The Tamalpais

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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 This failure had the potential to expose all the residents to use of an outdated antigen which could lead to an incorrect medical diagnosis for Tuberculosis (bacterial respiratory infection.)During an observation and interview on 9/9/2025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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.