Health inspection·August 22, 2023

F 0577 Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to place the results of State surveys (inspections) where they were accessible to residents, who were unable to view them without having to ask for assistance. This failure resulted in residents being unable to read the State survey reports when they did not know where the reports were kept, or could not reach or lift the binder containing the reports. Residents Affected - Some Findings: During a confidential resident council interview on 8/15/23 at 10:04 a.m., five out of five residents did not know where the results of the Department's inspections could be found for them to review. Anonymous Resident 1 stated he would be interested to read the inspection results. During an observation on 8/15/23 at 10:46 a.m., a binder containing the Department's survey results was found outside the dining room in a black, wall-mounted file holder approximately four feet from the floor. The binder contained several years of survey results and was heavy. The label on the front of the binder indicated the binder contained the Department's survey results and could not be read through the black file holder. The file holder was not labeled. During an observation and concurrent interview on 8/17/23 at 10:47 a.m., outside the dining room, Anonymous Resident 1 was queried about the binder in the black file holder. Anonymous Resident 1, who was seated in a wheelchair, stated he did not know what the binder was, but he thought the binder was a directory of some kind. Anonymous Resident 1 reached up and tried, unsuccessfully, to lift the binder out of the file holder. Anonymous Resident 1 verified he could not get the binder without asking for help. Anonymous Resident 1 verified it would be helpful if the file holder was lower on the wall. Upon learning the binder contained the survey results, Anonymous Resident 1 stated it would also be helpful if the file holder was labeled on the outside of the wall-mounted file holder with the same label that was on the binder. Anonymous Resident 1 stated he was going to go get his reading glasses and read the reports in the binder. During an interview on 8/21/23 at 1:55 p.m., outside the dining room, when asked how a passerby would know the purpose of the binder which was kept in the black file holder outside the dining room, the Social Services Assistant did not answer. When queried further, the Social Services Assistant stated, if a resident in a wheelchair wanted to read the survey binder, they could ask for help. Review of facility policy, Resident Rights, dated 7/1/20, indicated, Federal and state laws guarantee certain basic rights to residents residing in this facility. These rights include the resident's right to: . examine survey results; . Page 1 of 30 555595 555595 08/22/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0625 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Based on interviews and records review, the facility failed to ensure notices of the bed-hold policy were provided to two of three hospitalized residents (Resident 45 and Resident 42). This failure could have resulted in residents being unaware they could return to the facility after hospitalization, and if they needed to submit payment to reserve a bed. Findings: During an interview with Resident 45 on 8/15/23 at 9:24 a.m., Resident 45 stated he was transferred to the hospital twice since his admission to the facility. Resident 45 stated the facility did not discuss the facility's bed-hold policy either with him or his representative upon his transfer to the hospital. During a record review for Resident 45, the document titled, Notice of Transfer/ Discharge, dated 5/24/23 and 7/23/23, indicated Resident 45 was sent to the hospital. During a record review for Resident 42, the document titled, Notice of Transfer/ Discharge, dated 6/15/23, indicated Resident 42 was sent to the hospital. During a record review for Resident 42, the Progress Note, dated 8/4/23 at 1:12 a.m., indicated, At around 6:50 p.m. patient verbalized, 'I'm not feeling well, my heart beating fast.' The Progress Note indicated Resident 42 was transferred to the hospital for further evaluation. During an interview with the MDS (Minimum Data Set - an assessment tool completed by clinical staff to identify potential resident problems, strengths, and preferences) Coordinator (a nursing professional who helps manage a nursing team in a medical facility) on 8/18/23 at 12:17 p.m., when asked for a copy of the bed-hold notices given to Resident 45 and Resident 42 upon their hospital transfer, the MDS Coordinator stated a bed-hold notices were not given to Resident 45 and Resident 42 because both residents were receiving services under Medicare (federal health insurance for people 65 or older). During an interview with Licensed Staff J on 8/21/23 at 10:38 a.m., Licensed Staff J stated the admission nurse would discuss the bed-hold policy with the resident or his/her representative on admission. Licensed Staff J stated, when a resident was transferred to the hospital, the nurse transferring the resident to the hospital would be responsible for providing a bed-hold with either the resident or his/her representative. During an interview with Licensed Staff G on 8/21/23 at 10:43 a.m., when asked about the Facility Policy regarding bed-holds, Licensed Staff G stated nurses were responsible for obtaining bed-holds for all hospital transfers from either the resident or the responsible party. Review of the Facility policy and procedure titled, Bed-Holds and Returns, effective 7/01/20, indicated, Prior to transfers and therapeutic leaves, residents or resident representatives will be informed in writing of the bed-hold and return policy. The policy indicated, Prior to a transfer, written information will be given to the resident and/or the resident representative that explains in detail: 555595 Page 2 of 30 555595 08/22/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0625 a. The rights and limitations of the resident regarding bed-holds; Level of Harm - Minimal harm or potential for actual harm b. The reserve bed payment policy as indicated by the state plan (Medicaid residents); Residents Affected - Some c. The facility per diem rate required to hold a bed (non-Medicaid residents), or to hold a bed beyond the state bed-hold period (Medicaid residents); and d. The details of the transfer (per the Notice of Transfer; Rights to a Bed hold). 555595 Page 3 of 30 555595 08/22/2023 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 Resident 16 Residents Affected - Some During an interview on 8/15/23 at 11:49 a.m., Resident 16 stated he did not speak English and a Spanish-speaking staff member was obtained as an interpreter to conduct the interview. During a record review on 8/21/23 at 9:35 a.m., Resident 16's MDS assessments, with target dates 1/17/23 and 4/17/23, both indicated Resident 16 did not need an interpreter to communicate with a doctor or healthcare staff. During an interview on 8/21/23 at 2:53 p.m., Licensed Staff B verified she was Resident 16's nurse before he discharged home over the weekend (8/19/23). Licensed Staff B stated she needed an interpreter to speak with him. Review of the Facility policy and procedure titled, Resident Assessment Instrument (RAI), effective date 7/01/20 indicated: - The purpose of the assessment is to describe the resident's capability to perform daily life functions and to identify significant impairments in functional capacity. - Information derived from the comprehensive assessment helps the staff to plan care that allows the resident to reach his/her highest practicable level of functioning. - All persons who have completed any portion of the MDS Resident Assessment Form MUST sign such document attesting to the accuracy of such information. Based on interviews and records review, the facility failed to ensure the Minimum Data Set (MDS - health status screening and assessment tool) was accurately completed for three of 15 sampled residents (Residents 3, Resident 29 and Resident 16). This failure resulted in unidentified areas of risk for the residents in order to develop the most appropriate plan of care. Findings: Resident 3 During a record review for Resident 3, the Minimum Data Set (MDS -health status screening and assessment tool used for all residents), dated 6/15/23, indicated Resident 3 had a BIMS score of 02 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). During an interview with Unlicensed Staff B on 8/15/23 at 10:03 a.m., Unlicensed Staff B stated Resident 3 did not speak English. Unlicensed Staff B stated Resident 3 was able to communicate her needs in one-word-Spanish and answered yes or no questions through a Spanish translator. During a record review for Resident 3 and concurrent interview with the MDS Coordinator (MDSC - a nursing professional who helps manage a nursing team in a medical facility) on 8/18/23 at 11:54 a.m., the MDS assessment, dated 6/15/23, indicated Resident 3's race/ethnicity was White. The MDS 555595 Page 4 of 30 555595 08/22/2023 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 indicated Resident 3 did not need an interpreter to communicate with a doctor or healthcare staff. The MDS Coordinator stated Resident 3 was Hispanic. When the MDS Coordinator was asked if Resident 3 spoke English, she stated, very little. The MDS Coordinator