation on 8/16/23, at 1:50 p.m., Resident 2 was in her room, lying in her bed, supine, eyes closed. The TV was turned on. During an observation on 8/16/23, at 3:15 p.m., Resident 2 was in her room, lying in her bed, supine, eyes closed. The TV was turned on. During an observation on 8/17/23, at 10 a.m., Resident 2 was in her room, lying in her bed, supine, eyes closed. The TV was turned on. During an observation on 8/17/23, at 12:04 p.m., Resident 2 was in her room, lying in her bed, supine, eyes closed. The TV was turned on. During an interview and record review on 08/17/23, at 2:06 p.m., the Life Enrichment Director (LED), responsible for resident activities, stated the facility provided group activities daily for residents in the activities room at 11 a.m. and 4 p.m. For bed-bound residents, the LED stated activities were provided according to the resident's activity preferences, as indicated in the activities assessment and activities care plan. The LED provided Resident 2's activities assessment and activities care plan dated 12/20/22 which indicated Resident 2's preferences for activities including group activities, pet visits, intellectual activities, music, spiritual activities, television, and radio. The LED was asked for documentation of the activities offered to Resident 2. The LED stated she documented resident activities in their Activity Participation Record (APR). A review of Resident 2's APR for August 2023 indicated Resident 2 did not participate in any group activities, did not attend social dining, did not leave her room, and did not participate in physical activities for the period August 1-16, 2023. The APR indicated Resident 2 received Sensory Enrichment daily, which the LED stated meant hygiene/personal care provided by nursing staff. The APR indicated Resident 2 received daily room visits which the LED stated were family/friends visits on 8/2, 8/3, 8/6, 8/9 and 8/10, LED visits on 8/3 and 8/15, and nursing staff visits the other days. The only recreational activity provided by the facility to Resident 2 documented on the APR was TV. A review of the facility's Life Enrichment Calendar for August 2023, indicated at least 10 music activities for the period August 1-16 offered to residents in the activities room. The LED stated Resident 2 refused activities. The LED stated an RNA [Restorative Nursing Assistant - a type of CNA] recently reported to her that she tried to play music to Resident 2 but she cried. A review of facility document titled Facility Assessment dated 6/9/23, indicated the facility provides Opportunities for social activities/life enrichment (individual, small group, community) . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555227 If continuation sheet Page 3 of 14 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 08/18/2023 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 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 provide adequate supervision to one of two residents at risk for falls (Resident 117) when Resident 117 was left unsupervised on her wheelchair after lunch. This failure resulted in Resident 117 getting up from the wheelchair unassisted, falling, injuring her head, right knee, elbow, and being sent to the hospital for evaluation and treatment of her injuries. Findings: A review of Resident 117's admission Record indicated she was admitted to the facility on [DATE] with diagnoses including hemiplegia (paralysis) and hemiparesis (weakness or inability to move) following cerebral infarction (stroke ) affecting the left side of the body. A review of Resident 117's Fall Risk Evaluation (a standardized tool that assesses the resident's risk for falls based on different parameters), dated 7/10/23, indicated Resident 117 was at HIGH RISK for falls. The Fall Risk Evaluation indicated Resident 117 had the following fall risk factors: a history of falls, was confused, had gait and balance problems, and had predisposing diseases and took medications that increased the risk for falls. A review of Resident 117's Fall Risk Care Plan (a document indicating the care and services to be provided to the resident), dated 7/10/23, indicated Resident 117 was at risk for fall/injury due to: impaired/limited mobility, poor balance, limited ROM [range of motion - the ability to extend and flex limbs], deconditioning [weakness], and aging process [old age]. The Fall Risk Care Plan indicated fall prevention interventions including, anticipate and meet resident's needs, transfer safely with the assistance of one or more staff, visual checks every shift when up, and place resident in areas where staff can monitor resident's activities and whereabouts. A review of Resident 117's Care Plan Conference Summary dated 7/13/23, indicated, under Safety Issues Identified, that Res[ident] stands on own. A review of Resident 117's Minimum Data Set (MDS - a comprehensive, standardized, federally mandated resident assessment) dated 7/17/23, indicated Resident 117 had a BIMS (Brief Interview for Mental Status - the cognitive assessment tool of the MDS) score of 6 (scores of 0-7 indicate severe cognitive impairment), needed extensive assistance of at least two persons for transfers between surfaces such as bed, wheelchair and toilet, and was not steady, only able to stabilize with staff assistance with regards to balance during transitions and walking. A review