Health inspection·May 16, 2025

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete and obtain informed consent (a consent that provides the risks and benefits of taking a medication, possible side effects, alternate treatments, and risk of no use) for a psychotropic medication (medications that affect the mind, emotions and behavior) for one of 24 sampled residents (Resident 1). This failure had the potential for Resident 1 not to be fully informed and consent to receive psychotropic medications. Residents Affected - Few Findings: During a review of Resident 1's admission Record, dated 5/16/25, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of Bipolar Disorder (mental health condition characterized by extreme shifts in mood, energy and activity levels), and Major Depressive Disorder (mental health condition characterized by persistent sadness and loss of interest) and Anxiety Disorder (mental health condition characterized by excessive and persistent worry, fear or panic). During a concurrent interview and record review on 5/14/25 at 10:09 a.m. with Social Services Assistant (SSA), Resident 1's Order Summary Report, dated 5/14/25 and Informed Consents were reviewed. Resident 1's Order Summary Report indicated, Lamotrigine [medication used to treat bipolar disorder] oral tablet 200mg [milligram-unit of measure] . start date 2/4/25 . Resident 1's Informed Consent indicated there was no informed consent obtained for Lamotrigine. SSA confirmed Resident 1 did not have informed consent for Lamotrigine and stated, we need a consent for it. During an interview on 5/16/25 at 11:45 a.m. with Consultant Pharmacist, Consultant Pharmacist confirmed Lamotrigine needed informed consent prior to administration. During a review of the facility's policy and procedure (P&P) titled, Informed Consent, dated February 2025, the P&P indicated, The facility shall verify the written informed consent, obtained by the prescribing physician/LHP [licensed healthcare practitioner], is present . The written consent must be recorded in the resident's medical record. Before initiating treatment with psychotherapeutic drugs, facility staff must verify that the resident's health record contains written informed consent . Page 1 of 28 555595 555595 05/16/2025 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for two of 24 sampled residents (Resident 2 and Resident 35). This failure had the potential to result in Resident 2 and Resident 35 being unable to contact staff for assistance. Residents Affected - Few Findings: 1.During a review of Resident 2's admission Record, dated 5/16/25, the admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses of hemiplegia (inability to move one side of the body), and paraplegia (inability to move the lower parts of the body) and contracture of multiple sites (permanent shortening and stiffening of muscles, tendons, ligaments leading to limited movement and deformity). During a concurrent observation and interview on 5/12/25 at 6:32 p.m. with Resident 2, in room [ROOM NUMBER], Resident 2 was lying in bed with both hands contracted and her neck contracted to the left side. Resident 2's call light was placed by her collar bone, above her right hand. Resident 2 requested water and stated she was unable to move her hands or call for assistance because the call light was not within her reach. During a concurrent observation and interview on 5/12/25 at 6:37 p.m. with Resident 2's Roommate, in room [ROOM NUMBER], Resident 2's Roommate pressed her call light and stated she had to press her own call light for Resident 2 often because the call light was frequently not placed within Resident 2's reach. During an interview on 5/12/25 at 6:39 p.m. with Certified Nursing Assistant (CNA) 2, CNA 2 confirmed Resident 2's call light was not within reach and stated, it should be. During an interview on 5/13/25 at 8:25 a.m. with the Director of Nursing (DON), the DON stated the call light should always be within the reach of the residents. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, dated September 2022, the P&P indicated, Ensure that the call light is accessible to the resident . 2. During a review of Resident 35's admission Record, dated 5/16/25, the admission Record indicated Resident 35 was admitted to the facility on [DATE], with diagnoses of hemiplegia of the left side (inability to move the left side of the body), need for assistance with care, and aphasia (inability to understand or express speech). During a concurrent observation and interview on 5/12/25 at 5:56 p.m. in room [ROOM NUMBER] with Licensed Vocational Nurse (LVN) 4, Resident 35 was lying in bed with her call light dangling off the bed. LVN 4 confirmed Resident 35 was unable to reach her call light and stated her call light should always be within her reach. During an interview on 5/13/25 at 8:25 a.m. with the Director of Nursing (DON), the DON stated the call light should always be within the reach of the residents. During a review of the facility's policy and procedure (P&P) titled, Answering the Call Light, 555595 Page 2 of 28 555595 05/16/2025 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0558 dated September 2022, the P&P indicated, Ensure that the call light is accessible to the resident . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555595 Page 3 of 28 555595 05/16/2025 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0575 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. Based on observation, interview and record review, the facility failed to publicly post California Department of Public Health (CDPH) contact information for residents residing in facility. This failure resulted in residents not being afforded the right to make a complaint to CDPH regarding concerns with their care or the facility. Findings: During an interview on 5/13/25 at 2:04 p.m. with Resident Council members, eight out of eight residents stated they did not know how or where to file complaints to CDPH and could not recall if information was publicly available in the facility. During a concurrent observation and interview on 5/13/25 at 2:56 p.m. with the Activities Director (AD), CDPH contact information was not posted on the first or second floor of the facility. AD confirmed CDPH contact information was not posted in the facility. During a concurrent observation and interview on 5/13/25 at 2:58 p.m. with the Administrator (Admin) on first floor hallway. Admin confirmed CDPH contact information was not posted on first floor hallway. During an interview on 5/13/25 at 3:05 p.m. with the Director of Nursing (DON), the DON stated the facility does not have CDPH contact information posted for residents. During a review of the facility's Policy and Procedure (P&P) titled, Resident Rights, dated February 2021, the P&P indicated, These rights include the resident's right to: . communicate with outside agencies (e.g., local, state, or federal officials, state and federal surveyors .) regarding any matter. 555595 Page 4 of 28 555595 05/16/2025 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0584 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure a clean environment when: Residents Affected - Few 1. room [ROOM NUMBER] Bed A had a visibly soiled privacy curtain (curtain used between residents' beds). 2. Resident 2 had dirty clothes piled up on her nightstand. 3. room [ROOM NUMBER]'s air conditioner was in disrepair. These failures had the potential for residents to live in an unsafe and unclean, non-homelike environment. Findings: 1. During a concurrent observation and interview on 5/12/25 at 6:48 p.m. with Certified Nursing Assistant (CNA) 2, in room [ROOM NUMBER], Bed A's privacy curtain was visibly soiled with a brown substance in multiple spots. CNA 2 stated she was unaware of what the brown substance was, but the privacy curtain needed to be replaced immediately. During an interview on 5/14/25 at 10:58 a.m. with the Director of Nursing (DON), the DON stated curtains are changed when soiled. During a review of the facility's policy and procedure (P&P) titled, Cleaning and Disinfecting Residents' Rooms, dated August 2013, the P&P indicated, .curtains in resident areas will be cleaned when these surfaces are visibly contaminated or soiled . 2. During a concurrent observation and interview on 5/12/25 at 6:50 p.m. with Certified Nursing Assistant (CNA) 2, in room [ROOM NUMBER], there were approximately eight clothing items unfolded and piled up on Resident 2's nightstand. CNA 2 confirmed the clothing was dirty and stated dirty clothing needed to be put in a blue mesh bag and taken to the laundry. During an interview on 5/13/25 at 8:25 a.m. with the Director of Nursing (DON), the DON stated all dirty clothes should be placed in the laundry bag until taken to laundry. 