Health inspection·July 5, 2023

F 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and records review, the facility failed to evaluate and assess the need of restraint (the action of keeping someone or something under control) use for one of two sampled residents (Resident 1) when hand mittens (a type of glove or garment that covers a hand) were applied to Resident 1 ' s both hands. These failures had the potential for unnecessary restraint use restricting Resident 1 from accessing his body. Residents Affected - Few Findings: During a record review for Resident 1, the Face sheet (A one-page summary of important information about a resident) indicated Resident 1 was admitted on [DATE] with diagnoses including but not limited to Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities); Functional Quadriplegia (Complete inability to move due to severe disability or frailty); and Gastrostomy Status (a surgical opening into the stomach). During a record review for Resident 1, the Minimum Data Set (MDS -health status screening and assessment tool used for all residents) dated 2/01/23 indicated Resident 1 had a BIMS score of 00 out of 15 points (Brief Interview for Mental Status - a 15-point cognitive screening measure that evaluates memory and orientation. A score of 13 to 15 is cognitively intact, 08 to 12 is moderately impaired, and 00 to 07 is severe impairment). The MDS indicated Resident 1 did not have impairment to both hands. During an observation in Resident 1 ' s room and concurrent interview with Caregiver A on 4/20/23 at 11:00 a.m. Resident 1 was lying on his bed with Caregiver A at bedside. Resident 1 had blue hand mittens to both hands secured with a velcro strap (a fastener for clothes or other item). When Caregiver A was asked reason why Resident 1 had hand mittens on, Caregiver A stated Resident 1 kept on fiddling around his G-tube (Gastrostomy tube - a tube inserted through the wall of the abdomen directly into the stomach). When Caregiver A was asked if Resident 1 could remove the hand mittens on his own, Caregiver A stated no. Caregiver A stated he would remove the mittens at least 4 times a day for 15 minutes to air out then put it back on. During an interview and concurrent record review with the Director of Nursing (DON) on 4/20/23 at 2:45 p.m. when the DON was asked if Resident 1 was assessed for physical restraint use, the DON stated Resident 1 was not assessed for physical restraint because the facility was a restraint free facility. When the DON was asked for reason why Resident 1 had mittens to both hands, the DON stated the mittens were not considered physical restraint. She stated, mittens were applied on admission to prevent Resident 1 from pulling the G-tube out. After review of the Physician ' s order for Resident 1, Page 1 of 15 555595 555595 07/05/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0604 the DON stated there was no order for the mittens. Level of Harm - Minimal harm or potential for actual harm Review of the Facility policy and procedure titled admission of the Resident effective date July 2016 indicated, It is the policy of this facility to admit residents in an organized manner and gather appropriate assessment data. Residents Affected - Few The policy indicated forms to be completed on admission to include but not limited to Physical Restraint Assessment (only as indicated). Review of the Code of Federal Regulations (CFR - compilation of administrative laws governing federal regulatory agency practice and procedures) §483.10(e) revised in 2/03/23 indicated, The resident has a right to be treated with respect and dignity, including: §483.10(e)(1) The right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms. 555595 Page 2 of 15 555595 07/05/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and records review, the facility failed to ensure the Minimum Data Set (MDS - health status screening and assessment tool) was accurately completed for 1 of 2 sampled residents (Resident 1). This failure resulted to an unidentified health concerns and areas of risk for the residents in order to develop the most appropriate plan of care. Residents Affected - Few Findings: During a record review for Resident 1, the Face sheet (A one-page summary of important information about a resident) indicated Resident 1 was admitted on [DATE]. During a record review for Resident 1, the Physician Progress Note dated 1/28/23 indicated Resident 1 had the following diagnoses including but not limited to Severe Protein Calorie Malnutrition (inadequate intake of food as a source of protein, calories, and other essential nutrients); Diabetes Mellitus (disease that result in too much sugar in the blood); and Developmental Delay (when a child does not achieve developmental milestones in comparison to peers of the same age range). During a review of the document titled After Summary Visit dated 1/26/23 indicated Resident 1 ' s weight was 128 lbs. During an interview and concurrent