of Resident 117's Progress Notes indicated Progress Note dated 7/21/23, at 2:50 p.m., indicating: Resident [117] was found on the floor by CNA [Certified Nursing Assistant], skin tear approx[imately] 1 inch to . head, X2[two] skin tears to R[ight] knee and X1[one] skin tear to R[ight] elbow . New orders to transport to [Hospital] for further evaluation. A review of Resident 117's Post Fall Assessment, dated 7/21/23, at 3 p.m., indicated: Per AM [day shift] nurse, Resident [117] was found on the floor by her wheelchair. Resident [117] told AM nurse and CNA she wanted to go back to bed. Resident sustained multiple skin tears on her head, right knee, and right forearm. The Post Fall Assessment indicated the following as contributing factors to the fall: Resident has intermittent confusion and lacks safety awareness. She is also impulsive and will (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555227 If continuation sheet Page 4 of 14 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 08/18/2023 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 - Actual harm Residents Affected - Few get up w/o [without] assist from staff d/t [due to] confusion. The Post Fall Assessment indicated as recommendations to prevent further falls: Staff will . supervise resident at nursing station. Do not leave [Resident 117] alone in room. During an interview on 8/15/23, at 2 p.m., the Director of Nursing (DON) stated Resident 117 was admitted to the facility on [DATE] for rehabilitation following a stroke and was at high risk for falls. The DON stated that Resident 117 was extremely restless and impulsive and frequently tried to get out of bed. The DON stated on 7/21/23 Resident 117 had a late lunch in her room in her wheelchair assisted by CNA A. The DON stated Resident 117 finished her lunch and while CNA A was out of the room Resident 117 attempted to get up from the wheelchair unassisted and fell to the floor. The DON stated she heard CNA B shout she [Resident 117] is on the floor. The DON stated she went to Resident 117's room and found she had been assisted back to her wheelchair by staff. The DON stated Resident 117 had injuries to her forehead, right elbow, and right knee. The DON stated Resident 117 was sent to the hospital the same day for evaluation and treatment after her fall. During an interview on 8/16/23, at 9:10 a.m., CNA B stated she was assigned to care for Resident 117 when Resident 117 fell on 7/21/23. CNA B stated Resident 117 was really restless that day and trying to crawl out of bed. CNA B stated on 7/21/23 Resident 117 had lunch in her room, in her wheelchair, assisted by CNA A, and finished eating at around 2:30 p.m. CNA B stated after Resident 117 finished her meal, CNA A left Resident 117's room to take Resident 117's lunch tray to the cart on the hallway, and at this time CNA B heard Resident 117's wheelchair alarm go off (a type of alarm combined with a chair sensor or chair pad that operates, or sounds the alarm, by detecting a reduction of pressure, for example when the resident gets out of the wheelchair), ran towards her room, and found Resident 117 on the floor. CNA B stated Resident 117 had a cut on her forehead and was bleeding from it. A review of Resident 117's Hospital record titled History and Physical (H&P), dated 7/21/23, indicated, The patient was brought in as a limited trauma [some injuries] after an unwitnessed fall from her wheelchair at her care facility. The H&P's Physical Exam indicated She has a small laceration [cuts] on her forehead . She has several areas of skin abrasions [scratches] on both lower extremities. She also has some mild bruising on her upper extremities. During an interview on 8/17/23, at 11:22 a.m., the family of Resident 117 stated Resident 117 fell because she was left unsupervised in her wheelchair after lunch. The family stated Resident 117 had a routine of eating lunch, going to the commode (a portable toilet place next to the bed for residents with mobility difficulties), and then going to bed. The family stated Resident 117 should not have been left alone or unsupervised in her wheelchair because she had a history of trying to get up unassisted. The family stated she had discussed this fall risk factor with staff during the care plan conference after Resident 117's admission on [DATE]. During an interview and record review on 8/18/23, at 8:54 a.m., the MDS Coordinator provided the admission care plan conference for Resident 117's titled Care Plan Conference Summary dated 7/13/23. Resident 117's Care Conference Summary indicated, under Safety Issues Identified, that Res[ident] stands on own. The MDS Coordinator was asked what this meant. The MDS Coordinator stated it meant Resident 117 was at risk of falls because she attempted to get up on her own (from the bed or wheelchair). A review of facility policy and procedure titled Falls and Fall Risk, Managing, Revised March 2018, indicated: Based on previous evaluations and current data, the staff will identify interventions (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555227 If continuation sheet Page 5 of 14 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 08/18/2023 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 related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555227 If continuation sheet Page 6 of 14 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 