3. During a concurrent observation and interview on 5/12/25 at 7:04 p.m. with the Director of Nursing (DON) in room [ROOM NUMBER], under the window the air conditioner vents were missing and broken, and visibly dirty with food particles. The DON confirmed the air conditioner was dirty and in disrepair. The DON stated maintenance needed to be contacted to fix the air conditioner. During an interview on 5/16/25 at 8:26 a.m. with the Maintenance Supervisor (MS), MS stated air conditioners should not have broken or missing vents and a work order should have been placed immediately. During a review of the facility's policy and procedure (P&P) titled, Interior General Maintenance, undated, the P&P indicated, .to maintain in good repair at all times, all interior surfaces, 555595 Page 5 of 28 555595 05/16/2025 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0584 fixtures, emergency and fire systems, equipment, appliances and furnishings to provide a safe, clean comfortable environment for our patients . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555595 Page 6 of 28 555595 05/16/2025 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 Based on interview and record review, the facility failed to assess and submit accurate data for one of 24 sampled residents (Resident 35) when the Minimum Data Set (MDS- an assessment tool used to guide resident care) did not reflect Resident 35's current status. This failure resulted in the transmission of inaccurate data to the Centers for Medicare and Medicaid Services (CMS). Residents Affected - Few Findings: During a concurrent interview and record review on 5/15/25 at 11:34 a.m. with Minimum Data Set Coordinator (MDSC), Resident 35's MDS 3.0 Section I- Active Diagnoses, dated 3/4/25, and Order Summary Report, dated 5/15/25 were reviewed. Resident 35's MDS 3.0 Section I- Active Diagnoses indicated Resident 35 had an active diagnosis of viral hepatitis (an infection that damages the liver). Resident 35's Order Summary Report indicated there was no treatment for viral hepatitis. The MDSC stated Resident 35's MDS should not have been checked yes for hepatitis because she was not receiving any active treatment. During an interview on 5/15/25 at 11:38 a.m. with MDS Registered Nurse (MDS RN), MDS RN confirmed the MDS should have not been checked yes for viral hepatitis and stated the Resident Assessment Instrument (RAI) instructs to only select yes if there has been treatment within the past 7 days. During a review of CMS Long-Term Care Facility [LTCF] Resident Assessment Instrument 3.0 User's Manual, dated October 2024, CMS LTCF RAI 3.0 User's Manual indicated, Code disease that have a documented diagnosis in the last 60 days and have a direct relationship to the resident's current functional status, cognitive status, mood or behavior status, medical treatments . Example of inactive Diagnoses . the resident has recovered . with no residual effects and no continued treatment . 555595 Page 7 of 28 555595 05/16/2025 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 observation, interview, and record review, the facility failed to ensure licensed nurses followed professional standards of practice when they documented they administered medications which were not dispensed by the pharmacy for one of 24 sampled residents (Resident 6). This failure resulted in inaccurate documentation and the potential for Resident 6 to experience adverse effects such as shortness of breath. Residents Affected - Some During a review of Resident 6's face sheet (demographics), the face sheet indicated Resident 6 was admitted on [DATE] with diagnoses including COPD (Chronic Obstructive Pulmonary Disease [ongoing lung condition that makes it difficult to breathe]) and asthma (a condition which makes it difficult to breathe). During an observation on 5/14/25 at 10:18 a.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 was observed administering Resident 6's respiratory medications. LVN 1 did not administer a Budesonide inhaler (medication inhaled into the lungs to prevent inflammation of the airways). LVN 1 stated that she did not have the medication in her medication cart, and she would need to call the pharmacy and request they send the medication. During a record review on 5/14/25 at 1:30 p.m. of Resident 6's Respiratory MAR (Medication Administration Record), dated April 2025 and May 2025, the MAR indicated that the resident received Budesonide on 4/25/25 at 8:00 p.m., 4/27/25 at 8:00 p.m., 4/28/25 at 8:00 a.m. and 8:00 p.m., 4/29/25 at 8:00 p.m., and 4/30/25 at 8:00 a.m. and 8:00 p.m., and 5/1/25- 5/12/25 at 8:00 a.m. and 8:00 p.m. During an interview on 5/15/25 at 10 a.m. with the Pharmacist, the Pharmacist stated, on 4/25/25, the pharmacy sent a fax to the facility requesting clarification of Resident 6's respiratory medications as they were concerned about duplicate therapy. The Pharmacist stated the facility did not respond to the request for clarification, so the pharmacy did not dispense Resident 6's Budesonide. The Pharmacist confirmed the medication was never delivered to the facility and was not available for administration. During a concurrent interview and record review on 5/15/25 at 10:40 a.m. with LVN 2, Resident 6's MAR was reviewed. LVN 2 confirmed she documented that she administered Budesonide to Resident 6 multiple times during the months of April and May 2025. LVN 2 stated she was unaware how she could have administered the medication when it was not dispensed from the pharmacy and stated she would ask her supervisor. During a follow up interview on 5/15/25 at 12:13 p.m. with LVN 2, LVN 2 stated that she would like to check the medication cart to see if the Budesonide was there. LVN 2 verified that Budesonide for Resident 6 was not in the medication cart. LVN 2 stated that she documents after she administers the medications and was not sure what happened. During a concurrent interview and record review on 5/15/25 at 12:17 p.m. with Registered Nurse (RN) 1, RN 1 confirmed the pharmacist sent a request to clarify the order for Budesonide and agreed that the medication was not dispensed. Resident 6's MAR was reviewed with RN 1, RN 1 confirmed she documented she administered Budesonide to Resident 6 on multiple days in May 2025. RN 1 confirmed she did not administer the medication and stated, I made an honest mistake. During a concurrent interview and record review on 5/15/25 at 4:17 p.m. with LVN 3, LVN 3 confirmed 555595 Page 8 of 28 555595 05/16/2025 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some he documented he administered Budesonide to Resident 6 on multiple days in April 2025. LVN 3 stated he was not certain if he gave the medication. During an concurrent interview and record review on 5/16/25 at 9:47 a.m. with the Director of Nursing (DON), DON confirmed licensed nurses documented they administered Budesonide on multiple dates in April and May. The DON confirmed the pharmacy did not dispense the medication. DON stated nursing staff should verify all medications listed on the MAR are available in the medication cart and notify the pharmacy when medications are not available. DON stated nursing staff should not have documented Budesonide was administered. During a review of Lippincott Nursing Center online titled, Nursing Documentation, dated August 2024, the document indicated, .Documentation Characteristics .Accurate and relevant .Documentation Entries .Accurate, truthful, and comprehensive . During a review of the American Nurses Association Guidance for Registered Nurses titled, Principals for Nursing Documentation, dated 2010, the guidance indicated, Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice. If patient documentation is not timely, accurate .it will interfere with the ability of those who were not involved in and are not familiar with the patient's care to use the documentation. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, dated 2001, the P&P indicated, .Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate . During a review of the facility's P&P titled, Administering Medications, dated October 2021, the P&P indicated, .The individual administering medications verifies the resident's identity before giving the resident his/her medications checks the label THREE (3) times to verify the right resident, right medication, right dosage, right time, and right method (route) of administration before giving the medication . 