record review for Resident 1 with the MDS Coordinator (MDSC - a nursing professional who helps manage a nursing team in a medical facility) on 5/18/23 at 10:47 a.m., when asked about her process of gathering data entered to the MDS assessment, the MDSC stated MDS data were obtained from interviews with direct care staff and records review either from hospital records, Activities of Daily Living (ADL) Records, Medication Administration Record (MAR), Nurse's Notes, Physician's progress notes and other sources that is related to the resident's care. During a review of the MDS assessment dated [DATE] and concurrent interview with the MDSC on 5/18/23 at 10:51 a.m., The MDSC stated Resident 1 ' s MDS assessment was inaccurately completed due to the following data entered: - Section A1550 indicated Resident 1 did not have Developmental Delay (DD); however, the MDSC stated Resident 1 had Developmental Delay. - Section I5600 indicated Resident 1 did not have Malnutrition; however, the MDSC stated Resident 1 had a diagnosis of Severe Protein Calorie Malnutrition on admission. - Section K0300 indicated Resident 1 did not have 5% or more weight loss in the last month or 10% 5% or more weight loss in the last 6 months; however, the MDSC stated Resident 1 had significant weight loss in the past 4 months. - Section K0510 indicated Resident 1 was not on Therapeutic diet (modification of a regular diet to fit the nutrition needs of a particular person); however, the MDSC stated Resident 1 was receiving Diabetisource (tube feeding formula with pureed fruits and vegetables designed to meet the unique nutritional needs of patients with diabetes). When the MDSC was asked about the purpose of MDS 555595 Page 3 of 15 555595 07/05/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few assessment, she stated MDS gives a whole picture of Resident 1 ' s functional abilities, health condition and services provided. Review of the Facility policy and procedure titled Comprehensive Assessment and Care Delivery Process revised in December 2016 indicated, Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing, and initiating interventions, and then monitoring results and adjusting interventions. The policy indicated, The objective of the information collection (assessment) phase is to obtain, organize, and subsequently analyze information about the patient. the policy indicated, Gather relevant information from multiple sources, including: - Observation; - Physical assessment; symptom or condition related assessments; - Resident and family interview; - Hospital discharge summaries; - Consultant reports; - Lab and diagnostic test results; and - Evaluations from other disciplines (for example dietary, respiratory, social services, etc.). 555595 Page 4 of 15 555595 07/05/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and records review, the facility failed to ensure one of two sampled residents (Resident 1) with a pressure ulcer (localized damage to the skin and/or underlying soft tissue, usually over a bony area, or related to a medical or other device) received necessary interventions and services to promote healing and pain control when: Residents Affected - Few 1. The facility did not provide pain medication to Resident 1 prior to wound treatment. This failure resulted to Resident 1 to experience pain and discomfort. 2. The facility did not complete the Nutritional Comprehensive Assessment for Resident 1 upon admission. This failure had the potential for further wound deterioration and delayed wound healing. (Reference F692) 3. The facility used two incontinence briefs at a time for Resident 1. This deficient practice had the potential to compromise Resident 1 ' s skin integrity which could contribute to further wound deterioration, delayed wound healing and the development of new skin breakdown. Findings: 1. During a record review for Resident 1, the Face sheet (A one-page summary of important information about a resident) indicated Resident 1 was admitted on [DATE] with diagnoses including but not limited to Stage 4 Pressure Ulcer (Full thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bone, or supporting structure [such as tendon, or joint capsule]); Severe Protein Calorie Malnutrition (inadequate intake of food as a source of protein, calories, and other essential nutrients); Diabetes Mellitus (disease that result in too much sugar in the blood); and Functional Quadriplegia (Complete inability to move due to severe disability or frailty). During a record review for Resident 1, the Pain Care Plan initiated on 1/26/23 indicated Resident 1 was at risk for pain related to generalized body pain. Care Plan interventions indicated: Anticipate the resident's need for pain relief & respond to any complaints of pain. Provide pain interventions & follow up for effectiveness of interventions as applicable; Evaluate the effectiveness of pain interventions every shift and PRN; Review for compliance, alleviating of symptoms, dosing