The Tamalpais

Based on interview and record review, the facility failed to provide a Registered Nurse (RN) for eight consecutive hours a day, seven days a week from January 2025 to August 2025 for all the residents residing in the facility.This failure had the potential to result in insufficient nursing care and services for the vulnerable residential population residing in the facility.During a review of the facility's Payroll Based Journal (PBJ) Staffing Data Report, dated Quarter 2 2025 (January 1 - March 31), the PBJ Staffing Data Report indicated, the facility had no RN hours for the following Sundays: 1/5/2025, 2/2/2025, 2/16/2025, 3/2/2025, and 3/30/2025.During a review of the facility's Skilled Daily Staffing, assignment report dated Sunday, 8/17/2025, the Skilled Daily Staffing report indicated there was no RN coverage for skilled nursing.During a review of the facility's Skilled Daily Staffing, assignment report dated Sunday, 8/31/2025, the Skilled Daily Staffing report indicated there was no RN coverage for skilled nursing.During an interview on 9/10/2025 at 7:47 a.m. with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to have a dedicated full-time infection preventionist (IP) according to the California Assembly [NAME] (AB) 2644 (Chapter 287, Statutes of 2020). This failure had the potential to negatively affect the facility's infection prevention and control program and the residents' quality of care.Findings:During an interview on 9/10/25 at 3:21 p.m., with the IP, the IP stated her responsibilities included assist with infection surveillance, track and trend infections, train staff in infection control, keep up to date with infection control and prevention guidelines, and participate in the infection control committee and the quality assurance and performance improvement (QAPI). The IP stated she was employed as a full-time IP for the Continuing Care Retirement Community's (CCRC, a residential community for seniors that offers various levels of care on a single campus) 3 levels of care - independent living, assisted living, and the skilled nursing facility (SNF). IP stated she tries to devote most of her time to the SNF because the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to remove one multidose vial of PPD diagnostic antigen (chemical used to indicate tuberculosis) from the medication refrigerator 30 days after opening per facility policy. This failure had the potential to expose all the residents to use of an outdated antigen which could lead to an incorrect medical diagnosis for Tuberculosis (bacterial respiratory infection.)During an observation and interview on 9/9/2025 at 3:02 p.m. in the medication refrigerator located in the nursing station, with the Director of Nursing (DON), the DON verified a vial of PPD diagnostic antigen label indicated an opening date of 7/25/2025. The DON stated that the vial should have been discarded 30 days after opening.During an interview on 9/10/2025 at 4:48 p.m. with DON, the DON indicated that the facility policy was to label a multidose vial with the date when opened and to discard the vial 30 days after opening. The DON stated that medications lose effectiveness or potency after opening. During a review of the facility's policy and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of 2 sampled discharge residents (Resident 26), had a discharge order and discharge summary maintained in their medical record. This failure had the potential to adversely affect Resident 26's continuity of care after discharge. Findings:During a review of Resident 26's Face Sheet, the Face Sheet indicated Resident 26 was admitted to the facility on [DATE] with diagnoses of atrial fibrillation (irregular heart rhythm), myocardial infarction (heart muscle damage), asthma (difficulty breathing), high blood pressure, and elevated liver enzymes.During a concurrent interview and record review on 9/10/2025 at 3:13 p.m. with Minimum Data Set Registered Nurse (MDSRN - nurse who specializes in collecting patient data in a long-term care facility), Resident 26's electronic medical record (EMR) was reviewed. The MDSRN indicated that the physician should write a discharge order and discharge summary to provide the resident guidance for continued medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to develop a care plan (an individualized plan that provides direction on the type of care a resident needs) for one of 17 sampled residents (Resident 2). This failure had the potential for Resident 2 to not receive the specific services necessary to meet her needs.Findings: During a review of Resident 2's Profile Face Sheet (demographic), the Profile Face Sheet indicated Resident 2 was admitted to the facility on [DATE] with a femur (bone of the thigh) fracture and Alzheimer's Disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline).During an observation