stated Resident 3 could use simple words and answer yes or no questions. Residents Affected - Some Resident 29 During a record review for Resident 29, the document titled, Weekly Skin Alteration Report, dated 7/14/23 at 9:06 a.m., indicated, Resident 29 had a right buttock skin loss (unintended damage to and loss of the upper layer of the skin)/blister (a small, fluid-filled bubble on the skin and caused by friction, burning, or other damage) measuring 4.5 cm (centimeter - a metric unit of length) x (by) 4.0 cm x UTD (unstageable full thickness tissue loss in which actual depth of the ulcer is completely obscured by slough [thick, stringy, yellow dead tissue] and/or eschar [dark, crusty dead tissue] in the wound bed). The document indicated the wound had 75 percent eschar. During a record review for Resident 29 and concurrent interview with the MDS Coordinator on 8/22/23 at 10:06 a.m., the MDS assessment, dated 7/26/23, indicated Resident 29 had no pressure ulcer (also known as bedsore - damage to an area of the skin caused by constant pressure on the area for a long time) or any other skin problems during the observation period. The MDS Coordinator stated Resident 29 had a ruptured blister to his right buttock during the observation period; however, she stated the wound was not classified as a pressure ulcer. The MDS Coordinator verified the MDS did not show Resident 29 had a skin problem. When the MDS Coordinator was asked about her process of collecting MDS data for the resident's MDS assessments, she stated she would review the physician and nurse's notes, skin evaluations from nurses, skin progress notes, family interviews, and a visual check for any existing wound. 555595 Page 5 of 30 555595 08/22/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident 16 During an interview on 8/15/23 at 11:49 a.m., Resident 16 stated he did not speak English, and a Spanish-speaking staff member was obtained as an interpreter to conduct the interview. During a record review on 8/21/23 at 9:35 a.m., Resident 16's face sheet indicated his primary language was English. The MDS assessments, with target dates 1/17/23 and 4/17/23, both indicated Resident 16 did not need an interpreter to communicate with a doctor or healthcare staff. Resident 16's care plan included a focus area, dated 8/14/23, which indicated, Residents have a communication problem [related to] language barrier Spanish is primary language [sic]. Interventions included, Provide translator as necessary to communicate with the resident, and Resident prefers to communicate in Spanish. During a record review and concurrent interview on 8/21/23 at 2:53 p.m., Licensed Staff G verified she was Resident 16's nurse before he discharged home over the weekend (8/19/23). Licensed Staff G stated she needed an interpreter to speak with him. Licensed Staff G reviewed Resident 16's care plan and verified his Spanish-speaking care plan was dated 8/14/23. Licensed Staff G then verified his admit date was 1/12/23, and stated his need for an interpreter should have been care planned on admission. Resident 159 During an observation on 8/15/23 at 2:52 p.m., Resident 159 was lying in her bed with a nasal cannula administering oxygen from an oxygen compressor/concentrator (Oxygen concentrators filter surrounding air, compressing it to the required density and then deliver purified medical grade oxygen to the patient). Review of Resident 159's medical record revealed an admission date of 8/3/23, with multiple medical diagnoses including acute respiratory failure with hypoxia (low oxygen levels) and pneumonia (infection in the lungs). Resident 159's care plan did not include oxygen use. Resident 159's nursing skilled charting note, dated 8/16/23, revealed, Patient was on continuous oxygen but now has gone PRN (changed oxygen use to as needed) per MD orders. During a record review and concurrent interview on 8/21/23 at 2:51 p.m., Licensed Staff G reviewed Resident 159's care plan and confirmed Resident 159 did not have a care plan for using oxygen. Licensed Staff G verified Resident 159 used oxygen as needed, and stated she should have a care plan for using oxygen. When queried, Licensed Staff G stated the care plan helped with implementing care to the patient. Based on observation, interviews, and records review, the facility failed to develop and implement person-centered care plans for 3 of 15 sampled residents (Resident 3; 16; and 159). This failure had the potential for facility staff to provide inadequate care to vulnerable residents when their individual needs and interests were not addressed appropriately. Findings: 555595 Page 6 of 30 555595 08/22/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0656 Resident 3 Level of Harm - Minimal harm or potential for actual harm During an interview with Unlicensed Staff B on 8/15/23 at 10:03 a.m., Unlicensed Staff B stated Resident 3 did not speak English. Unlicensed Staff B stated Resident 3 was able to communicate her needs in a one-word Spanish sentence and answers yes or no questions through a Spanish translator. Residents Affected - Some During a record review for Resident 3 and concurrent interview with the MDS (Minimum Data Set - an assessment tool completed by clinical staff to identify potential resident problems, strengths, and preferences) Coordinator (MDSC - a nursing professional who helps manage a nursing team in a medical facility) on 8/18/23 at 11:54 a.m., the MDS assessment, dated 9/14/22, indicated Resident 3 did not need an interpreter to communicate with a doctor or healthcare staff. The MDS Coordinator verified communication was not a triggered area (MDS item responses that indicate the need for additional assessment based on problem identification which form a critical link between the MDS and decisions about care planning) of the MDS. The MDS Coordinator stated communication was not triggered, therefore a care plan for communication was not developed. The MDSC stated a resident's care plan was updated every three months following the completion of the scheduled MDS assessment; however, after review of Resident 3's care plan, the MDS Coordinator verified the communication care plan for Resident 3 was initiated on 8/15/23. 555595 Page 7 of 30 555595 08/22/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and records review, the facility failed to meet professional standards for pain medication administration for one of 15 sampled residents (Resident 29). This failure had the potential to compromise the resident's health and well-being for not getting the required dose of medication according to the doctor's order. Residents Affected - Few Findings: During a record review for Resident 29, the Face sheet indicated Resident 29 was admitted on [DATE], with diagnoses including but not limited to Cutaneous T-cell lymphoma (CTCL- is a rare type of cancer that begins in white blood cells [responsible for protecting your body from infection]); Malignant Neoplasm of Prostate (when cells in the prostate gland [found only in males; the hollow organ where urine is stored] start to grow out of control); and Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a record review for Resident 29, the document titled Weekly Pressure Ulcer Report, dated 8/14/23 at 9:12 p.m., indicated Resident 29 had a Stage IV (Full thickness skin loss with extensive destruction; tissue necrosis (tissue death); or damage to muscle, bone, or supporting structure [such as tendon, or joint capsule]) pressure ulcer to his right buttock. During a wound treatment observation in Resident 29's room on 8/16/23 at 12:52 p.m., Resident 29 had an open wound to his right buttock. When the Treatment Nurse asked Resident 29 if he had pain, Resident 29 stated he had back pain. Resident 29 had tensed muscle (muscles become tight and stiff, often because you are anxious or frightened) while holding onto the bed rail, jolted (move with sudden lurches [an abrupt uncontrolled movement]), and heard saying, Ouch when the Treatment Nurse removed the gauze pack from Resident 29's wound. The Treatment Nurse immediately stopped the procedure and stated she would get an order from the doctor for pain medication. During an interview with Licensed Staff F on 8/16/23 at 1:02 p.m., when Licensed Staff F was asked if she administered pain medication to Resident 29 prior to his wound treatment, Licensed Staff F stated she gave Resident 29 his scheduled 0.25 ml (milliliter -a unit of volume) of oral morphine (a narcotic drug used for pain relief and sometimes used to ease breathing problems) at around 11:45 a.m. During a record review for Resident 29, the Medication Administration Record (MAR) for August 2023, indicated a doctor's order written on 6/09/23, for Tylenol tablet (drug used to relieve pain) to be given every four hours as needed for mild pain. During an interview with the Director of Nursing (DON) on 8/21/23 at 3:03 p.m., when asked about her expectations from nurses when giving pain medications to residents, the DON stated she expected the nurses to assess the resident for level of pain every shift and to administer pain medication according to the doctor's order. During a record review for Resident 29 and concurrent interview with the MDS Coordinator (MDSC - a nursing professional who helps manage a nursing team in a medical facility) on 8/22/23 at 10:18 a.m., the MDSC verified the Medication Administration Record (MAR) indicated a doctor's order, written on 7/17/23, for Morphine Sulfate 0.25 ml to be given every six hours for respiratory (breathing) 555595 Page 8 of 30 555595 08/22/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0658 distress. The MDSC concurred the order was not ordered for pain management. Level of Harm - Minimal harm or potential for actual harm The MDSC then verified there was a doctor's order written on 8/16/23, for Morphine Sulfate Oral (by mouth) Solution to give 0.25 ml for mild pain; 0.5 ml for moderate pain and 1 ml severe pain every 4 hours as needed. After review of the MAR, the MDSC verified Resident 28 received 1 ml of Morphine Sulfate for a pain level of 4 (A numerical scale from 0 to 10 based on self-reported data when 0 means no pain; 1-3 means mild pain; 4-6 is considered moderate pain and 7-10 is severe pain) on 8/16/23, and 0.5 ml for a pain level of 8 on 8/21/23. When the MDSC was asked about the risk of giving Resident 29 0.5. ml of Morphine Sulfate when his pain level was 8, the MDSC stated Resident 29 received an insufficient dose of Morphine and had the potential for uncontrolled pain. The MDSC stated Resident 29's nurse should have administer the pain medication according to the doctor's order. Residents Affected - Few Review of the facility policy and procedure titled, Administering Medications effective date 7/01/20, indicated, Medications must be administered in accordance with the orders, including any required time frame. Review of the Facility policy and procedure titled, Pain Assessment and Management, revised on 7/01/22 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. 555595 Page 9 of 30 555595 08/22/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm Based on interviews and records review, the facility failed to ensure one of 15 sampled residents (Resident 3) was provided with a communication tool or resources to effectively communicate her needs. This failure had the potential for Resident 3 not to understand and carry out activities of daily living (ADL) which could lead to a decline in Resident 3's quality of life. (Reference F679) Residents Affected - Few Findings: During a record review for Resident 3, the Minimum Data Set (MDS -health status screening and assessment tool used for all residents), dated 6/15/23, indicated Resident 3 had a BIMS score of 02 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). During an interview with Unlicensed Staff B on 8/15/23 at 10:03 a.m., Unlicensed Staff B stated Resident 3 did not speak English. Unlicensed Staff B stated Resident 3 was able to communicate her needs in one-word Spanish sentence and answered yes or no questions through a Spanish translator. During an interview with Witness I on 8/15/23 10:48 a.m., Witness I stated she was in the facility every day to visit Resident 3. Witness I stated Resident 3 was always in bed and had not seen any activities provided to Resident 3. Witness I stated Resident 3 did not speak English and had very limited ability to communicate her needs. During an interview with the Activities Director on 8/17/23 at 12 p.m., when asked what activities were provided to Resident 3, the Activities Director stated he was providing one-on-one room visits to Resident 3. When the Activities Director was asked if he spoke Spanish, he stated No. The Activities Director stated he would say, Hello to Resident 3 and ask Resident 3 how she felt in English; however, the Activities Director stated Resident 3 would not respond. During a record review for Resident 3 and concurrent interview with the MDS Coordinator (MDSC - a nursing professional who helps manage a nursing team in a medical facility) on 8/18/23 at 11:54 a.m., the MDS assessment, dated 9/14/22, indicated Resident 3 did not need an interpreter to communicate with a doctor or healthcare staff. The MDS Coordinator stated Resident 3 was Hispanic. When the MDS Coordinator was asked if Resident 3 spoke English, she stated, very little. The MDS Coordinator verified communication was not a triggered area (MDS item responses that indicate the need for additional assessment based on problem identification which form a critical link between the MDS and decisions about care planning) of the MDS. The MDS Coordinator stated communication was not triggered, therefore a care plan for communication was not developed. The MDSC stated a resident's care plan was updated every three months following the completion of the scheduled MDS assessment; however, after review of Resident 3's care plan, the MDS Coordinator verified the communication care plan for Resident 3 was initiated on 8/15/23. Review of the facility policy and procedure titled, Translation and/or Interpretation of Facility Services, revised in November 2020, indicated, This facility's language access program will ensure that individuals with limited English proficiency (LEP) shall have meaningful access to information and services provided by the facility. The policy indicated, Competent oral translation of vital 555595 Page 10 of 30 555595 08/22/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0676 information that is not available in written translation, and non-vital information shall be provided in a timely manner and at no cost to the resident through the following means (as available to the facility): Level of Harm - Minimal harm or potential for actual harm - A staff member who is trained and competent in the skill of interpreting; Residents Affected - Few - A staff interpreter who is trained and competent in the skill of interpreting; - Contracted interpreter service; - Voluntary community interpreters who are trained and competent in the skill of interpreting; and - Telephone interpretation service. 555595 Page 11 of 30 555595 08/22/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on interviews, and records review, the facility failed to ensure showers for one of three sampled residents (Resident 29) was given during his scheduled shower days. This failure to maintain Resident 29's personal grooming and hygiene needs had the potential to raise the risk of unidentified skin issues, bacterial or fungal infections. Residents Affected - Some Findings: During a record review for Resident 29, the Minimum Data Set (MDS - an assessment tool completed by clinical staff to identify potential resident problems, strengths, and preferences), dated 4/25/23, indicated Resident 29 had a BIMS score of 07 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 it was somewhat important for Resident 29 to choose between a tub bath, shower, bed bath or sponge bath. The MDS indicated Resident 27 required total assistance from facility staff with bathing needs. Review of the document titled, Shower Schedules PM, indicated Resident 29 was scheduled for showers every Wednesday and Saturday in the evening. During a record review for Resident 29, the document titled, Documentation Survey Report, from 7/1/23 to 7/31/23, indicated Resident 29 did not receive shower for the month of July. The document indicated Resident 29 received a bed bath on 7/4/23 and 7/15/23. During a record review for Resident 29, the document titled, Documentation Survey Report, from 8/01/23 to 8/16/23, indicated Resident 29 did not receive shower. The document indicated Resident 29 received a bed bath on 8/2/23, 8/7/23, 8/8/23, 8/10/23, 8/14/23 and 8/16/23. During an interview with Resident 29 on 8/14/23 at 12:09 p.m., Resident 23 was asked how often he got his shower in a week, Resident 23 stated he remembered having a shower once and would love to have another shower if he could. During an interview with Unlicensed Staff K on 8/17/23 at 10:17 a.m., when asked how often did the residents get their shower in a week, Unlicensed Staff K stated, I believe twice a week. Unlicensed Staff K stated she would give showers to the residents whenever they asked for a shower. When Unlicensed Staff K was asked about the risk for residents who did not get showers, Unlicensed Staff K stated, it could be an infection control issue. Unlicensed Staff K stated it was during showers when the CNAs (Certified Nursing Assistants) checked the resident's skin from head-to-toe to identify any skin problems. During a record review and concurrent interview with the Director of Staff Development (DSD) on 8/21/23 at 1:39 p.m., after review of the document titled, Documentation Survey Report, for July 2023 and August 2023, the DSD verified Resident 29 received two bed baths and no showers for the month of July. The DSD verified Resident 29 received six bed baths and no shower from 8/01/23 to 8/16/23. The document indicated Resident 29 received partial baths in between bed baths. When the DSD was asked about the difference between bed bath and partial bath, she stated partial bath only involved washing of resident's face, his arms, and his peri area. The DSD stated bed bath involved washing the resident from head-to-toe including washing of hair and back. When the DSD was asked about the reason 555595 Page 12 of 30 555595 08/22/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some for Resident 29 not getting his shower, the DSD stated she thought Family Member C did not want Resident 29 to get up. When the DSD was asked if there was a documentation in Resident 29's record stating Family member C did not want Resident 29 getting up or not getting showered, she stated she would look into it. During an interview with Care Giver L on 8/21/23 at 1:45 p.m., when asked about Resident 29's shower schedule, Care Giver L stated Resident 29 was scheduled for showers in the evening, however, he stated he had not observed any of the facility staff provide a shower to Resident 29. Care Giver L stated Resident 29 would occasionally ask for shower in the afternoon, however, the CNA would always told him his schedule for showers was in the morning. During a review of the Doctor's Order for Resident 29, dated 7/17/23, with the DSD, the Doctor's order indicated, Do not ambulate or out of chair. When the DSD was asked if the order indicated Resident 29 could not have shower, she stated, No. Review of the facility policy and procedure titled, Bath, Shower/Tub effective 7/1/20, indicated, It is the policy of this facility to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. 555595 Page 13 of 30 555595 08/22/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