schedules & resident satisfaction with results, impact on functional ability and impact on cognition. During a record review for Resident 1, the Pressure Ulcer Care Plan initiated on 2/10/23 indicated Resident 1 was admitted with stage 4 pressure ulcer to bilateral buttocks and unstageable pressure ulcer (full thickness skin loss in which the base of the ulcer is covered by slough and /or eschar (dead tissue) to coccyx (tailbone). Care Plan interventions indicated: Monitor and document wound healing. Measure length, width, and depth where possible. Assess and document status of peri wound tissue, wound bed, and healing progress weekly.; Monitor and report to MD signs and symptoms of infection or worsening of skin condition; and Wound consult and treatment with follow-up as indicated. During a record review for Resident 1, the Physician ' s Order indicated an order for Tylenol (treat minor aches and pains and reduces fever) written on 3/25/23 to be given for fever and mild pain as needed. During a record review for Resident 1, the Treatment Administration Record (TAR) indicated a wound 555595 Page 5 of 15 555595 07/05/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0686 treatment order written on 4/13/23 to be given two times a day. Level of Harm - Actual harm During a record review for Resident 1, the Medication Administration Record (MAR) for April 2023 indicated an order for Tylenol written on 3/25/23 to be given for fever and mild pain as needed. The MAR from 4/01/23 to 4/19/23 did not have licensed nurses ' initials indicating Resident 1 received pain medication. Residents Affected - Few During an observation in Resident 1 ' s room on 4/20/23 at 1:01 p.m., Licensed Staff D was observed providing pressure ulcer treatment to Resident 1 with the assistance of the Assistant Director of Nursing (ADON). Caregiver A was in the room to provide assistance with turning Resident 1 to his side. The wound appeared clean, no discharge (cells, bacteria, and fluid produced by the body), with minimal slough (dead skin tissues) noted at the bottom of the wound, wound bed was pale red in color with approximately 1.5 centimeter (a unit of length) of undermined (occurs when significant erosion occurs underneath the outwardly visible wound margins resulting in more extensive damage beneath the skin surface) wound tissue. Resident 1 was observed grimacing and verbalized, hurts a couple of times while Licensed staff D cleansed the wound using kerlix gauze (a thin, translucent fabric with a loose open weave). When Caregiver A was asked what Resident 1 had said, he stated, he said it hurts. Licensed staff D acknowledged Resident 1 was in pain and asked Resident 1 to bear with her as she continued cleaning the wound. When Licensed staff D was asked if Resident 1 was medicated for pain prior to wound treatment. Licensed staff D stated Licensed Staff E gave Resident 1 his pain medication in the morning of 4/20/23. During an interview with Licensed Staff E on 4/20/23 at 3:28 p.m., when Licensed Staff E was asked about the time Resident 1 received his pain medication on 4/20/23, Licensed Staff E stated she did not give Resident 1 any pain medication. Licensed Staff E stated Resident 1 could experience pain during wound treatment and should have pain medication prior to wound treatment; however, she stated Resident 1did not show any signs of pain/ discomfort. When Licensed Staff E was asked how she would assess for non-verbal signs of pain, she stated, facial grimacing, moves hand a lot, tried to roll back. Review of the Facility policy and procedure titled Pressure Ulcer Treatment revised in December 2007 under Interventions/Care Strategies indicated, Pressure ulcer treatment requires a comprehensive approach, including: Debridement, Managing infections, Managing systemic issues (edema, venous insufficiency, etc.), Maximizing the potential for healing, and Pain control. Steps in the procedure include but not limited to Assess the resident's level of pain and provide analgesics, as ordered, before wound care. Review of the Facility policy and procedure titled Pain Assessment and Management effective date June 2016 indicated, The purposes of this procedure are to help the staff identify pain in the resident. and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. Procedure indicated, Pain management is defined as the process of alleviating the resident's pain to a level that is acceptable to the resident and is based on his or her clinical condition and established treatment goals. The policy indicated, Review the resident's clinical record to identify conditions or situations that may predispose the resident to pain including but not limited to Pressure, venous (relating to a vein) or arterial ulcers (also known as ischemic ulcer – reduced blood flow to an area of the body). 