Health inspection·January 17, 2020

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to inform one of 18 residents (Resident 54) regarding his right to formulate an advance directive (AD - a document by which a person makes provision for health care decisions in the event that, in the future, he/she becomes unable to make those decisions). This failure placed the residents at risk for receiving treatment and services against their wishes if they cannot or can no longer be able to make healthcare decisions for themselves. Findings: During a review of Resident 54's Resident Face Sheet (RFS), the RFS indicated Resident 54 was initially admitted on [DATE] and was re-admitted on [DATE]. The RFS indicated that Resident 54 made decisions for himself. The RFS also indicated Resident 54 did not have a copy of AD on file. During a review of Resident 54's Minimum Data Set (MDS - a resident assessment tool) dated 12/22/19 indicated a Brief Interview for Mental Status (BIMS - an assessment used to help detect cognitive impairment) score of 15 indicating Resident 54 was cognitively intact. During an interview on 1/14/20 at 12:57 PM with Resident 54, he was asked if the facility had given him information about formulating an AD since readmission. Resident 54 stated, . No, I don't think we talked about it . During an interview on 1/16/20 at 11:40 AM with Social Services Staff (SS) 1, SS 1 stated that residents are offered to formulate an AD during admission . offered as part of the admission packet . SS 1 further stated, . We ask them during admission, sometimes offer it during care conference . It's a good practice to offer . During an interview on 1/16/20 at 11:48 AM, SS 2 was asked if the facility discussed with Resident 54 about formulating an AD. SS 2 stated, Yes, or we review it (referring to AD) . during quarterly care conference . During a concurrent interview on 1/16/20 at 11:53 AM with SS 1 and SS 2, SS 2 reviewed Resident 54's clinical record and stated that there was no documentation of discussion regarding formulation of AD with Resident 54. SS 1 was asked about the facility policy when a resident was admitted without an advance directive. SS 1 stated, . We discuss with resident . document discussion with resident . unfortunately, it's (referring to the documentation of discussion with Resident 54) not in our IDT (Interdisciplinary Team) . During a review of Resident 54's IDT Qtrly [quarterly] Care Conference Notes (IDT Notes) with completion dates of 7/1/19 and 1/16/20, the IDT Notes indicated Resident 54 did not have an advance directive. During a review of the IDT admission Care Conference Notes dated 12/23/19, there was no documentation that Resident 54 was asked if he would like to formulate an AD. During a review of the facility's policy and procedure (P&P) titled, Advance Directive Policy and Procedure, dated 11/1/19, the P&P indicated, . Policy . The facility will respect each resident's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 2 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookside Skilled Nursing Hospital 2620 Flores Street San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0578 Level of Harm - Minimal harm or potential for actual harm right to participate in and/or make his/her treatment decisions. Procedure . 3. Residents who are competent at the time of admission and who have not previously executed an Advance Directive shall be asked if they would like one prepared. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 3 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookside Skilled Nursing Hospital 2620 Flores Street San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to timely notify the resident and/or their representative of changes in the Medicare Part A (federally funded insurance plan covering skilled services) insurance coverage and billing for one of three residents when: Residents Affected - Few 1. The facility did not provide a Notice of Medicare Non-Coverage (NOMNC - a form given to Medicare recipients notifying them that Medicare Part A coverage is being terminated and providing information on how to file an appeal of that decision) to the representative of Resident 637. 