08/18/2023 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review the facility did not follow the procedure when they stored an oxygen tank, which was empty per the gauge, in the Resident's room (one of fifteen residents, Resident 10.) This failure, storing oxygen tanks in residents' rooms, was a potential safety and/or fire hazard. The failure of having an empty oxygen tank puts the residents at risk of not getting supplemental oxygen in an emergency. Residents Affected - Few Findings: During an observation on 8/14/23 at 11:55 a.m., Resident 10 was up in her chair in her room for lunch. Resident 10 was on oxygen at 1 liter (a measurement) per minute using a nasal cannula, tubing to the nose. The tubing was connected to an oxygen concentrator device. An oxygen tank stored in a corner just past the bathroom in Resident 10's room was found. The gauge on the tank read empty. During an interview on 8/14/23 at 2:20 p.m., Licensed Nurse C stated we keep the tanks in the rooms for emergencies. Licensed Nurse C stated Resident 10 only needed oxygen at night. Licensed Nurse C acknowledged that the tank was empty and took the oxygen tank out of Resident 10's room. During a review of the facilities policy and procedure titled Physical Environment -Fire and Life Safety, dated 5/2011, indicated under section: Oxygen Safety: Store oxygen in clean dry locations away from direct sunlight. Label all oxygen cylinders (tanks) to indicate the contents . i.e., full, half full or empty, etc. and . Do not store oxygen cylinders in any resident room or living area. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555227 If continuation sheet Page 7 of 14 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 08/18/2023 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 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Based on interview and record review, the facility failed to ensure timely documentation of resident assessments for the risk of entrapment from bed rails and obtaining informed consent prior to installation of bed rails for 15 of 15 residents. This failure placed residents at risk of entrapment. Findings: During an interview and concurrent record review on 8/18/23 at 8:05 a.m., the DON (Director of Nursing) stated all 31 resident beds had bilateral quarter-size bedrails. The DON provided a copy of form titled Interdisciplinary Assessment and Progress Notes which had a field for evaluation of bed rails for entrapment risks and space to document informed consent completed for all residents upon admission. The DON reviewed the charts of all 15 facility residents and stated the entrapment risk assessment fields had not been completed. During an interview on 8/18/23, at 11:45 a.m., the DON stated assessment of bed rails for risk of entrapment had been completed and documented and informed consent obtained for all but two residents, and no residents were at risk for entrapment. A review of facility policy and procedure titled Bed Safety and Bed Rails, dated August 2022, indicated: Regardless of mattress type, width, length, and/or depth, the bed frame, bed rail and mattress will leave no gap wide enough to entrap a resident's head or body. Prior to the installation or use of a side or bed rail, alternatives to the use of side or bed rails are attempted . If attempted alternatives do not adequately meet the resident's needs the resident may be evaluated for the use of bed rails .The resident assessment to determine risk of entrapment includes .A resident or part of his/her body could be caught between rails, the opening of the rails, or between the bed rails and mattress . Before using bed rails for any reason, the staff shall inform the resident or representative about the benefits and potential hazards associated with bed rails and obtain informed consent . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555227 If continuation sheet Page 8 of 14 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 08/18/2023 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on observation, interview and record review, the facility failed to ensure Agency/Registry (staffing agencies that hire and train staff and place nursing professionals in a variety of nursing positions) Licensed Nurses and Certified Nursing Assistants (CNAs) had the competencies and skills necessary to care for its residents' needs when: 1) the facility did not verify that Agency/Registry Licensed Nurses and CNAs had valid and complete competency/skills checks to meet resident needs prior to working at the facility; 2) an Agency/Registry Licensed Nurse (Licensed Nurse E) did not perform hand hygiene per facility policies prior to medication administration to five residents (cross-reference to Tag F880 - Infection Control); 3) an Agency/Registry Licensed Nurse (Licensed Nurse E) attempted to perform a medical procedure involving blood draw using needles on a resident who did not have orders for and did not need the procedure, and was only stopped by the resident who refused the procedure; and 4) the facility did not have a policy and procedure governing its use of Agency/Registry Licensed Nurses and CNAs. These failures placed residents at risk of incompetent care and not having their care needs met. Findings: 1) During a resident group interview on 8/15/23, at 11:00 a.m., residents reported dissatisfaction with the services