555595 Page 9 of 28 555595 05/16/2025 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement interventions the physician prescribed to prevent skin breakdown for one of 24 sampled residents (Resident 37) when Resident 37's pressure reducing mattress (mattress designed to prevent development of pressure ulcers (bedsores) or worsening of existing ulcers by redistributing air and pressure while the machine controlled the air flow) was not turned on for an unknown amount of time. This failure had the potential to result in Resident 37 developing a pressure ulcer, skin damage, skin infections, and discomfort. Residents Affected - Few Findings: During a review of Resident 37's Face Sheet (demographics), the Face Sheet indicated Resident 37 was admitted to the facility on [DATE] with diagnoses including dementia (progressive decline in cognitive function, memory, and behavior) and abnormalities of gait and mobility. During a concurrent observation and interview on 5/13/25 at 8:43 a.m. with Resident 37 in Resident 37's room, the machine connected to her pressure reducing mattress bed was turned off. Resident 37 confirmed the machine was turned off and does not remember when it was last turned on. Resident 37 stated that she stayed mostly in bed and does not remember the last time staff assisted her to get up. During a concurrent observation and interview on 5/13/25 at 9:55 a.m. with Certified Nurse Assistant (CNA) 3 in Resident 37's bedroom, CNA 3 confirmed the machine connected to Resident 37's mattress was turned off. CNA 3 stated the machine should be turned on because it helped prevent pressure ulcers, CNA 3 left the room with the machine still turned off. During a concurrent observation and interview on 5/13/25 at 10:10 a.m. with Licensed Vocational Nurse (LVN) 5, LVN 5 walked into Resident 37's room, plugged in the machine and turned it on. LVN 5 stated the machine and mattress helped prevent pressure ulcers and should always be on, or else the mattress might deflate. During an interview on 5/14/25 at 12:05 p.m. with the Director of Nursing (DON), the DON stated the pressure reduction mattress machine should be turned on for Resident 37. During a review of Resident 37's Braden Scale Assessment (assessment tool used to predict pressure sore risk), dated 4/28/25, the assessment indicated Resident 37 had slightly limited sensory perception, was occasionally moist, walked occasionally and spends majority of each shift in bed or chair, had slightly limited mobility, had potential problem for friction and shear, and overall scored as being at risk for developing a pressure sore. During a review of Resident 37's Care Plan, undated, the document indicated Resident 37 was at risk for skin impairment and further decline of skin integrity related to decreased or lack of physical activity, non-adherence to proper hygiene practices, side effects to medications, and thin fragile skin. The document indicated interventions included physician prescribed pressure reduction mattress to bed. During a review of Resident 37's Physician Orders, dated 4/9/25, the order indicated, Low Air Loss Mattress set mode alternating and setting based on setting on comfort OR weight of resident. Check setting and functionality every shift. 555595 Page 10 of 28 555595 05/16/2025 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, interview and record review, the facility failed to ensure four of 24 sampled residents (Resident 1, 2, 35 and 58) received restorative nursing care (RNA -specialized form of nursing that focuses on helping patients regain or maintain their functional abilities and minimize weakness) per physician order. This failure had the potential to result in contractures (permanent shortening and stiffening of muscles, tendons, ligaments leading to limited movement and deformity) and decline in muscle strength. Findings: 1. During a review of Resident 1's admission Record, dated 5/16/25, the admission Record indicated Resident 1 was admitted to the facility on [DATE], with diagnoses of abnormalities of gait and mobility, absence of right leg below the knee and right artificial hip joint. During a concurrent observation and interview on 5/12/25 at 5:14 p.m. with Resident 1 in room [ROOM NUMBER], Resident 1 was self-propelling her wheelchair in her room and had a prosthetic right leg. Resident 1 stated she did not receive physical therapy or RNA. Resident 1 further stated she had to complete her own exercises for her lower body because she did not want to deteriorate. During a concurrent interview and record review on 5/14/25 at 10:13 a.m. with Restorative Nursing Assistant (RNA 1), Resident 1's Order Summary Report, dated 5/14/25 and Weekly RNA Progress Note, dated from 3/26/25 to 5/14/25, were reviewed. Order Summary Report indicated, RNA 3x a week AROM [active range of motion] exercise . start date 3/26/25 . Weekly RNA Progress Note indicated there had been no RNA therapy since 1/24/25. RNA 1 stated she was unaware that Resident 1 was supposed to receive RNA. RNA 1 was unable to provide any note or communication instructing Resident 1 to refrain from RNA therapy. During a concurrent interview and record review on 5/14/25 at 12:13 p.m. with Director of Rehabilitation (DOR), Resident 1's Restorative Nursing Referral & Care Plan, dated 3/26/25 and Weekly RNA Progress Note, dated 1/24/25 to 5/14/25 were reviewed. Restorative Nursing Referral & Care Plan indicated, Risk for decline in range of motion, risk of decreased muscle strength, decreased functional use of extremity, risk of deformity and/or contracture . Task: RESTORATIVE - 3xs/wk [3 times a week] BLE [bilateral lower extremities- both legs] AROM [Active Range of Motion]. RNA program was reviewed with [RNA name] . date 3/26/25 . Weekly RNA Progress Note indicated there had been no RNA sessions therapy completed since 1/24/25. DOR stated she was told the surgeon did not want Resident 1 to have any physical therapy until after her next surgery. DOR confirmed there was no documentation from surgeon and stated, No, I didn't follow up with the physician. DOR further stated since there was no documentation indicating Resident 1 can't continue RNA therapy, then Resident 1 should have received RNA three times a week since 3/26/25. During an interview on 5/14/25 at 10:53 a.m. with the Director of Nursing (DON), the DON stated he was unaware of Resident 1 not receiving RNA therapy. The DON confirmed RNA 1 was responsible for looking at resident's orders for RNA therapy. During a review of the facility's policy and procedure (P&P) titled, Restorative Nursing Services, dated July 2017, the P&P indicated, Residents will receive restorative nursing care as needed to help promote optimal safety and independence . Restorative goals may include, but are not limited to 555595 Page 11 of 28 555595 05/16/2025 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 supporting and assisting the resident in . developing, maintaining or strengthening his/her physiological and psychological resources, maintaining his/her dignity, independence and self-esteem . 