2. During a record review for Resident 1, the Care plan initiated on 2/09/23 indicated [Resident 1] required enteral feeding (also known as tube feeding - a way of delivering nutrition directly to 555595 Page 6 of 15 555595 07/05/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0686 Level of Harm - Actual harm Residents Affected - Few your stomach or small intestine [part of the digestive system]). Care Plan intervention includes but not limited to: Registered Dietician (RD) to evaluate quarterly and as needed; Monitor caloric intake, estimate needs. Make recommendations for changes to enteral feeding as needed. During a record review for Resident 1, the document titled Nutrition Comprehensive Assessment dated 2/09/23 under Primary Nutrition Diagnosis indicated, On PEG tube feeding (Percutaneous Endoscopic Gastrostomy - allows nutrition, fluids, and medications to be delivered directly into the stomach, eliminating the need to swallow by bypassing the mouth and esophagus) since 1/13/23 - not at calculated goal rate. During an interview and concurrent record review with the RD on 5/18/23 at 11:10 a.m. about the facility policy on resident ' s nutritional assessment, the RD stated newly admitted residents would be assessed within 7 days from admission. When the RD was asked about the process of determining resident ' s nutritional needs, she stated, it would be based either on resident ' s ideal body weight or actual body weight. Review of the document titled Nutrition Comprehensive Assessment dated 2/09/23 with the RD indicated Resident 1 ' s admission weight was 108 lbs. The RD stated the nutrition comprehensive assessment for Resident 1 was completed two weeks late. During a review of the document titled After Visit Summary dated 1/26/23 with the RD on 5/18/23 at 11:17 a.m., the document indicated Resident 1 ' s weight was 128.4 lbs. The RD verified Resident 1 had 20 lbs. (16%) weight loss from 1/26/23 to 2/01/23. Review of the Facility policy and procedure titled Pressure Ulcer Treatment revised in December 2007 under Interventions and Preventive Measures indicated, Dietitian will assess nutrition and hydration and make recommendations based on the individual resident's assessment. Review of the Facility policy and procedure titled Weight Management revised on 6/16/16 indicated, The facility strives to maintain acceptable parameters of nutritional status unless the resident's clinical condition demonstrates that this is not possible; and to provide a therapeutic diet for residents with nutritional problems. 3. During a record review for Resident 1, the Face sheet indicated Resident 1 had a diagnoses including but not limited to Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities); Functional Quadriplegia (Complete inability to move due to severe disability or frailty); and Gastrostomy Status. During a record review for Resident 1, the Minimum Data Set (MDS -health status screening and assessment tool used for all residents) dated 7/6/22 indicated Resident 1 had a BIMS score of 00 out of 15 points (Brief Interview for Mental Status - a 15-point cognitive screening measure that evaluates memory and orientation. A score of 13 to 15 is cognitively intact, 08 to 12 is moderately impaired, and 00 to 07 is severe impairment). The MDS indicated Resident 1 was always incontinent of bowel and bladder function (no control of the flow of urine and the release of stool). The MDS indicated Resident 1 required extensive (resident involved in activity; staff provide weightbearing support) one-person physical assistance with toilet use. During a wound treatment observation in Resident 1 ' s room on 4/20/23 at 1:01 p.m., Licensed Staff D was observed providing pressure ulcer treatment to Resident 1 with the assistance of the 555595 Page 7 of 15 555595 07/05/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0686 Level of Harm - Actual harm Residents Affected - Few Assistant Director of Nursing (ADON). Caregiver A was in the room to provide assistance with turning Resident 1 to his side. Resident 1 was observed wearing two incontinence briefs. Blue brief was under the yellow brief. When the ADON was asked if there was a reason for Resident 1 to have two incontinence brief on at a time, she stated she did not know he was wearing two briefs. The ADON stated Family Member B was very involve with Resident 1 ' s care and probably instructed the CNAs (Certified Nursing Assistants) to put two diapers on at a time. During an Interview with Caregiver A on 4/20/23 at 1:17 p.m., when Caregiver A was asked about reason for Resident 1 to have two incontinence brief on at a time, Caregiver A stated, [Resident 1 had frequent urination and bowel movement due to the tube feeding. However, he stated he would check Resident 1 for wetness every one-hour to one and a half hour. During a review of the Incontinence Care Plan initiated on 1/26/23 indicated, [Resident 1] was incontinent with bladder and bowel. Care Plan goal indicated, Will remain free from skin breakdown due to incontinence and brief use. Care Plan interventions indicated, Provide incontinence care after episodes and apply skin protectant cream.; and report any signs and symptoms of breakdown to the license nurse. Review of the Facility policy and procedure titled Activities of Daily living (ADL) effective date 7/01/20 indicated, Resident who are unable to carry out activities of daily living will receive the services necessary to maintain good nutrition, grooming and personal hygiene. 