provided by Agency/Registry Licensed Nurses and CNAs. The residents reported the Agency/Registry staff were not familiar or knowledgeable about the residents and their needs. During an interview and record review on 8/16/23, at 10:13 a.m., the Director of Staff Development (DSD) stated the facility used a mix of directly hired and Agency/Registry Licensed Nurses and CNAs. The DSD stated directly hired Licensed Nurses and CNAs had to pass a skills/competency check demonstrating the skills to meet resident needs. The DSD provided the checklists he used to assess their skills/competency. A review of the Licensed Nurse skills/competency checklist indicated five pages with about 70 different skills/competencies. A review of the CNA skills/competency checklist indicated one page with about 72 different skills/competencies. The DSD stated their directly hired Licensed Nurses and CNAs must successfully complete these checklists upon hire and annually thereafter. For Agency/Registry Licensed Nurses and CNAs, the DSD stated the facility relied on skills/competency checks performed by the agencies that employed them, but he checked them online before the staff were allowed to work with residents. The DSD provided a ledger indicating the use of Agency/Registry Licensed Nurses and CNAs for the week of 8/9/23 to 8/15/23. The ledger indicated that Agency/Registry Licensed Nurses and CNAs worked on six of the seven days, as follows: 8/9/23: one CNA during two shifts (each shift consisting of eight hours); 8/11/23: one CNA during one shift; 8/12/23: one Licensed Nurse during one shift and four CNAs during six shifts; 8/13/23: one Licensed Nurse during one shift and four CNAs during four shifts; 8/14/23: one CNA for one shift; and 8/15/23: two CNAs during two shifts. The DSD was asked to provide the skills/competency checks for three agency staff that worked at the facility during the week of 8/9/23 to 8/15/23: CNAs G and H and Licensed Nurse I. The DSD accessed the website of Agency A that employed CNAs G and H and opened the staff profiles of CNAs G and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555227 If continuation sheet Page 9 of 14 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 08/18/2023 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 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some H. The DSD stated the skills/competency checks were found under the Annual Competencies tab, which he opened. The Annual Competencies tab contained the following statement: I have read and been informed of facility mandated annual competencies related to my profession as a healthcare provider. and listed 29 topics including hand hygiene, patient rights, restraints, and sexual harassment and others. The list had an Expiration Date of 7/15/24. This was the only document related to skills/competencies found in their file. The DSD was asked what the statement in the Annual Competencies tab meant, if Agency A had verified the skills/competencies listed or it was merely an affirmation by the CNAs they had those skills/competencies, and what the Expiration Date meant. The DSD stated he did not know. The DSD then accessed the website of Agency B, which employed Licensed Nurse I. There were no skills/competency checklists for Licensed Nurse I available for verification there. 2) During five observations on 8/17/23, from 5:45 a.m. to 6:35 a.m., Licensed Nurse E, an Agency/Registry Licensed Nurse, prepared and administered medications to five residents without observing the facility's hand hygiene policies and procedures. (Cross-reference to Tag F-880). 3) During an observation and interview on 8/17/23, at 6:45 a.m., Licensed Nurse E stated she was going to check the blood sugar level of Resident 5, who received insulin (a medication to control blood sugar), and had orders to have his blood sugar level checked daily. (Blood sugar levels are checked by pricking the tip of the resident's finger with a small needle called a lancet to produce a blood drop which is placed on a test strip. The test strip is then inserted into a portable device called glucometer which analyses the blood and indicates the blood sugar level). Licensed Nurse E collected a plastic basked with Resident 5's name containing a glucometer, lancets, test strips, alcohol swabs, gloves, and other supplies, and entered Resident 9's room. Licensed Nurse E did not ask Resident 9's name or checked her wrist band (containing the resident's name and date of birth ) or identify Resident 9 by other means. Licensed Nurse E informed Resident 9 she was going to check her blood sugar level. Resident 9 asked what she was doing. Licensed Nurse E repeated she was going to check her blood sugar level, and asked if she could prick her right middle index finger. Resident 9 once more asked what she was doing. Licensed Nurse E again informed Resident 9 she was going to check her blood sugar level and proceeded to wipe Resident 9's right index finger with an alcohol swab. Licensed Nurse E then took a lancet and placed it against Resident 9's finger. Resident 9 recoiled her right hand and stated she did not have blood sugar checks done. Licensed Nurse E checked Resident 9's wrist band, stated she was the wrong resident, and left the room. A review of Resident 9's physician orders indicated no order for blood sugar checks. During an interview on 8/17/23, at 4 p.m., the MDS Coordinator/Case Manager stated only two residents at the facility had orders for blood sugar checks: Residents 5 and 6. 