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 observations, interviews, and records review, the facility failed to provide meaningful activities for two of 15 sampled residents (Residents 3 and 29). This failure resulted in residents not receiving activities according to their preferences and needs, which could potentially impact their physical, mental, and psychosocial well-being. Residents Affected - Some Findings: Resident 3 During a record review for Resident 3, the Face sheet (A one-page summary of important information about a resident) indicated Resident 3 was admitted on [DATE], with diagnoses including but not limited to Major Depressive Disorder (a mental disorder characterized by a persistently depressed mood and long-term loss of pleasure or interest in life) and Anxiety Disorder (intense, excessive, and persistent worry and fear about everyday situations). During a record review for Resident 3, the Minimum Data Set (MDS -health status screening and assessment tool used for all residents), dated 9/14/22, indicated it was somewhat important for Resident 3 to have books, newspapers, and magazines to read; listen to music; be around animals such as pets; keep up with the news; do things with groups of people; go outside to get fresh air when the weather is good; and participate in religious services or practices. The MDS indicated Resident 3 was receiving Hospice Care (type of health care that focuses on the palliation of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life). During a review of the Care Plan, initiated on 2/17/23, for Resident 3, the Care Plan indicated Resident 3 was on a comfort care. The Care Plan intervention indicated: [Resident 3] will continue to receive daily visitation with family/friends; Will honor/respect resident rights; and Will provide room visitation 1 to 3 times a week, to ensure daily needs are met. During an observation on 8/15/23 at 9:34 a.m., Resident 3 was in her room, on her bed lying on her back with her eyes closed. During an interview with Unlicensed Staff B on 8/15/23 at 10:03 a.m., Unlicensed Staff B stated Resident 3 did not speak English. Unlicensed Staff B stated Resident 3 was able to communicate her needs in Spanish in simple words and answered yes or no questions through a Spanish translator. During an interview with Witness I on 8/15/23 10:48 a.m., Witness I stated she was in the facility every day to visit Resident 3. Witness I stated Resident 3 was always in bed and had not seen any activities provided to Resident 3. Witness I stated Resident 3 did not speak English and had very limited ability to communicate her needs. During an observation on 8/16/23 at 3:04 p.m., Resident 3 was in her room, on her bed lying on her back. Resident 3 was awake; her television was off. The privacy curtain was pulled over blocking Resident 3's view of the activity outside of her room. During an observation on 8/17/23 at 10:15 a.m., Resident 3 was in her room, on her bed lying on her back, awake. The television in front of Resident 3 was turned on to an English program. 555595 Page 14 of 30 555595 08/22/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0679 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview with Unlicensed Staff K on 8/17/23 at 10:17 a.m., when asked who provided activities to residents in their rooms, Unlicensed Staff K stated either the RNA or the therapist provided activity to the resident. Unlicensed Staff K stated she would coordinate with activity personnel should the resident need to get out of bed for an activity. During an interview with the Activities Director on 8/17/23 at 12 p.m., when asked what activities were provided to Resident 3, the Activities Director stated he was providing one-on-one room visits to Resident 3. When the Activities Director was asked if Resident 3 spoke English, the Activities Director stated, No, she speaks Spanish. When the Activities Director was asked if he spoke Spanish, he stated, No. The Activities Director stated he would say, Hello to Resident 3 and ask Resident 3 how she felt, in English, during his visit; however, the Activities Director stated Resident 3 would not respond. The Activities Director stated no other activities were provided for Resident 3; however, he stated he was planning to contact an outside organization to provide support for Spanish speaking residents. When the Activities Director was asked if Resident 3's psychosocial needs (any combination of mental health, emotional, spiritual, or behavioral needs, concerns or aspects of the resident's life which are identified as important to the resident) were met, the Activities Director stated, No. During an observation on 8/18/23 at 11:24 a.m., Resident 3 was in her room, on her bed, lying on her back staring at the wall. Resident 3's television was off. Resident 29 During a record review for Resident 29, the Face sheet indicated Resident 29 was admitted on [DATE], with diagnoses including but not limited to Cutaneous T-cell lymphoma (CTCL- is a rare type of cancer that begins in white blood cells [responsible for protecting your body from infection]); Malignant Neoplasm of Prostate (when cells in the prostate gland [found only in males; the hollow organ where urine is stored] start to grow out of control); and Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities). During a record review for Resident 29, the MDS, dated [DATE], indicated Resident 29 had a BIMS score of 07 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 it was very important for Resident 29 to have books, newspapers, and magazines to read; keep up with the news; and do his favorite activities. The MDS indicated it was somewhat important for Resident 29 to listen to music; be around animals such as pets; do things with groups of people; and go outside to get fresh air when the weather was good. The MDS indicated Resident 29 was receiving Hospice Care. During an observation on 8/15/23 at 9:32 a.m., Resident 29 was in his room, lying on his bed, asleep. Resident 29 was turned on his left side facing the window with a pillow on his back. During an observation on 8/15/23 at 12:06 p.m., Resident 29 was in his room, lying on his bed facing the window with a pillow on his back. Resident 29 was heard saying, Hello. During an observation on 8/15/23 at 12:21 p.m., Resident 29 was in his room, lying on his bed facing the window with a pillow on his back. Resident 29 was again heard saying, Hello. During an observation on 8/16/23 at 11:36 a.m., Resident 29 was in his room on his bed with his 555595 Page 15 of 30 555595 08/22/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0679 eyes closed. Resident 29 was lying on his back with the head of bed slightly elevated. Level of Harm - Minimal harm or potential for actual harm During an observation on 8/16/23 at 2:45 p.m., Resident 29 was in his room lying on his bed awake. The head of bed was elevated at approximately 45 degrees. Residents Affected - Some During an observation on 8/17/23 at 10:45 a.m., Resident 29 was in his room on his bed, asleep. Resident 29 was lying on his back with the head of bed elevated at approximately 30 degrees. During an interview with the Activities Director on 8/17/23 at 12:03 p.m., when asked what activities were provided to Resident 29, the Activities Director stated Resident 29 used to participate with movies, and music.; however, he stated Resident 29 had been sleeping a lot and refusing to participate with activities. When the Activities Director was asked if Resident 29's refusal for activities was documented on his care plan, the Activities Director stated, No. During an observation on 8/21/23 at 10:52 a.m., Resident 29 was in his room on his bed, asleep. Resident 29 was lying on his back with the head of bed elevated at approximately 30 degrees. During an observation on 8/21/23 at 1:51 p.m., Resident 29 was in his room on his bed with eyes closed. Resident 29 was lying on his back with the head and foot of bed elevated. Review of the Activities Director's Job Description, revised in January 2010, indicated, The primary purpose of your job position is to plan, organize, develop, and direct the overall operation of the Activity Department in accordance with current federal, state, and local standards, guidelines and regulations, our established policies and procedures, and as may be directed by the Administrator and/or Activity Consultant, to assure that an on-going program of activities is designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well-being of each resident. 