on 9/8/25 at 5:38 p.m., outside of Resident 2's room, an Enhanced Barrier Precautions (EBP, are infection control interventions designed to reduce the spread of multidrug-resistant organism, MDROs - a germ that is resistant to many antibiotics) sign was posted on the wall below Resident 2's name plate. The EBP indicated, Stop. Everyone must:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable well-being for two of 17 sampled residents (Resident 8 and Resident 22) when:1. Resident 8 was observed without a wanderguard device (a wearable device designed to help prevent residents at risk of wandering from leaving a designated area in a care facility) per physician's order and there was no elopement assessment prior to placing a wander guard device on Resident 8. These failures had the potential to adversely affect Resident 8's physical and psychosocial well-being.2. Resident 22's floor mats were not placed as ordered by the physician. This failure had the potential to cause injury to Resident 22. Findings: 1.During a review of Resident 8’s “Profile Face Sheet (demographic),” the “Profile Face Sheet” indicated Resident 8 was admitted to the facility on [DATE] with a diagnosis of dementia (a general term for a decline in mental ability that is…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure the kitchen preparation area was maintained in a safe and sanitary manner when one of the staff with facial hair was observed cooking food not wearing a beard net. This failure had the potential to place all residents who received food prepared in the kitchen at risk for food contamination.During an observation on 9/8/2025 at 2:20 p.m. of the kitchen, [NAME] 1 was observed without a beard net covering his facial hair while standing next to the stove cooking.During a concurrent observation and interview on 9/10/2025 at 10:04 a.m. with Director of Dining Services (DDS), in the kitchen, the DDS verified that [NAME] 1 did not wear a beard net.During a record review of the facilities policy and procedure (P&P) titled, Uniform Dress Code, dated 1/2020, the P&P indicated, Restrain all facial hair with a beard net/restraint.During a review of the FDA Food Code 2022, 2-402 - Hair Restraints, the code states, Food employees shall wear hair restraints such . beard restraints . that covers hair, that are designed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow and implement infection control practices for two of 17 sampled residents (Resident 2 and Resident 7) when:1.Two staff members did not wear personal protective equipment (PPE) while providing care to Resident 2 who was in Enhanced Barrier Precautions (EBP, are infection control interventions designed to reduce the spread of multidrug-resistant organism, MDROs - a germ that is resistant to many antibiotics) 2. One staff member did not clean and disinfect reusable blood pressure cuff in between resident use. These failures had the potential to cause the spread of infections to residents.Findings: 1.During a review of Resident 2’s “Profile Face Sheet (demographic),” the “Profile Face Sheet” indicated Resident 2 was admitted to the facility on [DATE] with a femur (bone of the thigh) fracture and Alzheimer’s Disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline). During an observation on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure proper infection control practices during medication administration for three (Residents #8, #12, and #87) of nine residents observed during medication administration. Findings included: A review of a facility policy titled Personal Protective Equipment - Gloves, revised in July 2009, revealed, Gloves must be worn when handling blood, body fluids, secretions, excretions, mucous membranes and/or non-intact skin. Further review of the policy revealed, 3. The use of gloves will vary according to the procedure involved. The use of disposable gloves is indicated: a. when it is likely that the employee's hands will come in contact with blood, body fluids, secretions, excretions, mucous membranes, and/or non-intact skin while performing the procedure. A review of a facility policy titled Handwashing/Hand Hygiene, revised in August 2019, revealed, This facility considers hand hygiene the primary means to prevent the spread of infections. The policy revealed, 7. Use an alcohol-based…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, record reviews, and facility document reviews, the facility failed to provide advance beneficiary notices 48 hours prior to discharge from Medicare Part A services for two (Resident #19 and Resident #21) of three sampled residents reviewed for beneficiary notices. Findings included: A review of Resident #19's Profile Face Sheet revealed the facility admitted Resident #19 on 08/17/2023 with diagnoses that included acidosis (a buildup of acid in the bloodstream), acute kidney