2. The facility did not provide a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN - a form given to Medicare receipting notifying them of the services available in the facility and the cost of those services when their insurance coverage ends) to the representative of Resident 637, on time. This failure had the potential to prevent the residents from filing a timely appeal of the decision to discharge from Medicare Part A services, and had the potential to not allow the residents to be informed about the services available and the cost of services. Findings: During a review of the facility's .Beneficiary Notice - Residents discharged Within the last Six Months . (Beneficiary Notice List) on 1/15/20, at 9 a.m., beneficiary notice list indicated, Resident 637 remained in the facility after being discharged , or terminated, from Medicare Part A service on 1/10/20. During a review of Resident 637's SNF ABN on 1/15/20, at 3:21 p.m., Resident 637's SNF ABN (undated) indicated, Beginning on 01/11/19 you may have to pay out of pocket for this care . Resident 637's SNF ABN included, no signature or date from the resident's representative, and there was no comments or Additional Information. During a review of Resident 637's .Beneficiary Protection Notification Review (Beneficiary Notification Checklist), on 1/15/20, at 3:10 p.m., Beneficiary Notification Checklist indicated, the last covered day of Part A service was 1/10/20. Beneficiary Notification Checklist included, the section on the SNF ABN had a check in the box: Other Explain, with a comment next to the box indicating, Resident 637's representative was mailed the SNF ABN on 1/11/2020, the day after the last covered day. The Beneficiary Notification Checklist included, a check in the box indicating a NOMNC had not been provided. During a review of Resident 637's clinical record on 1/15/20, at 2:50 p.m., Resident 637's clinical record indicated, a representative made his decisions. Resident 637's clinical record included, no record of a SNF ABN or NOMNC provided. During a concurrent record review and interview on 1/16/20, at 8:30 a.m., with Business Office Manager (BOM), BOM stated, . The NOMNC and the SNF ABN are given before their [Medicare Part A] insurance coverage ends .the forms [SNF ABN and NOMNC] inform the resident or their representative of the last covered date [under Medicare Part A] . what services the facility offers and how much the services cost when their [Medicare Part A] coverage ends . BOM stated, she explains and provides the SNF (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 4 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookside Skilled Nursing Hospital 2620 Flores Street San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0582 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few ABN and the NOMNC; the resident and/or their representative signs and dates the NOMNC and the SNF ABN, upon being delivered in person or via mail. BOM further stated, the refusals and telephone notifications is documented with a date and time. BOM added, the resident's SNF ABN and NOMNC were uploaded into the resident's electronic clinical record and the paper copy was stored in the business office. BOM stated, the resident's clinical record would not have additional documentation regarding the SNF ABN and/or the NOMNC. BOM reviewed Resident 637's Beneficiary Notification Checklist, submitted 1/15/20, and Resident 637's SNF ABN, (undated). BOM stated, the resident's representative needs to be provided the SNF ABN or NOMNC, but the NOMNC was not provided to their representative. BOM continued, .I mailed her [Resident 637's representative] a copy of it [Resident 637's SNF ABN], and the resident's SNF ABN was mailed to their representative (on 1/11/20), after their last covered day of Medicare Part A service (on 1/10/20). BOM reviewed the resident's clinical record and the business office files. BOM stated, she was unable to provide any additional documentation or records. BOM stated, the resident's SNF ABN .needed to give[en] ahead of time ., and the resident's NOMNC .needed to give[en] . During a concurrent interview and record review on 1/16/20 at 9:05 a.m., with Social Services Director (SSD), Resident 637's clinical record was reviewed. SSD stated, the resident's clinical record included no documentation pertaining to the resident's SNF ABN or NOMNC, and the resident's SNF ABN or NOMNC had not been uploaded into the computer [the resident's clinical record]. SSD reviewed Resident 637's Beneficiary Notification Checklist, submitted 1/15/20, and Resident's SNF ABN (undated). SSD stated, the resident's SNF ABN was provided, late, and a NOMNC was not provided. SSD stated, If the business office doesn't have additional records, then there's nowhere else the information [regarding the SNF ABN or the NOMNC] would be [stored or documented] The Business Office [Manager] is in charge [notifying the resident and/or their representative] of the NOMNCs and the SNF ABNs . There was no facility policy and procedure provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 5 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookside Skilled Nursing Hospital 2620 Flores Street San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** During an interview on 1/16/20, at 1:44 PM, with Restorative Nursing Assistant (RNA), RNA stated Resident 