2. During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted to the facility on [DATE], with diagnoses of hemiplegia (inability to move one side of the body), and paraplegia (inability to move the lower parts of the body) and contracture of multiple sites. During a concurrent observation and interview on 5/12/25 at 6:32 p.m. with Resident 2, in room [ROOM NUMBER], Resident 2 was lying in bed with her neck contracted to the left and both hands contracture without a brace or splint. Resident 2 had a food tray at bedside and stated she was unable to feed herself and needed staff to feed her. Resident 2 stated her goal was to be able to feed herself and brush her teeth. Resident 2 further stated she did not receive RNA often and did not have a brace or splint for her contracted hands. During an interview on 5/14/25 at 10:14 a.m. with RNA 1, RNA 1 stated she saw Resident 2 twice a week but not for upper arms. RNA 1 further stated Resident 2 left hand was contracted and had stopped using it therefore wanting staff to feed her. RNA 1 stated she informed the Director of Rehabilitation (DOR) of Resident 2 needing a splint or brace for her hands. During an interview on 5/14/25 at 11:10 a.m. with Occupational Therapist (OT) 1, OT 1 stated she worked with Resident 2 a lot and we mostly focused on self-feeding and oral care because it was Resident 2's goal that she had set for herself. OT 1 further stated Resident 2 reached her goals but then declined and was discharged from occupational therapy and continued with RNA. OT 1 confirmed Resident 2 did not have a brace or splint for either hand. During a concurrent interview and record review on 5/14/25 at 12:01 p.m. with DOR, Resident 2's Order Summary Report, dated 5/14/25 and Weekly RNA Progress Notes, dated 3/27/25 to 5/14/25 were reviewed. The Order Summary Report indicated, RNA BLE PROM [Passive Range of Motion] exercises 3x/week 3/27/25 . RNA BUE [Bilateral Upper Extremities] PROM exercises 3x/week 3/27/25 . The Weekly RNA Progress Notes from 3/27/25 to 5/14/25 indicated Resident 2 was seen once a week for upper extremities. DOR stated she was not aware of Resident 2 only receiving one out of the three RNA therapy sessions ordered. DOR confirmed Resident 2 was unable to provide oral care and feed herself, and does not have a brace or splint. During a review of Resident 2's Occupational Therapy Treatment Encounter Note(s), dated 2/26/25, the Occupational Therapy Treatment Encounter Note(s) indicated Resident 2 needed partial/moderate assistance for oral hygiene. During a review of Resident 2's MDS- Section GG- Functional Abilities, dated 3/10/25, the MDS indicated Resident 2 was dependent on staff for oral hygiene. During a review of the facility's policy and procedure (P&P) titled, Restorative Nursing Services, dated July 2017, the P&P indicated, Residents will receive restorative nursing care as needed to help promote optimal safety and independence . Restorative goals may include, but are not limited to supporting and assisting the resident in . developing, maintaining or strengthening his/her physiological and psychological resources, maintaining his/her dignity, independence and self-esteem . 3. During a review of Resident 35's admission Record, the admission Record indicated Resident 35 555595 Page 12 of 28 555595 05/16/2025 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 was admitted to the facility on [DATE] with a diagnosis of abnormalities of gait and mobility, contracture of right knee, and hemiplegia (inability to move one side of the body). During a concurrent interview and record review on 5/14/25 at 10:17 a.m. with Restorative Nursing Assistant (RNA) 1, Resident 35's Order Summary Report, dated 5/14/25 was reviewed. The Order Summary Report indicated, RNA for BUE [bilateral upper extremities- both arms] exercises 2x/week- start date 1/24/25 . RNA PROM on 3x/week- start date 3/26/25 . RNA 1 stated she provided RNA therapy for Resident 35's lower extremities only. RNA 1 further stated she did not provide RNA to upper extremities because she did not look at the orders. During a concurrent interview and record review on 5/16/25 at 9:38 a.m. with Director of Rehabilitation (DOR), Resident 35's Weekly RNA Progress Note, dated 4/25/25 and Restorative Nursing Referral & Care Plan, dated 1/17/25 were reviewed. Weekly RNA Progress Note indicated Resident 35 never received RNA for bilateral upper extremities. Restorative Nursing Referral & Care Plan indicated, Risk for decline in range of motion, risk of decreased muscle strength, decreased functional use of extremity, risk of deformity and/or contracture . extremity of focus- upper extremity- bilateral . RESTORTATIVE- Passive ROM Program #1 RNA 2x/week . Program was reviewed with [RNA 1 name] . DOR confirmed Resident 35 had not been seen for BUE exercises since the order on 1/24/25. DOR stated DON oversaw the RNA program and she was never made aware of Resident 35 not receiving exercises for BUE. DOR further stated RNA 1 reported to the DON. During an interview on 5/16/25 at 11:16 a.m. with the DON, the DON stated he does not verify the weekly RNA progress notes against orders. DON further stated he quickly scans the reports to make sure they are submitted. During a review of the facility's policy and procedure (P&P) titled, Restorative Nursing Services, dated July 2017, the P&P indicated, Residents will receive restorative nursing care as needed to help promote optimal safety and independence . Restorative goals may include, but are not limited to supporting and assisting the resident in . developing, maintaining or strengthening his/her physiological and psychological resources, maintaining his/her dignity, independence and self-esteem . 4. During a review of Resident 58's Face Sheet (demographics), the Face Sheet indicated Resident 58 was admitted to the facility on [DATE] with diagnoses which included cellulitis (skin infection) of left lower limb, and abnormalities of gait (manner of walking) and mobility. During an interview on 5/13/25 at 3:08 p.m. with Resident 58, Resident 58 stated he did not feel physically ready to go home and believed physical therapy would be beneficial. Resident 58 further stated the facility informed him his insurance no longer covered physical therapy and his physical therapy services ended on 5/11/25. During an interview on 5/14/25 at 3:46 p.m. with Physical Therapist (PT) 1, PT 1 stated Resident 58 was discharged from physical therapy on 5/11/25 due to the insurance no longer covering physical therapy. During an interview on 5/15/25 at 8:28 a.m. with the Business Manager (BM), the BM stated Resident 58 informed her that he did not feel strong and would like to stay in the facility until the end of month, so he could get stronger and return home. The BM further stated Resident 58 was on a shared cost plan and accepted personal financial responsibility for room and board cost for his remaining stay at the facility. 555595 Page 13 of 28 555595 05/16/2025 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 During a concurrent observation and interview on 5/15/25 at 9:23 a.m. with Resident 58, Resident 58 was observed in the Dining Room seated at a table with a wheelchair next to him. Resident 58 stated staff instructed him to use a wheelchair and not use his walker to ambulate to the dining room. Resident 58 stated he would prefer to use his walker, so he could get stronger and go home. During an interview on 5/15/25 at 10:03 a.m. with Director of Rehabilitation (DOR), DOR stated that Resident 58 was not currently in RNA program. DOR stated Resident 58 was not eligible for RNA program because Resident 58 had the ability to ambulate with a walker independently. During an interview on 5/15/25 at 10:18 a.m. with Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 58 was instructed not to ambulate independently with his walker because he was at risk for falling. Instead, Resident 58 was instructed to use a wheelchair. During an interview on 5/15/25 at 11:41 a.m. with the BM, BM stated RNA program was included in the cost of Resident 58's room and board. During an interview on 5/15/25 at 12:09 p.m. with the Director of Nursing (DON), the DON stated Resident 58 was not in the RNA program. The RNA program was based on evaluations from Rehabilitation Department. DON stated, DOR informed him Resident 58 was not eligible for RNA program. DON stated no interventions had been implemented for Resident 58 to prevent mobility decline. During an interview on 5/16/25 at 11:18 a.m. with DOR, DOR stated the purpose of the RNA program was to maintain and prevent further mobility decline in residents who were discharged from physical therapy. DOR stated the Physical Therapy Department was responsible for performing RNA eligibility assessment for Resident 58 when he was discharged from physical therapy. DOR confirmed Resident 58 should not use a wheelchair. DOR further stated Resident 58 should be ambulating using walker with staff encouragement. The facility did not provide Resident 58's RNA Eligibility Evaluation during the survey. 