555595 Page 16 of 30 555595 08/22/2023 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 - Minimal harm or potential for actual harm Based on observations, interviews, and record reviews, the facility failed to accurately assess and provide necessary services to prevent the development of a facility-acquired pressure ulcers (injuries to skin and underlying tissue resulting from prolonged pressure on the skin) and worsening of the pressure ulcer, for one of five sampled residents, Resident 20, when: Residents Affected - Few The facility did not identify the presence of a pressure ulcer timely for Resident 20, which resulted in the development of an Unstageable (Full thickness tissue loss in which the ulcer is covered with by slough Slough is necrotic (dead) tissue that needs to be removed from the wound for healing to take place) and/or eschar (Eschar, pronounced es-CAR, is dead tissue that sheds or falls off from the skin. It's commonly seen with pressure ulcer wounds) in the wound bed (the base or floor of the wound) pressure ulcer on her sacrum (The sacrum is a triangular bone composed of five vertebrae (small bones forming the backbone) that make up the second to last portion of the spine) two days after her weekly skin check. This failure resulted in Resident 20 being sent to the hospital for possible wound infection. Findings: Review of Resident 20's MDS (Minimum Data Set - health status screening and assessment tool used for all residents) assessments, dated 6/28/23, indicated in Section M, Skin Conditions, the MDS Nurse made an entry on the MDS assessment that Resident 20 was not at risk of developing pressure ulcers. The MDS assessment indicated Resident 20 did not have one or more unhealed pressure ulcers. The MDS Nurse indicated, Resident 20 did not have other ulcers, wounds, and skin problems. In Section G, Functional Status, the MDS assessment indicated Resident 20 needed extensive assistance (resident involved in activity, staff provide weight bearing support) with bed mobility (how resident moves to and from lying position, turns side to side, and positions body while in bed) with one staff needed to provide physical assistance to perform the task. The MDS assessment in Section G indicated Resident 20 also required one-person extensive assistance to use the toilet. Review of Resident 20's NSG (Nursing) Weekly Skin Check, dated 7/31/23, at 12:30 p.m., and 8/7/23, at 12:31 p.m., conducted by the Treatment Nurse, indicated Resident 20 did not have skin conditions, changes, ulcers, or injuries. Under the Comments/Summary section of these weekly skin check records, the Treatment Nurse entered, No new skin issues. Review of Resident 20's NSG Weekly Pressure Ulcer Report, dated 8/9/23, at 5:17 p.m., conducted by the Treatment Nurse, indicated Resident 20 had developed a new onset pressure ulcer. The record indicated the new pressure ulcer was located on the sacrum with the length measured at 7 cm, and the width at 7 cm. Resident 20's new pressure ulcer was classified as, Unstageable. During a concurrent record review and interview on 8/17/23, at 4:11 p.m., with the Treatment Nurse, she stated she did the skin assessments on Resident 20 on 8/7/23 and 8/9/23. The Treatment Nurse stated she made an, honest mistake, when she did the weekly skin check assessment for Resident 20 on 8/7/23. The Treatment Nurse stated she did a head-to-toe assessment on Resident 20 but only checked the front part of her body while Resident 20 was seated on the edge of her bed. The Treatment Nurse stated she documented on 8/9/23, that Resident 20 had developed a new onset pressure ulcer on her sacrum. During an interview on 8/17/23, at 4:21 p.m., with the DON (Director of Nursing), she stated she 555595 Page 17 of 30 555595 08/22/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few had oversight of the nurses who performed wound care. When the DON was asked about her expectation for head-to-toe assessments, she stated her expectation was that the nurses would assess the front and the back side of the residents. During an interview on 8/21/23, at 1:55 p.m., with Licensed Staff J, she stated, if she needed to know what the interventions were for a resident with a pressure ulcer, she would look at that resident's orders and care plans. Licensed Staff J stated, if a care plan revision for any change in condition was needed, she would report this to the DON or to the Treatment Nurse. Licensed Staff J stated she could revise the care plan if she needed to. Review of Resident 20's, Care Plan, for her pressure ulcer indicated, Resident 20 noted with unstageable pressure ulcer to sacrum 8/9/23. The goal for this pressure ulcer care plan was that Resident 20's pressure ulcer would not exhibit signs and symptoms of infection. The care plan indicated the interventions included administer treatment and dressing as ordered (by a physician) and turning and repositioning Resident 20, and avoid positioning Resident 20 on her pressure ulcer location. Review of Resident 20's, Treatment Administration Record (TAR), dated August 2023, the TAR indicated, Turn and reposition Q2H (every two hours), start date 8/11/23, 2 p.m. The TAR indicated turning and repositioning of Resident 20 did not happen until one day, twenty hours, and forty-seven minutes, after the pressure ulcer was discovered on 8/9/23, at 5:17 p.m. Review of Resident 20's, Health Status Note, dated 8/17/23, at 8:11 p.m., authored by the Treatment Nurse, indicated, Patient (Resident 20) was seen by MD (Resident 20's physician) and assessed patient pressure ulcer on her sacrum. Noted of increased purulent (Purulent drainage is a thick and milky discharge from a wound. It often indicates an infection and needs treatment as soon as possible) drainage, odor, and skin redness surrounding on wound bed. Received order from MD to send to ER (Emergency Room) for further evaluation . Review of Resident 20's ED (Emergency Department) Provider Notes, dated 8/17/23, at 2:48 p.m., indicated, Patient (Resident 20) presents with, 'weeping' (an injury that is producing excessive fluid during healing or from inflammation) sacral decubitus (pressure ulcer). Under History of Present Illness, the provider note indicated, . the patient has had a wound present for a month, she states that it is getting worse she might have a low-grade fever the last couple of days . Review of Resident 20's, Hospital Medicine H&P (History and Physical) Note, dated 8/17/23, at 9:29 p.m., indicated, Chief Complaint, was low back wound, pain. The hospital attending physician indicated, Patient (Resident 20) stated that she has been suffering from wound on her back since more than one month which has gradually got worse . Under Physical Exam, the attending hospital physician commented on Resident 20's skin as, Ulcer with dead tissue, pus (a generally yellowish white fluid formed in infected tissue, consisting of white blood cells (responsible for protecting the body from infection), cellular debris, and necrotic tissue), surrounding erythema (redness) on low back. The H&P note indicated on Resident 20's mental status, She is alert and oriented to person, place, and time. Review of Resident 20's, Surgery H&P Note, dated 8/20/23, at 12:20 p.m., indicated, .A bedside I&D (incision and drainage) was performed in the ED and patient (Resident 20) admitted to medicine services with IV (Intravenous-within a vein) Vancomycin and Zosyn (antibiotics). On exam it appears opened to a large wound with purulent drainage . Review of Resident 20's, Hospital Progress Notes, dated 8/20/23, indicated that a specimen 555595 Page 18 of 30 555595 08/22/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few collected on Resident 20's pressure ulcer on 8/17/23, at 6:34 p.m., grew moderate MRSA (Methicillin Resistant Staphylococcus Aureus bacteria) and scant growth of Proteus Mirabilis (proteus mirabilis organisms are normal fecal (stool) flora and are present in soil and water). Review of hospital photographs of Resident 20's pressure ulcer, taken on 8/21/23, and 8/23/23, indicated the muscle tissue was exposed, consistent with a Stage 4 pressure ulcer. Review of a facility policy and procedure (P&P) titled, Prevention of Pressure Ulcer/ Injuries, dated 7/2/22, indicated, The purpose of this procedure is to provide information regarding identification of pressure ulcer/injury risk factors and interventions for specific risk factors. Under Mobility/Repositioning, the P&P indicated, Choose a frequency for repositioning based on the resident's mobility, support surface in use, skin condition and tolerance, and the resident's stated preference. Under, Monitoring, the P&P indicated, Evaluate, report, and document potential changes in the skin. Review of the facility policy and procedure titled, Repositioning, effective date 7/04/20, indicated, It is the policy of this facility to provide guidelines for the evaluation of resident repositioning needs, to promote comfort for all bed- or chair-bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents. The policy indicated: - Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation and providing pressure relief. - Positioning the resident on an existing pressure ulcer should be avoided since it puts additional pressure on tissue that is already compromised and may impede healing. - Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. - Frequency of repositioning a bed- or chair-bound resident should be determined by condition of the skin and overall condition of the resident. Review of an article from the National Library of Medicine, titled, Advances in Wound Care, dated 2/1/2018, under causation, (cause of pressure ulcer), it indicated, .Pressure ulcers occur over predictable pressure points where bony protuberances (a body part that bulges (protrudes) outward from a surface) are more likely to compress tissues when the patient is in prolonged contact with hard surfaces . The article indicated that the bony protuberances are the following: occiput (back of the head), scapula (shoulder blade), elbow, sacrum, ischium (lower and back sides of the hip bone), and heels . The diagram of the bony protuberances in this article indicated that all predictable pressure points are on the back side of the patient or resident and not the front side. 555595 Page 19 of 30 555595 08/22/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