4) During an interview on 08/18/23, at 10:33 a.m., the DSD stated there was no policy and procedure on the use of Agency/Registry Licensed Nurses and CNAs. A review of facility policy and procedure titled Staffing, Sufficient and Competent Nursing, Revised August 2022, indicated: Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555227 If continuation sheet Page 10 of 14 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 08/18/2023 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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on interview and record review, the facility failed to indicate in its Facility Assessment the use of Agency/Registry (temporary) Licensed Nurses and Certified Nursing Assistants (CNAs). This failure resulted in an incomplete and inaccurate Facility Assessment. Findings: During an interview on 8/14/23, at 10:30 a.m., the Administrator provided a copy of the Facility Assessment, dated 6/9/23. A review of the Facility Assessment indicated no mention of the use of Agency/Registry Licensed Nurses or CNAs. During an interview and record review on 8/16/23, at 10:13 a.m., the Director of Staff Development (DSD) stated the facility used Agency/Registry Licensed Nurses and CNAs. The DSD provided a ledger indicating the use of Agency/Registry staff in the past week, for the period of 8/9/23 to 8/15/23. The ledger indicated the use of Agency/Registry staff on six of seven days, as follows: 8/9/23: one CNA for two shifts (each shift consisting of eight hours); 8/11/23: one CNA for one shift; 8/12/23: one Licensed Nurse for one shift and four CNAs for a total of six shifts; 8/13/23: one Licensed Nurse for one shift and four CNAs for a total of four shifts; 8/14/23: one CNA for one shift; and 8/15/23: two CNAs for a total of two shifts. (Cross-reference to Tag F726). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555227 If continuation sheet Page 11 of 14 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 08/18/2023 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm During an observation on 8/17/23 at 10:30 a.m., from the hall a CNA was observed answering a call light. A CNA walked down the hall, past several rooms and hand sanitizing stations and entered the resident's room and assisted the resident into the wheelchair. The CNA did not use the hand sanitizer just outside the room nor washed hands at the bathroom sink prior to helping the resident. Residents Affected - Some During an interview on 8/17/23 at 1:35 p.m., the Infection Preventionist (IP) stated when staff should be doing hand hygiene. The IP stated the staff should be doing hand hygiene before entering the residents' rooms and when exiting the resident's room, and stated, Gel in, Gel out. During an interview on 8/17/23, at 4:20 p.m., the IP stated nurses should perform hand hygiene before preparing medications to administer to residents. A review of the facility policy and procedure titled Handwashing/Hand Hygiene, dated 8/2018, indicated this Facility considers hand hygiene the primary means to prevent the spread of infection . All personal shall follow the Handwashing/Hand Hygiene procedures to help prevent the spread of infections to other personal, residents and visitors. Based on observation, interview and record review, the facility failed to follow best practices for infection prevention and control when three of three Licensed Nurses (Licensed Nurses D, E and F) did not perform hand hygiene (washed hands or used hand sanitizer) before preparing medications and administering them to eight of eight residents (Residents 1, 3, 4, 5, 6, 9, 10 and 11) and when one Certified Nursing Assistant (CNA) provided care to a resident without performing prior hand hygiene. These failures placed Residents Residents 1, 3, 4, 5, 6, 9, 10 and 11 at risk of the spread of infections. Findings: During an observation on 8/16/23, at 4:35 p.m., Licensed Nurse D began preparing medications for Resident 9 on the medication cart on the hallway outside Resident 9's room. Licensed Nurse D placed three medications in a cup and entered Resident 9's room and gave them to Resident 9. License Nurse D did not perform hand hygiene before preparing the medications and administering them to Resident 9. During an observation on 8/16/23, at 5 p.m., Licensed Nurse D began preparing medications for Resident 11 on the medication cart on the hallway outside Resident 11's room. Licensed Nurse D placed two medications in a cup and entered Resident 11's room and gave them to Resident 11. License Nurse D did not perform hand hygiene before preparing the medications and administering them to Resident 11. During an observation on 8/16/23, at 5:10 p.m., Licensed Nurse D began preparing medications for Resident 10 on the medication cart on the hallway outside Resident 10's room. Licensed Nurse D placed three medications in a cup and entered Resident 10's room and gave them to Resident 10. License Nurse D did not perform hand hygiene before preparing the medications and administering them to Resident 10. During an observation on 8/16/23, at 5:15 p.m., Licensed Nurse D began preparing medications for Resident 5 on the medication cart on the hallway outside Resident 5's room. Licensed Nurse D placed two medications in a cup and entered Resident 5's room and gave them to Resident 5. License Nurse D did not perform hand hygiene before preparing the medications and administering them to Resident 5. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555227 If continuation sheet Page 12 of 14 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 08/18/2023 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 8/17/23, at 5:45 a.m., Licensed Nurse E began preparing medications for Resident 4 on the medication cart on the hallway outside Resident 4's room. Licensed Nurse E placed one medication in a cup and entered Resident 4's room and gave it to Resident 4. License Nurse E did not perform hand hygiene before preparing the medication and administering it to Resident 4. During an observation on 8/17/23, at 6 a.m., Licensed Nurse E began preparing medications for Resident 3 on the medication cart on the hallway outside Resident 3's room. Licensed Nurse E placed one medication in a cup and entered Resident 3's room and gave it to Resident 3. License Nurse E did not perform hand hygiene before preparing the medication and administering it to Resident 3. During an observation on 8/17/23, at 6:05 a.m., Licensed Nurse E began preparing medications for Resident 5 on the medication cart on the hallway outside Resident 5's room. Licensed Nurse E placed one medication in a cup and entered Resident 5's room and gave it to Resident 5. License Nurse E did not perform hand hygiene before preparing the medication and administering it to Resident 5. During an observation on 8/17/23, at 6:10 a.m., Licensed Nurse E began preparing medications for Resident 6 on the medication cart on the hallway outside Resident 6's room. Licensed Nurse E placed one medication in a cup and entered Resident 6's room and gave it to Resident 6. License Nurse E did not perform hand hygiene before preparing the medication and administering it to Resident 6. During an observation on 8/17/23, at 6:35 a.m., Licensed Nurse E began preparing medications for Resident 9 on the medication cart on the hallway outside Resident 9's room. Licensed Nurse E placed five medications in a cup and entered Resident 9's room and gave them to Resident 9. License Nurse E did not perform hand hygiene before preparing the medications and administering them to Resident 9. During an observation on 8/17/23, at 8:50 a.m., Licensed Nurse F began preparing medications for Resident 1 on the medication cart on the hallway outside Resident 1's room. Licensed Nurse F placed three medications in a cup and entered Resident 1's room and gave them to Resident 1. License Nurse F did not perform hand hygiene before preparing the medications and administering them to Resident 1. During an observation on 8/17/23 at 10:30 a.m., from the hall a CNA was observed answering a call light. A CNA walked down the hall, past several rooms and hand sanitizing stations and entered the resident's room and assisted the resident into the wheelchair. The CNA did not use the hand sanitizer just outside the room nor washed hands at the bathroom sink prior to helping the resident. During an interview on 8/17/23 at 1:35 p.m., the Infection Preventionist (IP) stated when staff should be doing hand hygiene. The IP stated the staff should be doing hand hygiene before entering the residents' rooms and when exiting the resident's room, and stated, Gel in, Gel out. During an interview on 8/17/23, at 4:20 p.m., the IP stated nurses should perform hand hygiene before preparing medications to administer to residents. A review of the facility policy and procedure titled Handwashing/Hand Hygiene, dated 8/2018, indicated this Facility considers hand hygiene the primary means to prevent the spread of infection . All personal shall follow the Handwashing/Hand Hygiene procedures to help prevent the spread of infections to other personal, residents and visitors. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555227 If continuation sheet Page 13 of 14 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 08/18/2023 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 0909 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. Based on interview and record review, the facility failed to monitor bed frames, mattresses, and bed rails for the risk of entrapment by bed rails as part of its regular maintenance program. This failure placed residents at risk of entrapment. Findings: During an interview and record review on 8/18/23, at 8:54 a.m., the Director of Maintenance (DM) stated the facility had in place a regular maintenance program. The DM was asked if bed frames, mattresses, and bed rails were inspected for the risk of entrapment as part of its regular maintenance program. The DM stated no. The DM stated resident beds were inspected for operation and condition only, not for the risk of entrapment. The DM provided records of the facility's regular maintenance program. A review of these records did not indicate the inspection of bed frames, mattresses, and bed rails for the risk of entrapment. A review of facility policy and procedure titled Bed Safety and Bed Rails, dated August 2022, indicated: Maintenance staff routinely inspects all beds and related equipment to identify risks and problems including potential entrapment risks. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555227 If continuation sheet Page 14 of 14