555595 Page 14 of 28 555595 05/16/2025 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 - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure one of 24 sample residents (Resident 35) was weighed daily per physician order. This failure had the potential to result in Resident 35 not being properly monitored for weight loss and nutritional interventions not being implemented in a timely manner. Residents Affected - Few Findings: During a review of Resident 35's admission Record, the admission Record indicated Resident 35 was admitted to the facility on [DATE] with diagnoses of dysphagia (difficulty swallowing) and severe protein-calorie malnutrition (serious medical condition characterized by a deficiency of both protein and calories, leading to severe weight loss and muscle wasting). During a review of Resident 35's Order Summary Report, dated 5/14/25, the Order Summary Report indicated, .Daily weights: Notify MD [Medical Doctor] of 3+ pounds weight gain in a day or 5+ pounds weight gain in 7 days . start date 1/25/25 . During a concurrent interview and record review on 5/14/25 at 10:31 a.m. with Registered Dietician (RD), Resident 35's Weights and Vitals Summary, dated 1/25/25 to 5/14/25 was reviewed. Weights and Vitals Summary indicated there was a total of 69 missing daily weights from 1/25/25 to 5/14/25. RD confirmed missing daily weights and stated Resident 35 had significant weight loss and should have been weighed every day. During a review of the facility's policy and procedure (P&P) titled, Weight Assessment and Intervention, dated March 2022, the P&P indicated, Resident weights are monitored for undesirable or unintended weight loss or gain . Residents are weighed upon admission and at intervals established by the interdisciplinary team . Weights are recorded in each unit's weight record chart and in the individual's medical record . 555595 Page 15 of 28 555595 05/16/2025 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to label an enteral feeding (a method to provide food through a tube placed in the nose, the stomach, or the small intestine) bottle, an enteral feeding pump bag, and a syringe used for enteral feeding for one of 24 sampled residents (Resident 35). This failure had the potential for expired enteral feeding supplement and equipment to be used for Resident 35. Findings: During a review of Resident 35's admission Record the admission Record indicated Resident 35 was admitted to the facility on [DATE] with a diagnosis of dysphagia (difficulty swallowing) and severe protein-calorie malnutrition (serious medical condition characterized by a deficiency of both protein and calories, leading to severe weight loss and muscle wasting). During an observation on 5/12/25 at 6:04 p.m., in Resident 35's room, a Jevity 1.5 (an enteral feeding formula) was observed infusing at 50 ml/hr (milliliter per hour- a unit of measurement). Upon further inspection, the bottle of Jevity 1.5, an enteral feeding pump bag that contained a clear liquid substance, and a syringe inside an open bag were hanging on a pole unlabeled and undated. During a concurrent observation and interview on 5/12/25 at 6:11 p.m., with Licensed Vocational Nurse (LVN) 4, LVN 4 confirmed the bottle of Jevity 1.5, the enteral feeding pump bag, and the syringe were unlabeled with resident's name and undated. LVN 4 stated the bottle of Jevity 1.5 needed to be labeled with the resident's name, resident's room number, formula, date and infusion rate. LVN 4 further stated the syringe and enteral feeding pump bag needed to have the resident name and date it was opened and used. During an interview on 5/12/25 at 6:21 p.m. with the Director of Nursing (DON), the DON stated all enteral feeding materials should be labeled and dated. During a review of Resident 35's Order Summary Report, dated 5/14/25, the Order Summary Report indicated, Enteral Feed Order every shift Enteral: Tube Feeding Jevity 1.5 at 50 ml/HR x 24 hours to provide 1800 kcal/day via g-tube . During a review of the manufacturer Jevity 1.5 Product Information, dated 7/22/24, the Jevity 1.5 Product Information indicated, .hang for no more than 24 hours. During the review of the facility's policy and procedure (P&P) titled, Enteral Tube Feeding via Continuous Pump, dated November 2018, the P&P indicated, On the formula label document initials, date and time the formula was hung/administered and initial that the label was checked against the order . 555595 Page 16 of 28 555595 05/16/2025 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the medication error rate was not five percent or greater when five identified medication errors out of 26 opportunities were observed: Residents Affected - Few 1. Budesonide (medication inhaled into the lungs to prevent inflammation of the airways) was omitted for Resident 6. 2. Midodrine (medication used to treat orthostatic hypotension [a condition characterized by a sudden drop in blood pressure upon standing, leading to dizziness, light-headedness, and fainting]) was omitted for Resident 6. 3. Ipratropium 0.03% (nasal spray used to treat conditions affecting the lungs and nasal passages) was not administered according to manufacturer instructions and was administered at the incorrect time for Resident 6. 4. Trelegy (medication inhaler used for long-term control of breathing problems which causes shortness of breath) was administered at the incorrect time to Resident 6. 5. Midodrine was administered through a gastronomy tube (G-Tube) (small, flexible tube inserted through the stomach to deliver nutrition, fluids, and medication) and was not flushed with water after administration for Resident 35. These failures resulted in an overall medication error rate of 19.23% and had the potential for Resident 6 and Resident 35 to experience side effects of medication errors. Findings: 1. During a review of Resident 6's face sheet (demographics), the face sheet indicated Resident 6 was admitted on [DATE] with diagnoses including COPD (Chronic Obstructive Pulmonary Disease [ongoing lung condition that makes it difficult to breathe]), asthma (a condition which makes it difficult to breathe), and orthostatic hypotension (a condition characterized by a sudden drop in blood pressure upon standing, leading to dizziness, light-headedness, and fainting). During an observation on 5/14/25 at 8:47 a.m. in Resident 6's room, Licensed Vocational Nurse (LVN) 1 was observed administering Resident 6's morning medications. LVN 1 did not administer Budesonide to Resident 6. During a review of Resident 6's Order Summary Report, dated 4/25/25, the order indicated, Budesonide-Formoterol Fumarate inhalation Aerosol 80-4.5 MCG/ACT (unit of measurement in a single dose from inhaler), 2 puff inhale orally two times a day for COPD rinse mouth and spit out after inhalation, start date 4/25/25 2000. During an interview on 5/14/25 at 10:05 a.m. with LVN 1, LVN 1 stated she forgot about the respiratory medications during the morning medication pass and that she would give them now. During a concurrent observation and interview on 5/14/25 at 10:18 a.m. with LVN 1 in Resident 6's room, LVN 1 did not administer Budesonide. LVN 1 stated that she did not have the medication in her 555595 Page 17 of 28 555595 05/16/2025 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0759 med cart. Level of Harm - Minimal harm or potential for actual harm During an interview on 5/14/25 at 1:00 p.m. with LVN 1, LVN 1 stated that she did not know why Budesonide was not in the med cart and that she would follow up with pharmacy before she leaves at 7:00 p.m. LVN 1 stated it was important for the resident to receive Budesonide to prevent shortness of breath. Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled, Administering Medication, dated April 2019, the P&P indicated, .Medications are administered in accordance with prescriber orders, including any required time frame .Medications are administered within one (1) hour of their prescribed time, unless otherwise specified . During a review of the facility's P&P titled, Administering Oral Medications, dated October 2010, the P&P indicated, .Follow the medication administration guidelines in the policy entitled Administering Medications .Report other information in accordance with facility policy and professional standards of practice . 