failure, and chronic kidney disease. A review of Resident #19's Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNFABN) form indicated their last covered day was 09/01/2023. The form was signed and dated 12/04/2023. A review of Resident #21's Profile Face Sheet revealed the facility admitted Resident #21 on 06/16/2023 with diagnoses that included pneumonia (lung infection), Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), and Alzheimer's disease (A progressive disease that destroys memory and other important…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, interviews, facility policy review, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure a significant change in status comprehensive assessment was completed within 14 days of hospice services election for one (Resident #24) of one sampled resident reviewed for hospice services. Findings included: A review of a facility policy titled Hospice Care, revised in May 2021, revealed, 5. If appropriate a change of condition Minimum Data Set (MDS) shall be completed per RAI guidelines. A review of the CMS Long-Term Care RAI 3.0 User's Manual, Version 1.18.11, dated October 2023, Chapter 2: Assessments for the RAI revealed, 03. Significant Change in Status Assessment (SCSA) (A0310A = 4) The SCSA is a comprehensive assessment for a resident that must be completed when the IDT [interdisciplinary team] has determined that a resident meets the significant change guidelines for either major improvement or decline. The user's manual further specified, An SCSA…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews, the facility failed to ensure a pro re nata (PRN, as needed) psychotropic medication (medications that affect the mind, emotions, and behavior) order specified the duration of use or stop date for one (Resident #20) of five sampled residents reviewed for unnecessary medications. Findings included: A review of Resident #20's Profile Face Sheet revealed the facility most recently admitted the resident on 03/30/2023 with diagnoses that included mild cognitive impairment (a condition in which people have more memory or thinking problems than other people their age) and unspecified disorientation. A review of Resident #20's Baseline & Comp [comprehensive] Care Plan, undated, revealed a Problem area that indicated Resident #20 required the use of psychotropic medications to manage their mood and/or behavior symptoms. The care plan specified the resident required antianxiety medication related to anxiety (Intense, excessive and/or persistent worry and fear) under hospice care. A review of Resident #20's physician's orders revealed orders dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record review, and facility policy review, the facility failed to ensure medications were not repackaged in one (third-floor medication cart) of two medication carts, and the facility failed to ensure an opened multi-dose vial was discarded in one (second-floor medication room) of one medication room observed. Findings included: During an interview on 12/08/2023 at 10:47 AM, the Director of Nursing Services (DNS) stated the facility did not have a policy that addressed repackaging medications. A review of a facility policy titled 5.3 Storage and Expiration Dating of Medications, Biologicals, Syringes and Needles, revised on 04/01/2022, revealed, Once any medication or biological package is opened, Facility [sic] should follow manufacturer/supplier guidelines with respect to expiration dates for opened medications. 1. Medication administration observation was conducted on 12/06/2023 at 7:59 AM with Licensed Vocational Nurse (LVN) #1. LVN #1 prepared Resident #12's medications, which included acetaminophen 325 milligrams (mg). LVN #1 removed one…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure proper hand hygiene was maintained in the kitchen when a kitchen staff member handled dirty dishes and then handled clean dishes without washing hands in between. This could potentially spread infectious microorganisms in a vulnerable population. Findings: During an observation and concurrent interview on 10/23/19 at 11:56 a.m., a kitchen staff member loaded used coffee cups into a rack for the dishwasher. The kitchen staff member then went over to the clean side of the dishwashing area and placed clean dishes in plastic bins up on a shelf. The staff member did not wash his hands before handling the clean dishes. When queried, Director of Food Services stated his expectation was for the staff member to wash his hands and re-glove when switching from handling dirty dishes to clean dishes. In response to a request for a dish washing policy, an untitled document, not dated, was provided with the policy statement, Facility will adhere to the Safety standards to ensure high standards of cleanliness and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.