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 records review, the facility failed to ensure staff provided appropriate respiratory care for one of three sampled oxygen dependent residents (Resident 3), when the facility did not attach a humidifier bottle (moistens the air to prevent a resident's nasal membranes from becoming dry, sore and scabby) to the oxygen (O2 - life-supporting component of the air) concentrator [a device used to provide oxygen to a resident in a steady even flow by means of a nasal cannula (a small, soft plastic tube that is divided into two prongs, which are placed in the nostrils)] when Resident 3 was on 5 liters (a metric unit of volume) of oxygen. This failure had the potential to result in Resident 3's discomfort associated with a dry nose from continuous oxygen use. Residents Affected - Few Findings: During a record review for Resident 3, the document titled, Order Summary Report, indicated a doctor's order, written on 9/08/22, for Resident 3 to be on continuous oxygen via (by way of) nasal cannula to maintain an O2 sat (oxygen saturation/sat -refers to how much oxygen [air] is carried from the lungs to tissues and organs in the body) above 92 percent. During a record review for Resident 3, the Minimum Data Set (MDS -health status screening and assessment tool used for all residents), dated 6/15/23, indicated Resident 3 was receiving Hospice Care (type of health care that focuses on the palliation or ease of a terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life). During a record review for Resident 3, the document titled, Order Summary Report, indicated a doctor's order, written on 6/30/23, to change the oxygen humidification bottle every week. During a record review for Resident 3, the Progress Note titled, Health Status Note, dated 8/20/23 at 5:43 p.m., indicated, at approximately 8:11 a.m., a CNA (Certified Nursing Assistant) reported to the licensed staff that Resident 3's O2 sat was 84 percent. The Progress Note indicated the licensed staff increased Resident 3's oxygen to 4 liters. During an observation on 8/21/23 at 10:53 a.m., in Resident 3's room, Resident 3 was on her bed, asleep, with O2 inhalation thru the concentrator at 5 liters per minute via nasal cannula without a humidifier attached to the concentrator. During an interview and concurrent observation with Licensed Staff N on 8/21/23 at 10:55 a.m., when Licensed Staff N was asked how much oxygen was Resident 3 was supposed to have, Licensed Staff N stated Resident 3 had an order for O2 at 2-3 liters per minute. When Licensed Staff N was asked how much O2 was Resident 3 receiving at time of interview, Licensed Staff N checked the concentrator and stated, 5 liters. Licensed Staff N also verified there was no humidifier attached to the concentrator. When Licensed Staff N was asked about the risk for Resident 3 when receiving 5 liters of O2 without a humidifier, Licensed Staff N stated, [Resident 3] could have dry nose. During an electronic record review for Resident 3 with Licensed Staff N on 8/21/23 at 11:02 a.m., Licensed Staff N verified there was a doctor's order to change the oxygen humidifier every week for Resident 3. Review of the Facility policy and procedure titled, Oxygen Administration, effective date 7/01/20, indicated general guidelines for oxygen administration to include but not limited to: Oxygen tubing 555595 Page 20 of 30 555595 08/22/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0695 Level of Harm - Minimal harm or potential for actual harm and humidifier will be changed and labeled every 7 days and as needed. The policy indicated, The following equipment and supplies will be necessary when performing this procedure: Portable oxygen cylinder (strapped to the stand); Nasal cannula, nasal catheter, mask (as ordered); . Humidifier bottle. Residents Affected - Few 555595 Page 21 of 30 555595 08/22/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews and records review, the facility failed to ensure the medication error rate was below 5%, when two of four licensed staff (Licensed Staff M and F) did not follow the doctor's order and manufacturer's specifications regarding administration of medication. The failures resulted in a 17% medication error rate which had the potential to compromise the residents' health and well-being for not getting the required medication according to the doctor's order. Residents Affected - Some Findings: 1. During an observation on 8/16/23 at 8:24 a.m., in front of Resident 212's room, Licensed Staff M was preparing the medications for Resident 212. Licensed Staff M poured one tablet of Aspirin 81 mg (milligram-a unit of mass) EC (enteric coated - Coated with a material that permits transit through the stomach to the small intestine before the medication is released) into the medicine cup. Licensed Staff M administered the medication to Resident 212. During a review of the Medication Administration Record (MAR) for Resident 212 and concurrent interview with Licensed Staff M on 8/16/23 at 10:50 a.m., Licensed Staff M verified the Aspirin order for resident 212 indicated, Aspirin Oral Capsule 81 mg. When Licensed Staff M was asked if she had Aspirin Oral Capsule in her medication cart, Licensed Staff M stated she did not have the oral capsule, however, she stated she had the chewable and enteric coated tablet. 2. During an observation on 8/16/23 at 8:56 a.m., in Resident 34's room. Licensed Staff F was handing the Fluticasone nasal spray (used to relieve symptoms of nonallergic rhinitis such as sneezing and runny or stuffy nose) to Resident 34 and instructed him to spray one spray in each nostril. Licensed Staff F did not shake the spray bottle prior to giving the medicine to Resident 34 and did not instruct Resident 34 to shake the medicine prior to spraying the medicine into each nostril. During an observation on 8/16/23 at 9:04 a.m., at the nurses' station, Licensed Staff F was preparing the medications for Resident 21. Licensed Staff F poured the following medications into the medicine cup: Calcium Citrate (used to treat conditions caused by low calcium [a chemical element that is present in teeth and bones] levels); Docusate (a stool softener); Levetiracetam (control certain types of seizures [a sudden attack of convulsions]; Quetapine (antipsychotic -drug to manage psychosis) and Senna (use to treat constipation). During a record review for Resident 21, the MAR indicated an order for Cerovite Senior Oral Tablet (Multiple Vitamins with Minerals) to be given once a day and Methadone (medication used to treat severe pain) tablet to be given at 9 a.m. and 9 p.m., every day. During an interview and concurrent record review with Licensed Staff F on 8/16/23 at 10:20 a.m., when asked the reason for not giving the Methadone to Resident 21, Licensed Staff F stated Resident 21 was not in pain. After review of the MAR with Licensed Staff F, Licensed Staff F verified the order for Methadone tablet indicated to be given at 9 a.m. and 9 p.m. When Licensed Staff F was asked the reason for putting residents on routine pain medication, Licensed Staff F stated, to provide pain control and prevent resident from having pain. During a review of the MAR for Resident 21 and concurrent interview with Licensed Staff F on 8/16/23 at 10:24 a.m., Licensed Staff F verified there was a doctor's, order written on 2/28/23, for Cerovite Senior Oral Tablet. When Licensed Staff F was asked reason for not giving Cerovite Senior Oral 555595 Page 22 of 30 555595 08/22/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0759 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Tablet to Resident 21, Licensed Staff F stated she did give the vitamin to Resident 21 and showed the medication bottle for the Multivitamin, however, the medicine bottle did not indicate multivitamin with minerals. During a review of the Medication Package Insert (includes details and directions health care providers need to prescribe a drug properly, including approved uses for the drug, contraindications, potential adverse reactions, available formulations, and dosage, and how to administer the drug) of Resident 34's Fluticasone nasal spray and concurrent interview with Licensed Staff F on 8/16/23 at 11:09 a.m., Licensed Staff F verified the medication package insert for Fluticasone nasal spray indicated, Shake well before use. Licensed Staff F stated she did not shake the medication prior to administering the nasal spray to Resident 34. When Licensed Staff F was asked what happened if the medication was not shaken before administering to the resident, Licensed Staff F stated the medicine would not be concentrated and the resident had the potential to not receive the required dose. Review of the facility policy and procedure titled, Administering Medications, effective date 7/01/20, indicated, Medications must be administered in accordance with the orders, including any required time frame. Review of the facility policy and procedure titled, Medication Administration - Nasal Administration, dated 09/10, indicated, Refer to medication package insert, medication label, or other appropriate reference to determine correct technique required for the administration of drops, sprays, pumps, gels, etc. The policy indicated, Shake the medication container well and remove cap from nozzle. 