2. During a review of Resident 6's face sheet (demographics), the face sheet indicated Resident 6 was admitted on [DATE] with diagnoses including COPD (Chronic Obstructive Pulmonary Disease [ongoing lung condition that makes it difficult to breathe]), asthma (a condition which makes it difficult to breathe), and orthostatic hypotension (a condition characterized by a sudden drop in blood pressure upon standing, leading to dizziness, light-headedness, and fainting). During a concurrent observation and interview on 5/14/25 at 8:47 a.m. with Licensed Vocational Nurse (LVN) 1 in Resident 6's room, LVN 1 was observed administering Resident 6's morning medications. LVN 1 did not administer Midodrine to Resident 6. LVN 1 stated that the Midodrine was missing from the med cart. During a review of Resident 6's Order Summary Report, dated 4/25/25, the order indicated Midodrine HCL Oral Tablet 10 mg (milligrams, unit of measurement), give 1 tablet by mouth two times a day for orthostatic hypotension hold if sbp (systolic blood pressure [the higher number in a blood pressure reading, representing the pressure in your arteries when your heart beats]) greater than 140. During an interview on 5/15/25 at 11:15 a.m. with the Director of Nursing (DON), the DON stated the nurse should check their emergency supply if a medication was missing, if it was not in the emergency supply, they should call pharmacy to get a stat delivery. During a review of the facility's policy and procedure (P&P) titled, Administering Medication, dated April 2019, the P&P indicated, .Medications are administered in accordance with prescriber orders, including any required time frame .Medications are administered within one (1) hour of their prescribed time, unless otherwise specified . During a review of the facility's policy and procedure (P&P) titled, Administering Oral Medications, dated October 2010, the P&P indicated, .Follow the medication administration guidelines in the policy entitled Administering Medications Report other information in accordance with facility policy and professional standards of practice . 3. During a review of Resident 6's face sheet (demographics), the face sheet indicated Resident 6 was admitted on [DATE] with diagnoses including COPD, asthma, and orthostatic hypotension. COPD 555595 Page 18 of 28 555595 05/16/2025 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 - Few (Chronic Obstructive Pulmonary Disease [ongoing lung condition that makes it difficult to breathe]), asthma (a condition which makes it difficult to breathe), and orthostatic hypotension (a condition characterized by a sudden drop in blood pressure upon standing, leading to dizziness, light-headedness, and fainting). During an observation on 5/14/25 at 8:47 a.m. with Licensed Vocational Nurse (LVN) 1 in Resident 6's room, LVN 1 was observed administering Resident 6's morning medications. LVN 1 did not administer Ipratropium 0.03% nasal spray to Resident 6. During a review of Resident 6's Physician's Orders, dated 4/25/25, the Physician Order indicated, Ipratropium Bromide Nasal Solution 0.03%, 1 spray in each nostril two times a day for nasal allergy . During an interview on 5/14/25 at 10:05 a.m. with LVN 1, LVN 1 stated she forgot about the respiratory medications and that she would give them now. During an observation on 5/14/25 at 10:18 a.m. with LVN 1 in Resident 6's room, LVN 1 administered Ipratropium nasal spray without priming the nasal spray bottle prior to administration. LVN 1 did not instruct the resident to blow her nose prior to administration, close the opposite nostril, or to lean her head back during the medication administration. During a review of Resident 6's Respiratory Medication Administration Record (MAR), dated 4/26/25, the MAR indicated, Ipratropium Bromide Nasal Solution 0.03%, 1 spray in each nostril two times a day for nasal allergy, start date 4/26/25. Hours listed on Respiratory MAR for administration indicated 0900 and 2100. During a review of the manufacturer's instructions pulled from Mayo Clinic website provided by the facility, last updated 4/30/25, manufacturer's instructions indicated: Prime the spray by pumping 2 sprays in the air if the bottle has not been used within 24 hrs. Gently blow your nose before using the spray. Close the opposite nostril and lean your head forward slightly. Spray into your nostril and sniff deeply through nose. Take spray out of your nose and lean your head backward for a few seconds. Spray the opposite nostril using the same steps. During an interview on 5/14/25 at 1:00 p.m. with LVN 1, LVN 1 stated the medication should be administered within one hour of the scheduled time. LVN 1 further stated she was unsure of the instructions for the nasal spray administration, and she should follow the instructions on the medication box. During an interview on 5/14/25 at 3:39 p.m. with the Consultant Pharmacist, Consultant Pharmacist stated it was important to have the resident blow their nose gently prior to the nasal spray and that the medication bottle should be primed prior to use. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, 555595 Page 19 of 28 555595 05/16/2025 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 - Few dated October 2010, P&P indicated, .Medications are administered one hour of their prescribed time .Medications are administered in accordance with prescriber orders, including any required time frame .Medications are administered within one (1) hour of their prescribed time, unless otherwise specified . During a review of the facility's P&P titled, Medication Administration Schedule, undated, the P&P indicated, .For all drugs, q12h. (every twelve hours), 9 a.m.; and 9 p.m. 4. During a review of Resident 6's face sheet (demographics), the face sheet indicated Resident 6 was admitted on [DATE] with diagnoses including COPD (Chronic Obstructive Pulmonary Disease [ongoing lung condition that makes it difficult to breathe]), asthma (a condition which makes it difficult to breathe), and orthostatic hypotension (a condition characterized by a sudden drop in blood pressure upon standing, leading to dizziness, light-headedness, and fainting). During an observation on 5/14/25 at 8:47 am. with Licensed Vocational Nurse (LVN) 1 in Resident 6's room, LVN 1 was observed administering Resident 6's morning medications. LVN 1 did not administer Trelegy to Resident 6. During a review of Resident 6's physician's order, dated 4/25/25, the order indicated, Trelegy Ellipta Inhalation Aerosol Powder Breath Activated 100-62.5-25 MCT/ACT (Fluticasone-Umeclidinium-Vilanterol) 1 puff inhale orally one time a day for COPD. During an interview on 5/14/25 at 10:05 a.m. with LVN 1, LVN 1 stated she forgot about the respiratory medications and that she would give them now. During an observation on 5/14/25 at 10:18 a.m. with LVN 1 in Resident 6's room, LVN 1 administered Trelegy to Resident 6. During a review of Resident 6's Respiratory MAR dated 4/26/25, the MAR indicated, Trelegy Ellipta inhalation Aerosol Powder Breath Activated 100-62.5-25 MCG/ACT, 1 puff inhale orally one time a day for COPD. During an interview on 5/14/25 at 1:00 p.m. with LVN 1, LVN 1 stated Resident 6's Trelegy was ordered once daily and confirmed medications should be administered within one hour of the scheduled time. During a review of the facility's policy and procedure (P&P) titled, Administering Medications, dated October 2010, P&P indicated, .Medications are administered one hour of their prescribed time .Medications are administered in accordance with prescriber orders, including any required time frame .Medications are administered within one (1) hour of their prescribed time, unless otherwise specified . During a review of the facility's P&P titled, Medication Administration Schedule, undated, the P&P indicated, .QD (daily); 9:00 a.m. 5. During a review of Resident 35's face sheet (demographics), the face sheet indicated Resident 35 was admitted on [DATE] with diagnosis of dysphagia (difficulty swallowing). During an observation on 5/15/25 at 7:25 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 crushed 555595 Page 20 of 28 555595 05/16/2025 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 two tablets of Midodrine and mixed with 30 mL (milliliters, unit of measurement) of water. LVN 2 administered crushed medication mixed in water through Resident 35's G-Tube. There was still crushed medication observed in the medicine cup. LVN 2 then added more water to the residual medication and administered it through the G-Tube. LVN 2 clamped the G-Tube without flushing the medication through the tube. Residents Affected - Few During a review of Resident 35's Order Summary Report, dated 1/24/25, order indicated, Midodrine HCL Oral tablet 5 mg; give 2 tablets via G-Tube three times a day for hypotension hold if sbp greater than 140. During an interview on 5/15/25 at 9:25 a.m. with LVN 2, LVN 2 stated that she flushed the G-Tube with 30 mL of water before starting administration of medication and after every medication. LVN 2 stated that she noticed there was still a little medication in the cup after giving the medication mixed with 30 mL water and she added another 30 mL of water in the medicine cup to make sure she received all the medication. LVN 2 stated she should have flushed with an additional 30 mL of clear water to ensure the mediation cleared the tubing and to prevent any clogs. During a review of the facility's policy and procedure (P&P) titled, Med Administration G-Tube, dated November 2018, the P&P indicated, .Dilute crushed (powdered) medication with at least 30 mL purified water .When the last of the medication begins to drain from the tubing, flush the tubing with 15 mL of warm purified water (or prescribed amount) . 