555595 Page 8 of 15 555595 07/05/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and records review, the facility failed to ensure one of two sampled residents (Resident 1) received appropriate treatment and services to maintain joint mobility and prevent further decrease in Range of Motion (ROM - the capacity for movement at a given joint in a specific direction). This failure had the potential risk for Resident 1 to develop joint contractures (condition of shortening and hardening of muscles, tendons, or other tissue which prevent full extension of a joint) to both upper and lower extremities. Findings: During a telephone interview with Family Member B on 4/19/23 at 3:07 p.m., Family Member B stated the rehabilitation therapist (a movement expert who helps patients rebuild their strength, flexibility, and range of motion) had told him that they would enroll Resident 1 to the facilities Restorative Nursing Assistant (RNA) program (a type of nursing care that aims to maintain or improve the functional ability and independence of residents) after he was discharged from Physical Therapy. Family Member B stated Resident 1 had been discharged from physical therapy since March 2023 and has not been on RNA program. Family Member B stated he was told the facility did not have an RNA to do the exercises. During a record review for Resident 1, the Face sheet (A one-page summary of important information about a resident) indicated Resident 1 was admitted on [DATE] with diagnoses including but not limited to Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities); and Functional Quadriplegia (Complete inability to move due to severe disability or frailty). During a record review for Resident 1, the document titled PT (Physical Therapy) Evaluation and Plan of treatment with start of care date of 2/14/23 indicated, [Resident 1] requires skilled PT services to increase LE (lower extremity) ROM and strength, enhance rehab potential, facilitate independence with all functional mobility. The document indicated, Risk Factors: Due to the documented physical impairments and associated functional deficits, the patient is at risk for: contracture(s), decreased skin integrity, decrease in level of mobility and further decline in function. During an observation in Resident 1 ' s room and concurrent interview with Caregiver A on 4/20/23 at 11:00 a.m. Resident 1 was on his bed, lying on his right side with his left knee flexed. Caregiver A was at bedside. When Caregiver A was asked if Resident 1 could stretch his knees, Caregiver A stated, he could but I had to help him stretch his legs to prevent contractures. Care giver stated he was not a Certified Nursing Assistant (CNA). Caregiver A stated Family Member B hired him to advocate for Resident 1 and provide assistance. During an interview and concurrent record review with the Director of Rehabilitation (DOR) on 5/18/23 at 12:52 p.m. when asked if RNA program was considered for Resident 1 to maintain his joint mobility, the DOR stated RNA was not considered due to Resident 1 could not follow instructions; however, when DOR was asked if RNA could not provide passive range of motion (PROM- someone physically moves or stretches a part of your body for you) for Resident 1, she stated, RNA could do PROM; however, we did not have an RNA and the CNAs did not have time to provide PROM to [Resident 1]. 555595 Page 9 of 15 555595 07/05/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0688 Level of Harm - Minimal harm or potential for actual harm Review of the Facility policy and procedure titled Restorative Nursing Services effective date 7/01/20 indicated, It is the policy to assist each and every resident to achieve the highest level of self-care possible. The concept of self-care is an integral part of the daily nursing care and includes at least the following: Proper positioning and body alignment; Active and passive range of motion exercises; Policy Interpretation & Implementation indicated: Residents Affected - Some - Restorative nursing care consists of nursing interventions that may or may not be accompanied by formalized rehabilitative services (e.g., physical, occupational or speech therapies). - Residents may be started on a restorative nursing program upon admission, during the course of stay or when discharged from rehabilitative care. 555595 Page 10 of 15 555595 07/05/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and records review, the facility failed to ensure that nutritional care and services were provided to one of two sampled Residents (Resident 1) when: Residents Affected - Few