67 needed more help in feeding now and recommended Resident 67 to be in the restorative dining program last month. Residents Affected - Few During a review of Resident's 67 care plan, dated 12/17/19, the care plan indicated activities of daily living (ADL) functional/rehabilitation potential decline in eating. Approach included, set up meal as needed. There was no other revision of ADL plan of care noted. Based on observation, interview, and record review, the facility failed to provide appropriate supervision during meal time for one of 18 residents (Resident 67). This failure had the potential to place Resident 67 at risk for aspiration (occurs when one inhales food into his/her lungs) and not receive adequate daily nutrition requirement. Findings: Resident 67 was admitted on [DATE] with diagnosis including sepsis (presence of infectious organisms in the blood stream) and generalized muscle weakness. During a review of the Minimum Data Set (MDS assessment tool) dated 12/12/19, the Brief Interview for Mental Status (BIMS, a tool to screen cognitive impairment) score is one (1) indicating severe cognitive impairment; the functional assessment indicated extensive assistance in eating requiring one person's help. During an observation on 1/14/20, at 12:48 PM, in resident's room, Resident 67 was in bed sitting, awake, with meal tray placed on the over bed table in front of him. Resident 67 was slowly eating the meat on his plate, coughing and tilting his head backwards while drinking milk from a glass. There was no staff member in the room. There was a Nurse Alert posted by the head of the bed that indicated, Safe swallowing precautions .supervision: intermittent .Standard Precautions: Sit fully upright . Notify RN if throat clearing, coughing . During a concurrent observation and interview on 1/14/20, at 12:55 PM, with Certified Nursing Assistant (CNA) 2, in Resident 67's room, CNA 2 came in the room and assisted Resident 67 with his meals. CNA 2 stated Resident 67 needed supervision with eating. During an interview on 1/14/20, at 1:24 PM with CNA 1, CNA 1 stated that Resident 67 was min [sic] assist, set-up, eats little by little, no problem. CNA 1 stated that intermittent supervision meant to check every 2 to 5 minutes. CNA 1 also stated that the speech therapist has worked with Resident 67 before and staff was instructed to stop feeding and call the nurse when the resident starts to cough during meals. During an interview on 1/15/20, at 10:08 AM, with the Speech-Language Pathologist (SLP - work to prevent, assess, diagnose and treat speech, language, and swallowing disorders), the SLP stated Resident 67 was not consistently safe with liquids and had instructed the family, caregiver and nursing regarding the plan of care which included sitting on a chair during meals with intermittent supervision. During an interview on 1/16/20, at 4:28 PM, with Assistant Director of Nursing (ADON), ADON stated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 6 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookside Skilled Nursing Hospital 2620 Flores Street San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0676 Level of Harm - Minimal harm or potential for actual harm intermittent supervision is not continuous, the CNAs were expected to check on the resident at least every five (5) minutes and the charge nurse make rounds to monitor CNAs are following the precautions posted at the bedside. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 7 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookside Skilled Nursing Hospital 2620 Flores Street San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few Note: The nursing home is disputing this citation. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide an environment and required devices to prevent accidents for one of three residents (Resident 47) when Resident 47 had unlocked wheelchair/bed brakes on 1/17/20 and at the time of her fall, on 10/8/19. Resident 47 had also not received an ultra low bed, anti-slid guards, per the plan of care. Furthermore, the facility did not ensure Resident 47 had a fall mat after the fall on 10/8/19. This deficient practice resulted in Resident 47 sustaining a fractured (broken) right clavicle (collarbone) due to an unwitnessed fall on 10/8/19. This deficient practice also raised the risk of reoccurring falls for Resident 47. Findings: During a review of Resident 47's Resident Face Sheet (face sheet), (undated), the face sheet included, a medical diagnoses of Alzheimer's disease (a type of brain disorder causing memory, thinking and behavior problems), old myocardial infarction (the blockage of oxygen rich blood to a section of heart muscle), difficulty in walking, history of falling, muscle weakness, and prediabetes (a condition