555595 Page 21 of 28 555595 05/16/2025 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement safe medication storage practices for two of 24 sampled residents (Resident 2 and 4) and 1 unsampled resident (Resident 30) when: 1. Resident 30's triamcinolone acetonide cream (medication used to treat various skin conditions) was found on Resident 30's bedside table. 2.Resident 2 had one large container of powdered Magnesium (supplement to support healthy nerve and muscle function), one bottle of [brand name] Sleep Aid, and one bottle of [brand name] PM (at night) Leg Cramp medication on top of a dresser at bedside. 3.Resident 4 had a bottle of multivitamins on the bedside table. These findings had the potential to result in the unauthorized administration of medications and serious adverse events such as overdosing or negative drug interactions. Findings: 1. During a review of Resident 30's Face Sheet (demographics), the Face Sheet indicated Resident 30 admitted on [DATE] with diagnosis of dementia (progressive decline in memory, thinking, and reasoning that impacts daily life). During a concurrent observation and interview on 5/12/25 at 6:23 p.m. with Certified Nurse Assistant (CNA) 4 in Resident 30's room, there was a jar of triamcinolone acetonide cream on Resident 30's bedside table. CNA 4 picked up the medication with the pharmacy label, looked inside, stated that she thought it was just [brand name ointment], and placed it back on Resident 30's bedside table. During an interview on 5/12/25 at 6:52 p.m. with Licensed Vocational Nurse (LVN) 6, LVN 6 stated Resident 30 was forgetful and should not have medications at the bedside for unsupervised use. During an interview on 5/16/25 at 9:10 a.m. with the Director of Nursing (DON), the DON stated that no medications were allowed to be at any resident's bedside. During an interview on 5/16/25 at 11:42 a.m. with Consultant Pharmacist, Consultant Pharmacist stated medications left at bedside could lead to administration without the staff's knowledge, and it was important that staff know what medications the residents are taking because it might result in negative outcomes including overdosing and various drug interactions. During a review of Resident 30's Physician Order, dated 5/9/2025, the order indicated, Triamcinolone Acetonide External Cream 0.1% . Apply to chest topically every morning and at bedtime. During a review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, undated, the P&P indicated, The facility stores all medications and biologicals in locked compartments . 555595 Page 22 of 28 555595 05/16/2025 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 2. During an observation on 5/12/25 at 6:40 p.m. in room [ROOM NUMBER], Resident 2 was lying in bed and on the dresser there was one large container of powdered magnesium, one bottle of [brand name] sleep aid, and one bottle of [brand name] PM leg cramp medication. During a concurrent observation and interview on 5/13/25 at 8:31 a.m. with the Director of Nursing (DON) in room [ROOM NUMBER]. Resident 2 was lying in bed and on the dresser, there was one large container of powdered magnesium, one bottle of [brand name] sleep aid, and one bottle of [brand name] PM leg cramp medication. The DON stated, No they shouldn't be there and the doctor needed to know what medications Resident 2 was taking. During an interview on 5/16/25 at 11:42 a.m. with the Consultant Pharmacist, the Consultant Pharmacist stated all medications should be dispensed from the pharmacy and if not then the nurses needed to keep the medications in the medication cart. The Consultant Pharmacist further stated the staff needed to know what residents were taking in case there was a drug interaction, wrong timing of administration or possible overdose. During a review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, undated, the P&P indicated, The facility stores all medications and biologicals in locked compartments . 3.During a concurrent observation and interview on 5/12/25 at 7:02 p.m. with Resident 4 in room [ROOM NUMBER], Resident 4 was lying in bed with a bottle of [brand name] multivitamin on the bedside table. Resident 4 stated, Yeah I take these everyday because these were stronger than the vitamins given by the nurses. During a concurrent observation and interview on 5/13/25 at 8:25 a.m. with the Director of Nursing (DON) in room [ROOM NUMBER], a bottle of multivitamins was on Resident 4's bedside table. The DON confirmed vitamins at bedside and stated the medication shouldn't be at bedside. During an interview on 5/16/25 at 11:42 a.m. with the Consultant Pharmacist, the Consultant Pharmacist stated all medications should be dispensed from the pharmacy and if not then the nurses needed to keep the medications in the medication cart. The Consultant Pharmacist further stated the staff needed to know what residents were taking in case there was a drug interaction, wrong timing of administration or possible overdose. During a review of the facility's policy and procedure (P&P) titled, Medication Labeling and Storage, undated, the P&P indicated, The facility stores all medications and biologicals in locked compartments . 555595 Page 23 of 28 555595 05/16/2025 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 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 store and prepare food in a safe and sanitary manner when: Residents Affected - Many 1. Lettuce was not rinsed per packing instructions prior to being chopped and plated onto salad bowls. 2. Two carts used for food transport from the Main Kitchen to the Nourishment Room were dirty. 3. Food items were not discarded after their use-by-date. 4. One bin of contaminated rice was not discarded. 5. Food items were not stored in sealed containers to prevent contamination. 6. Opened food items were not properly labeled with open and use-by-date. These failures had the potential to cause food-borne illnesses in an already medically fragile population. The kitchen served a population of 73 residents. Findings: 1. During a concurrent observation and interview on 5/12/25 at 5:06 p.m. with the Dietary Aide (DA ) in the Main Kitchen, the DA took romaine lettuce from a plastic package, chopped it, and plated the lettuce into salad bowls for distribution to the residents. The DA stated he did not rinse the lettuce prior to chopping because the lettuce came from the company already cleaned. The DA read the instructions on the packaging and confirmed the instructions are to, Rinse Before Use. During an interview on 5/12/25 at 5:10 p.m. with the Kitchen Manager (KM ), the KM stated the DA should have rinsed the lettuce prior to chopping and plating. During a review of the facility's policy and procedure (P&P) titled, Meat and Vegetable Preparation, undated, the P&P indicated, Raw, unprocessed for fruits and vegetables should be thoroughly washed 555595 Page 24 of 28 555595 05/16/2025 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0812 under clean, potable, running water before use. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's P&P titled, General Food Preparation and Handling, undated, the P&P also indicated, Manufacturer's cooking instructions should be followed on any commercially packaged food before using it in any food and ready to eat foods. Residents Affected - Many 2. During a concurrent observation and interview on 5/12/25 at 4:32 p.m. with the Registered Dietician (RD ) in the Main Kitchen, there were two dirty portable carts by the fridge doors. One cart, stocked with bananas, sodas in cans, juices in cups, yogurts, oranges, and condiments, had hair and a purple substance stuck to the surface. The other cart, empty, had a green gunky and wet orange substance on the top surface. The RD stated the carts were used to transport food items from the Main Kitchen to Nourishment Room on the unit where the residents resided. The RD confirmed the carts were dirty, should not be in the clean area of the kitchen, and should have been cleaned prior to being used for food storage and transport. During a review of the facility's policy and procedure (P&P) titled, General Food Preparation and Handling, undated, the P&P indicated, All food service equipment should be cleaned, sanitized, air dried and reassembled after each use. The P&P also indicated, The kitchen surfaces and equipment will be cleaned and sanitized as appropriate. During a review of the facility's P&P titled, Food Storage, undated, the P&P indicated, Food will be stored in an area that is clean, dry and free from contaminants. The P&P also indicated, Food will be stored . by methods designed to prevent contamination or cross contamination. 