a. The facility did not obtain Resident 1 ' s weight on admission and did not monitor Resident 1 ' s weekly weights. b. The facility did not complete the Nutritional Comprehensive Assessment for Resident upon admission. This failure resulted to a twenty (20) lbs. (pounds – any of various units of mass and weight) which yielded to 16 percent (%) weight loss for a period of seven days. Findings: a. During a record review for Resident 1, the Face sheet (A one-page summary of important information about a resident) indicated Resident 1 was admitted on [DATE] with diagnoses including but not limited to Severe Protein Calorie Malnutrition (inadequate intake of food) as a source of protein, calories, and other essential nutrients); Diabetes Mellitus (disease that result in too much sugar in the blood); Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities); Functional Quadriplegia (Complete inability to move due to severe disability or frailty); and Gastrostomy Status (a surgical opening into the stomach). During a review of the document titled After Summary Visit dated 1/26/23 indicated Resident 1 ' s weight was 128.4 lbs. Review of the Physician ' s Order written on 1/26/23 indicated, admission Weight. one time only for weight monitoring for 1 Day. During a telephone interview with Family Member B on 4/19/23 at 3:07 p.m., Family Member B stated Resident 1 was on tube feeding and was supposed to be weighed every Thursday; however, it was not done. Family Member B stated the facility staff had told him that Resident 1 ' s weight on admission was 108 lbs. During an interview and concurrent record review with the Director of Nursing (DON) on 4/20/23 at 3:00 p.m. The DON stated Resident 1 was readmitted to the facility from the hospital on 1/26/23. Review of the facility policy and procedure titled Weight Management effective date June 16, 2016, with the DON indicated, Weight will be obtained upon admission. After review of the document titled Weights and Vitals Summary for Resident 1, The DON stated Resident 1 weighed 108 lbs. on 2/01/23; however, there was no record of Resident 1 ' s admission weight. The DON stated the facility did not implement their policy to obtain Resident 1 ' s weight on admission. During a record review and concurrent interview with the Registered Dietician (RD) on 4/20/23 at 3:25 p.m., the document titled Weights and Vitals Summary indicated Resident 1 ' s weight on 12/02/22 was 133.2 lbs. and on 2/01/23, Resident 1 weighed 108 lbs. The RD stated Resident 1 had a significant weight loss and could have happened during Resident ' s acute hospitalization; however, RD could not verify Resident ' s admission weight on 1/26/23. 555595 Page 11 of 15 555595 07/05/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0692 Level of Harm - Actual harm Residents Affected - Few During a record review and concurrent interview with the DON on 4/20/23 at 3:42 p.m. the physician ' s order for Resident 1 written on 3/17/23 indicated, Monitor weekly weights times 6 weeks then reevaluate. The DON stated the facility did not Resident 1 until 4/07/23. During an interview with the RD on 5/18/23 at 11:17 a.m., when asked about the facility policy on resident ' s weight monitoring. The RD stated, policy for new admit residents was to obtain resident ' s weight on admission then weekly times 4 weeks, then monthly unless otherwise indicated. a. During a record review for Resident 1, the document titled Nutrition Comprehensive Assessment dated 2/09/23 under Primary Nutrition Diagnosis indicated, On PEG tube (Percutaneous Endoscopic Gastrostomy - allows nutrition, fluids, and medications to be delivered directly into the stomach, eliminating the need to swallow by bypassing the mouth and esophagus) feeding since 1/13/23 not at calculated goal rate. The document indicated under Nutritional Intervention, Weigh Weekly. During an interview and concurrent record review with the RD on 5/18/23 at 11:10 a.m. about the facility policy on resident ' s nutritional assessment, the RD stated newly admitted residents would be assessed within 7 days from admission. When the RD was asked about the process of determining resident ' s nutritional needs, she stated, it would be based either on resident ' s ideal body weight or actual body weight. Review of the document titled Nutrition Comprehensive Assessment dated 2/09/23 with the RD indicated Resident 1 ' s admission weight was 108 lbs. The RD stated the nutrition comprehensive assessment for Resident 1 was completed two weeks late. During a review of the document titled After Visit Summary dated 1/26/23 with the RD on 5/18/23 at 11:17 a.m., the document indicated Resident 1 ' s weight was 128.4 lbs. The RD verified Resident 1 had 20 lbs. (16%) weight loss from 1/26/23 to 2/01/23. Review of the Facility policy and procedure titled Weight Assessment and Intervention revised on 7/01/22 indicated, The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Policy Interpretation & Implementation includes but not limited to: 1. The nursing staff will measure resident weights on admission, then weekly times 4 weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter or as determined by MD. 2. Weights will be recorded in resident's medical record. 3. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will notify the Dietitian. 4. The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = (usual weight- actual weight) / (usual weight) x 700]: a. 1 month - 5% weight loss is significant; greater than 5% is severe. b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. 555595 Page 12 of 15 555595 07/05/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0692 c. 6 months - 10% weight loss is significant; greater than 10% is severe. Level of Harm - Actual harm Residents Affected - Few 555595 Page 13 of 15 555595 07/05/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 interview and record review, the facility failed to ensure medications were administered according to doctor ' s order for one of two sampled residents (Resident 1) when Resident 1 did not receive his ordered breathing treatment (medications enter the lungs through either an inhaler or a nebulizer [a device for producing a fine spray of liquid, used for example for inhaling a medicinal drug]) according to the scheduled treatment time. This failure had the potential risk for Resident 1 to experience discomfort from wheezing (a high pitched or coarse whistling sound that's heard in the respiratory airway when one breathes), shortness of breath, coughing, and chest tightness. Findings: During a telephone interview with Family Member B on 4/19/23 at 3:07 p.m., Family Member B stated Resident 1 was not getting his breathing treatment as scheduled. Family Member B stated the nurses told him they could give the Resident 1 ' s medication one hour before or one hour after the scheduled administration time; however, Family Member B stated Resident 1 ' s caregiver had told him that Resident 1 ' s breathing treatment was not given at times and that nurses were just signing the record that it was given. Family Member B stated he had observed Resident 1 with gurgly (bubbling sounds) breathing during one of his visits. During a record review for Resident 1, the Face sheet (A one-page summary of important information about a resident) indicated Resident 1 was admitted on [DATE] with diagnoses including but not limited to Acute Respiratory Failure (occurs when the respiratory system cannot adequately provide oxygen [air] to the body) with Hypoxia (caused by an underlying illness that affects blood flow or breathing); and Anxiety Disorder (intense, excessive, and persistent worry and fear about everyday situations). During a record review for Resident 1, the Physician ' s Order written on 1/26/23 indicated an order for a breathing treatment four times a day for cough. During a record review for Resident 1, the Medication Administration Record (MAR) indicated the breathing treatment was scheduled at 9:00 a.m.; 12:00 p.m.; 5:00 p.m. and 9:00 p.m. During a record review for Resident 1, the Medication Administration Audit Report for April 2023 indicated Resident 1 received the breathing treatment at the following dates and times: - On 4/02/23, Resident 1 received the treatment at 11:07 p.m. for the 9:00 p.m. dose. - On 4/03/23, Resident 1 received the treatment at 1:26 p.m. for the 9:00 a.m. dose. - On 4/04/23, Resident 1 received the treatment at 11:48 p.m. for the 9:00 p.m. dose. - On 4/11/23, Resident 1 received the treatment at 11:15 p.m. for the 9:00 p.m. dose. - On 4/12/23, Resident 1 received the treatment at 7:01 p.m. for the 5:00 p.m. dose. - On 4/12/23, Resident 1 received the treatment at 11:09 p.m. for the 9:00 p.m. dose. 555595 Page 14 of 15 555595 07/05/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0755 Level of Harm - Minimal harm or potential for actual harm During an interview with Licensed Staff C on 5/18/23 at 1:13 p.m. when asked about the timing for medication administration, Licensed Staff C stated they could administer medications to residents one hour before or one hour after the scheduled medication administration time. Licensed Staff C stated if licensed nurses missed the scheduled medication administration time for more than one hour, the expectation was to inform the resident ' s primary care physician and the Director of Nursing. Residents Affected - Some Review of the Facility policy and procedure titled Administering Medications revised on 7/01/22 indicated, It is the policy of this facility that medications shall be administered in a safe and timely manner as prescribed by the healthcare provider. Policy Interpretation & Implementation includes but not limited to: Medications must be administered in accordance with the orders, including any required time frame; and Medications must be administered within one (1) hour before and/or after their prescribed time, unless otherwise specified. 555595 Page 15 of 15