555595 Page 23 of 30 555595 08/22/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm Based on observation, interviews, and record reviews, the facility failed to ensure one of three sampled residents, Resident 109, was free from significant medication errors, when her pain medication, Oxycodone HCL (Oxycodone Hydrochloride is used to relieve pain severe enough to require opioid treatment and when other pain medicines did not work well enough or cannot be tolerated) was not administered, as ordered by the physician. This failure had the potential to result in ineffective pain management, sedation, or possible dependence or addiction to the medication. Residents Affected - Few Findings: A review of Resident 109's, Order Summary Report, dated 8/17/23, indicated she had a physician's order for Oxycodone HCL Oral Tablet 10 mg (milligram), give 0.5 tablet (1/2 tablet,= 5 mg) by mouth every 4 hours as needed for moderate pain (4-6) and Oxycodone HCL 10 mg Oral Tablet, give 1 tablet by mouth every 4 hours as needed for severe pain (7-10). During an interview on 8/15/23, at 10:42 p.m., with Resident 109, inside her room, Resident 109 was asked if she was having some pain today, and she stated, Yes. When Resident 109 was asked what her pain level (pain levels: 1-3,= mild pain, 4-6 moderate pain, 7-10 severe pain) was, she stated it was a, 4. Resident 109 stated there was one time when her pain level was severe, and she was only given a half tablet of Oxycodone. Resident 109 stated the nurse who administered the medication informed her this was per her medication orders. During a concurrent observation and interview on 8/15/23, at 11 a.m., with Licensed Staff Q, she was entering Resident 109's room and administering a medication. When Licensed Staff Q was asked what medication she administered to Resident 109, she stated it was her Oxycodone. Licensed Staff Q stated she gave the resident (Resident 109) 1 (one) 10 mg tablet of Oxycodone because Resident 109's CNA (Certified Nursing Assistant) informed her Resident 109's pain level was an 8 (severe pain). During an interview on 8/15/23, at 11:25 a.m., with Unlicensed Staff R, she stated she was Resident 109's CNA. Unlicensed Staff R stated she did not ask Resident 109 what her pain level was and did not report her pain level to Licensed Staff Q. A review of Resident 109's, Medication Administration Record (MAR), dated August 2023, indicated the following examples where medication errors, regarding her Oxycodone HCL pain medication, where identified: On 8/1/23, at 9:44 a.m., Resident 109's pain level was 9, and Licensed Staff J administered Oxycodone HCL 5 mg. The dose administered, per doctor's order, should have been Oxycodone HCL 10 mg. On 8/2/23, at 2:33 p.m., Resident 109's pain level was 0, no pain, Resident 109 was given Oxycodone 10 mg by the Treatment Nurse. Resident 109 should not have been administered Oxycodone HCL, per the doctor's orders. On 8/3/23, 8/4/23, 8/8/23, 8/9/23, 8/10/23, and 8/15/23, there were 11 (eleven) other incidences of significant medication errors regarding Oxycodone HCL which were administered to Resident 109. During a concurrent record review and interview on 8/18/23, at 1:47 p.m., with the Treatment Nurse, she stated she would first assess the pain level of a resident and administer the pain medication 555595 Page 24 of 30 555595 08/22/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few as ordered. The Treatment Nurse was asked to review Resident 109's MAR and asked her why she administered Oxycodone HCL 10 mg when she assessed Resident 109's pain level at 0, no pain. The Treatment Nurse stated she probably got confused and documented incorrectly. During a concurrent record review and interview on 8/18/23, 2:15 p.m., with Unlicensed Staff J, she stated she would first assess the resident's level of pain and administer what was ordered. Unlicensed Staff J was asked why she administered Oxycodone HCL 0.5 tab = 5 mg to Resident 109, after assessing her pain level was 9 (severe), Unlicensed Staff J stated it was probably an error on her part. During an interview on 8/21/23, at 3:02 p.m., with the DON (Director of Nursing), she stated she started doing in-services since Friday, 8/18/23, regarding the administration of Oxycodone HCL, per physician's order, to the resident (Resident 109). A review of a facility policy and procedure (P&P) titled, Administering Medications, dated 7/1/22, indicated, It is the policy of this facility to administer medications in a safe and timely manner as prescribed by the healthcare provider. 555595 Page 25 of 30 555595 08/22/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

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 follow policy and procedure when: 1. Steam table pans were not air-dried before stacking; 2. The drain under the dishwasher did not have an air gap (the unobstructed vertical space between the water outlet and the flood level of a fixture and prevents backflow of outlet water); and, 3. A pan of beef was not cooked to the appropriate temperature before placing on the steam table to serve. These failures could potentially result in food-borne illness in a vulnerable population. Findings: 1. During an observation and concurrent interview on 8/14/23 at 9:26 a.m., the initial kitchen tour was conducted with Registered Dietitian (RD). A drying rack shelf contained stacks of three different sizes of steam table pans. When the pans were pulled apart, water was present inside the stacked pans. The RD verified the pans were stacked wet and stated they should be dry before they were stacked. The RD began to separate the pans and placed them individually on the rack. During an interview on 8/18/23 at 3:30 p.m., the RD stated the pans could potentially grow bacteria if they were not allowed to air dry. Review of facility policy, Cleaning Dishes/Dish Machine, dated 2017, revealed, Dishes should be air dried on the dish racks. Do not dry with towels. 2. During an observation and concurrent interview on 8/14/23 at 9:26 a.m., the dishwashing machine had a black pipe, approximately 2.5 inches in diameter, draining water into a floor sink below it. The black pipe was sitting below the level of the floor. The RD verified the pipe should not be below the level of the floor. The RD lifted the pipe up out of the sink and stated it was usually higher. The RD got out her cell phone and stated she would call maintenance to come fix it. During an interview on 8/18/23 at 3:30 p.m., the RD stated an air gap prevented contamination of the dishwasher with bacteria if there were to be a backflow into the floor sink. Review of facility policy, Air Gap Drainage, dated 11/2017, revealed, 1. Plumbing systems (for potable water and for waste) shall remain separate. 2. The air gap space shall exist between the fixture outlet and the flood level rim of a receptacle (such as a sink, floor drain, standpipe, or other approved unit). 3. The air gap of any drainage pipe shall measure two times the diameter of the pipe. 6. Air gaps are found in appliances including but not limited to drains on ice machines, dish machines and floor drains beneath sinks. 