3. During a concurrent observation and interview on 5/12/25 at 4:32 p.m. with the Registered Dietician (RD) in the walk-in refrigerator of the Main Kitchen, the following items were not discarded past their use-by-date: a. Three hamburger buns (use-by-date of 5/10/25) b. One bag of frozen waffles (use-by-date of 5/10/25) c. One bottle of barbeque sauce (use-by-date 2/5/25) The RD stated the items should have been discarded before or on their use-by-date. During a concurrent observation and interview on 5/12/25 at 4:48 p.m. with the RD in the walk-in freezer of the Main Kitchen, the following items were not discarded past their use-by-date: 555595 Page 25 of 28 555595 05/16/2025 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0812 a. Level of Harm - Minimal harm or potential for actual harm One bag of frozen ravioli (use-by-date 5/3/25) b. Residents Affected - Many One bag of carrots (use-by-date 4/8/25) c. Two frozen pies (use-by-date 12/16/24) The RD stated the items should have been discarded before or on their use-by-date. During a review of the facility's policy and procedure (P&P) titled, Food Storage, undated, the P&P indicated, Refrigerated food storage: .All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. The P&P also indicated, Frozen Foods: .All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. 4. During a concurrent observation and interview on 5/12/25 at 5:20 p.m. with the Registered Dietician (RD) in the Main Kitchen, the uncooked white rice stored in a covered bin was contaminated with a green leafy substance. The RD confirmed contaminated rice container and stated, I think that's parsley. The RD confirmed the contaminated rice should have been discarded. During a review of the facility's policy and procedure (P&P) titled, Food Storage, undated, the P&P indicated, Food will be stored in an area that is clean, dry and free from contaminants. The P&P also indicated, Food will be stored . by methods designed to prevent contamination or cross contamination. 5. During a concurrent observation and interview on 5/12/25 at 4:32 p.m. with the Registered Dietician (RD) in the walk-in freezer of the Main Kitchen, the following items were observed open to the air and not properly stored in sealed containers: a. One bag of frozen chicken patties b. One bag of carrots c. One bag of breadsticks The RD stated the items should have been stored in a sealed container. During a concurrent observation and interview on 5/12/25 at 5:01 p.m. with the Kitchen Manager (KM ) in the Dry Storage Room, the following items were observed open to the air and not properly stored in sealed containers: 555595 Page 26 of 28 555595 05/16/2025 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0812 a. One bag of mashed potatoes mix (instant mashed potatoes in a dehydrated form) Level of Harm - Minimal harm or potential for actual harm b. One bag of poultry gravy mix (pre-packaged powder or granule to be mixed with water or broth to create gravy) Residents Affected - Many c. One bag of brown gravy mix The KM stated the bags used to store food items should be sealed closed to prevent contamination. During a review of the facility's policy and procedure (P&P) titled, Food Storage, undated, the P&P indicated, Refrigerated food storage: .f. All foods should be covered, labeled and dated. The P&P also indicated, Frozen Foods: .c. All foods should be covered, labeled and dated . Food will be stored . by methods designed to prevent contamination or cross contamination . plastic containers with tight fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables, and broken lots of bulk foods . 6. During a concurrent observation and interview on 5/12/25 at 4:32 p.m. with the Registered Dietician (RD) in the walk-in refrigerator of the Main Kitchen, there was one sealed plastic bag, not labeled with a use-by-date, that contained cooked pancakes covered in cling film. The RD confirmed pancakes should have been properly labeled with a use-by-date. During a concurrent observation and interview on 5/12/25 at 4:48 p.m. with the Registered Dietician (RD) in the walk-in freezer of the Main Kitchen, the following items were not properly labeled with an open and/or use-by-date: a. One bag of frozen chicken patties b. One bag of breadsticks The RD confirmed the food items should have been properly labeled with an open and use-by-date. During a concurrent observation and interview on 5/12/25 at 5:01 p.m. with the Kitchen Manager (KM ) in the Dry Storage Room, the one bag of mashed potatoes mix (instant mashed potatoes in a dehydrated form) in a plastic bag was not properly labeled with an open and/or use-by-date. The one bag of brown gravy mix (pre-packaged powder or granule to be mixed with water or broth to create gravy) in a plastic bag was not properly labeled with a use-by-date. The KM confirmed the items were not properly labeled. During a review of the facility's policy and procedure (P&P) titled, Food Storage, undated, the P&P indicated, All containers must be legible and accurately labeled and dated. The P&P also indicated, Refrigerated food storage: .f. All foods should be covered, labeled and dated. All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded. The P&P also indicated, Frozen Foods: .c. All foods should be covered, labeled and dated. All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded. 555595 Page 27 of 28 555595 05/16/2025 Smith Ranch Skilled Nursing & Rehabilitation Cente 1550 Silveira Parkway San Rafael, CA 94903

F 0865 Have a plan that describes the process for conducting QAPI and QAA activities. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review the facility's Quality Assurance Performance Improvement (QAPIdata-driven approach to improving quality in healthcare facilities) committee failed to identify the need for oversight of the Restorative Nursing Assistance (RNA) program. This failure resulted in residents not receiving the appropriate treatments per physician orders. (Refer to F688). Residents Affected - Many Findings: During a review of the facility's Restorative Program Monthly Audit, dated 5/1/25, the Restorative Program Monthly Audit was completed for the month of April 2025. The Restorative Program Monthly Audit indicated a total of 84 missed visits from 13 Residents reviewed. During a review of the facility's Order Listing Report, dated 5/15/25, the Order Listing Report indicated there are a total of 22 Residents currently receiving RNA services. During an interview on 5/16/25 at 11:16 a.m. with the Director of Nursing (DON) and Director of Rehabilitation (DOR), The DOR stated the DON oversees the RNA program because it falls under nursing and the DOR is only responsible for training staff and putting in RNA orders. The DOR further stated she does not complete any auditing for the RNA program. The DON stated he quickly scans the RNA weekly progress notes but does not verify the treatment provided against the orders. The DON and the DOR both confirmed they were unaware of any issues with the RNA program not fulfilling the physician orders. During a concurrent interview and record review on 5/16/25 at 1:01 p.m. with the Administrator (Admin) and the DON, the QAPI Meeting Minutes dated October 2024 to April 2025 were reviewed. The minutes indicated no focus on the RNA program. The Admin confirmed QAPI did not identify any concerns with the RNA program. During a review of the Facility's Quality Assurance Performance Improvement Plan (QAPIP), undated, the QAPIP indicated, Segments of Care . Inpatient Rehabilitation . Services Rendered . Provide appropriate levels of rehabilitation to the inhouse Residents and coordinate with their MD's [Medical Doctor] . Clinical care will be measured through: Consultant evaluations and feedback of practice, MDS-QI [Minimum Data Set Quality Improvement- an assessment tool used to guide resident care] scores, Family/Resident survey scores, QAPI tools . 555595 Page 28 of 28