Health inspection·April 10, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records review, the facility failed to report an allegation of abuse to the California Department of Public Health (CDPH) in accordance with Federal requirements for one of two sampled residents (Resident 1). This failure resulted in a delayed investigation of the alleged abuse by CDPH and had the potential for other residents to be at risk of abuse. Findings: On 4/02/24 at 1:42 p.m., CDPH received a Facility Reported Incident regarding a facility staff member being physically aggressive to Resident 1. A review of the Minimum Data Set (MDS - health status screening and assessment tool used for all residents) dated 1/16/24 indicated Resident 1 was admitted to the facility on [DATE] with a diagnosis including but not limited to Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities); Left eye blindness and Anxiety (intense, excessive, and persistent worry and fear about everyday situations). The MDS indicated Resident 1 had a BIMS score of 3 out of 15 points (Brief Interview for Mental Status - a 15-point cognitive (relating to the mental process involved in knowing, learning, and understanding things) screening measure that evaluates memory and orientation. A score of 00 to 07 is severe cognitive impairment). A review of the facility document titled Nurse's Notes dated 3/30/24 at 11:00 p.m., indicated Unlicensed Staff A reported to Licensed Nurse B that she witnessed Unlicensed Staff C slapping Resident 1's left hand and pushed Resident 1 to bed. The Nurse's Notes indicated the Director of Nursing (DON), Social Service, and Administrator were notified of the incident. The Nurse's Notes indicated the facility had twenty four (24) hours from 11:00 p.m. to call and fax the incident to the ombudsman (an official who investigates complaints against businesses, public entities, or officials) and authorities. During a telephone interview with Unlicensed Staff A on 4/11/24 at 8:52 a.m., when Unlicensed Staff A was asked about the incident with Resident 1 on 3/30/24, Unlicensed Staff A stated she saw Unlicensed Staff C slapped Resident 1's hands twice during transfer when Unlicensed Staff C had Resident 1 hold on to the transfer lift (used for a patient who is unable to assist with transferring in and out of a bed or wheelchair). Unlicensed Staff A stated she reported the incident to Licensed Nurse B. During an interview with Licensed Nurse D on 4/10/24 at 3:05 p.m., when Licensed Nurse D was asked what she would do if she received a report of an abuse allegation, Licensed Nurse D stated she would report to the supervisor and ombudsman. She stated she would call the police immediately if the (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555227 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 04/10/2024 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)