3. During an observation and concurrent interview on 8/16/23 at 11:06 a.m., kitchen staff were preparing for tray line for lunch service. Dietary Manager (DM) checked the temperature of the food on the steam table with a digital thermometer and logged the temperatures on the log. [NAME] A pulled a large steam table pan full of chopped beef patties out of the oven and placed them on top of the stove. The DM inserted the thermometer into the beef on the right side of the pan. The thermometer indicated 122 degrees Fahrenheit (F). The DM removed the thermometer and inserted it into the beef on the left side of the pan. The thermometer indicated 193 degrees F, and the DM stated, See? 193. When queried about the temperature of 122 degrees, the DM inserted the thermometer into the right side of the pan again. The thermometer indicated 133 degrees F. The DM removed the thermometer and inserted 555595 Page 26 of 30 555595 08/22/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many it into beef at the edge of the pan where it indicated 187 degrees F. The DM asked [NAME] A to put the beef on the steam table. [NAME] A placed the pan of beef on the steam table, and the DM checked the temperatures of the beverages. When asked about the cooking temperature of beef, [NAME] A stated beef had to be cooked to 155 degrees. When asked about the temperature of the beef of 133 degrees, the DM stated it was because the fan was blowing on the thermometer. When asked to check the temperature of the beef again, the DM inserted the thermometer into the beef on the side of the pan closest to her. The thermometer indicated 162 degrees F. The DM inserted the thermometer into the far side of the pan, with the probe all the way in the beef. The thermometer indicated it was less than 155 degrees F, and [NAME] A verified the beef was not done cooking. The DM inserted the thermometer into another area of the pan of beef. The thermometer indicated a temperature over 190 degrees F. The DM stated, See? When asked if it was proper technique to move the thermometer around the pan until the thermometer read over 155 degrees, [NAME] A stated, No. At 11:34 a.m., [NAME] A put the beef back in the oven. During an interview on 8/18/23 at 2:22 p.m., the RD stated beef needed to be cooked to 155 degrees and if not, it should be put back in the oven. When queried, the RD stated undercooked meat could lead to food-borne illness. Review of facility document titled, Resource: Minimum Cooking, Holding and Reheating Temperatures, dated 2017, revealed, Cooking is a critical control point in preventing food borne illness. Cooking to heat all parts of food to the temperature and for the specified time below will either kill dangerous organisms or inactivate them sufficiently so that there is little risk to the individual if the food is eaten promptly after cooking. The chart indicated chopped beef should be cooked to 155 degrees for a minimum of 15 seconds. 555595 Page 27 of 30 555595 08/22/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and records review, the facility failed to implement measures to reduce the risk of disease and infection transmission when: Residents Affected - Some 1. Two Unlicensed Staff (Unlicensed Staff B and H) did not perform proper hand hygiene before passing food trays to the residents. This failure had the potential for spreading disease-causing microorganisms and/or transmission of diseases to the residents. 2. Four residents (Resident 29, 209, 213 and 19) were not offered hand hygiene before meals. This failure had the potential risk for residents getting sick from common germs including Escherichia coli (E. coli - type of bacteria) which can cause stomach aches and vomiting. 3. Licensed Staff E did not perform hand hygiene, according to the facility policy, during medication pass. This failure had the potential for spreading disease-causing microorganisms and/or transmission of diseases to the residents. 4. Licensed Staff E did not follow the facility policy on subcutaneous injection (the injection is given in the fatty tissue, just under the skin), when Licensed Staff E put the needle cover back after administering the medication. This failure had the potential for accidental punctures of the fingers or hand with a contaminated needle. Findings: During an observation on 8/15/23 at 12:31 p.m., Unlicensed Staff H was bringing the meal tray to Resident 209. Unlicensed Staff H did not perform hand hygiene prior to entering Resident 209's room. Unlicensed Staff H also did not offer hand hygiene to Resident 209. During an observation on 8/15/23 at 12:34 p.m., Unlicensed Staff H was bringing the meal tray to Resident 213. Unlicensed Staff H did not perform hand hygiene prior to entering Resident 213's room. Unlicensed Staff H also did not offer hand hygiene to Resident 213. During an observation on 8/15/23 at 12:38 p.m., Unlicensed Staff B was bringing the meal tray to Resident 29. Unlicensed Staff B did not offer hand hygiene to Resident 29. After Unlicensed Staff B left Resident 29's room, Resident 29 started picking on his food and licking his finger. During an observation on 8/15/23 at 1:18 p.m., Unlicensed Staff B was collecting Resident 19's meal tray after eating. The hand sanitizing wipe on Resident 19's meal tray was unopened. During an observation on 8/15/23 at 2:20 p.m., Care Giver L was bringing Resident 29's meal tray out of the room. The hand sanitizing wipe on Resident 29's meal tray was unopened. During an interview with Unlicensed Staff H on 8/15/23 at 2:34 p.m., when Unlicensed Staff H was asked how she made sure infection control was observed or maintained when serving food trays to the residents, Unlicensed Staff H stated she would wash her hands with water or use hand sanitizer before and after entering the resident's room. Unlicensed Staff H stated if the resident was alert, she would remind him/her to use the hand sanitizing wipe provided with their meal tray. Unlicensed Staff H stated, for confused residents, she would assist them with hand hygiene using either the hand wipes or washcloth with soap. Unlicensed Staff H verified the hand sanitizing wipe on Resident 209's meal 555595 Page 28 of 30 555595 08/22/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some tray was unopened. When Unlicensed Staff H was asked about the risks for the resident if hand hygiene was not performed before meals, Unlicensed Staff H stated residents could get sick to his/her stomach and it was an infection issue. During an interview with Unlicensed Staff B on 8/15/23 at 2:39 p.m., when Unlicensed Staff B was asked how infection control was maintained or observed when serving food trays to the residents, Unlicensed Staff B stated she would wash her hands before entering the resident's room, serve the tray to the resident, remind or assist the resident to sanitize his/her hands using the hand sanitizing wipe provided with the food tray, then she would wash her hands after leaving the resident's room. When Unlicensed Staff B was asked what were the risks for the residents if they did not perform hand hygiene before touching their food, Unlicensed Staff B stated, Residents had germs in their hands and could get sick when they eat with a dirty hands. During an observation on 8/16/23 at 8:59 a.m., in Resident 34's room, Licensed Staff F administered a subcutaneous injection of Enoxaparin (an anticoagulant that helps prevent the formation of blood clots) to Resident 34's right lower abdomen. Licensed Staff F pulled the needle from Resident 34's skin after administering the medication and put the needle cover back before discarding the needle. During a medication pass observation on 8/16/23 at 9:12 a.m., Licensed Staff E was preparing the medications for Resident 209. Licensed Staff E did not perform hand hygiene prior to entering Resident 209's room to administer the medications. During an interview with Licensed Staff F on 8/16/23 at 11:09 a.m., when Licensed Staff F was asked about the reason for putting the needle cover back after administering the medication to Resident 34, Licensed Staff F stated the needle was not a retractable needle (a needle, typically fused to the syringe, that is spring-loaded and retracts into the barrel of the syringe when the plunger is completely depressed after an injection is given); however, when Licensed Staff F was asked to show Resident 34's Enoxaparin needle, Licensed Staff F verified the injection needle was retractable. When Licensed Staff F was asked about the risks of recapping (putting the needle cap back on the used syringe) needles, Licensed Staff F stated she could accidentally poke herself, and it was a potential health and safety risk. During an interview with the Infection Preventionist (IP) on 8/16/23 at 3:41 p.m., when asked about her expectation from staff regarding hand hygiene, the IP stated she expected the staff to perform hand hygiene before and after patient contact. The IP stated nurses were to perform hand hygiene before entering and leaving the resident's room during medication pass. During an interview with the Director of Staff Development (DSD) on 8/21/23 at 1:45 p.m., when asked about the facility policy regarding hand hygiene, the DSD stated direct care staff were expected to wash their hands with soap and water or use hand sanitizer before and after providing resident care, before and after medication pass and before and after serving meal trays to the resident. The DSD stated CNAs (Certified Nursing Assistants) were expected to offer and assist the residents with hand hygiene before all meals. The DSD stated CNAs could use the hand sanitizing wipes that came with the resident's meal tray or they could use a wet washcloth. Review of the Facility policy and procedure titled, Handwashing - Hand Hygiene, effective 7/01/20, indicated, All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. The policy indicated, Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or 555595 Page 29 of 30 555595 08/22/2023 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some non-antimicrobial) and water for the following situations: . Before and after direct contact with residents; Before preparing or handling medications; Before and after eating or handling food . Review of the Facility policy and procedure titled, Administering Medications, effective 70/1/20, indicated, Staff shall follow established facility infection control procedures for the administration of medications, as applicable. Review of the facility policy and procedure titled, Subcutaneous Injections, effective 7/01/23, indicated, Discard uncapped needle and syringe into designated sharps container. 555595 Page 30 of 30