where blood sugar levels were higher than normal). During a review of Resident 47's Minimum Data Set (MDS, a resident assessment and care screening tool), dated 11/25/19, the MDS indicated, Resident 47 scored a three on the Brief Interview for Mental Status (a structured cognitive test), meaning Resident 47 had severe cognitive impairment. The MDS also indicated, Resident 47 needed physical assistance from one person with transferring (moving between surfaces) and moving in the room. A review of Resident 47's Interdisciplinary Team Notes . Post Fall/Fall Scene Investigation Report (post fall investigation report), dated 10/8/19, the post fall investigation report indicated, on 10/8/19, Resident 47 fractured her right clavicle after the resident had an unwitnessed fall, at 11:45 a.m. The post fall investigation report added, the resident lost balance and fell when she tried to self-ambulate and used the side table as a walker. The post fall investigation report indicated, Wheelchair/bed brakes [were] unlocked at the time of the fall. The post fall investigation report added Resident 47 needed assistance from two certified nursing assistants and one charge nurse, at the time of the fall. During a review of Resident 47's progress notes on 1/16/20 included, notes written by the resident's health care provider and by other disciplines (e.g. nursing, hospice, and the registered dietitian). The progress notes indicated, on 10/8/19, a certified nursing assistant found Resident 47 lying on her bedroom floor. The progress notes indicated, on 10/8/19, Resident 47 reported she was standing up from her bed and was holding onto the bedside table; the bedside table slid, and she lost balance and fell onto her right side. The progress notes included, no documentation the resident's items were within reach and fall precautions were implemented at the time of the fall. The progress notes included, no documentation of Resident 47 having an ultra low bed or anti-slid guards between 10/7/19 and 10/14/19 (including the time of the fall). The progress notes also indicated, Resident 47 received an order for a floor mat and an x ray (using electro magnetic radiation to take images of the inside of the body) of the right shoulder after the fall, on 10/8/19. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 8 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookside Skilled Nursing Hospital 2620 Flores Street San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm During a review of Resident 47's radiology (a branch of medicine that uses imaging technology to diagnose and treat disease) interpretation, dated 10/8/19, the radiology interpretation indicated, the resident's oblique fracture involving the lateral aspect of the right clavicle was most likely acute. In other words, the break in the resident's right collar bone occurred suddenly and recently and sudden. Residents Affected - Few Note: The nursing home is disputing this citation. During a concurrent observation and interview on 1/14/20, at 9:19 a.m., with Resident 47, in the bedroom of Resident 47, Resident 47 sat in a wheel chair and followed simple questions and/or directions. Resident 47 had instances of repeating herself and answering interview questions inappropriately. A sheet of paper on the resident's bedroom wall included an alert indicating Resident 47 was at risk for falls. There wasn't a floor mat, an ultra low bed, or any anti-slid guards in Resident 47's bedroom. During a review of Resident 47's .Fall Risk Observation (FRO), dated 8/26/19, the fall risk observation indicated, Resident 47 received a fall risk score of 14; a fall risk score of ten or higher .represents a high risk for fall. The FRO indicated, the resident had not been referred to a fall prevention program or any other program. The FRO further indicated the resident's current care plan was continue[d], and not updated. During a review of Resident 47's comprehensive care plan on 1/16/20, the comprehensive care plan included, the revision history and the comprehensive care plan in place at the time of the fall on 10/8/19. Resident 47's most recent comprehensive care plan (as of 1/16/20) included, a fall risk care plan which had edits to the focus and goal on 12/16/19, but the approaches were not edited after 4/30/19. The resident's fall risk care plan included, approaches such as anti-slid guards on the entire length of the floor on the right side of the resident's bed, switching the resident's bed to an ultra low bed, and ensuring the resident's equipment was within reach. The comprehensive care plan included, another care plan regarding the resident's right clavicle fracture sustained after an unwitnessed fall, which was created on 10/8/19 and edited on 12/15/19 (most recent date as of 1/16/20); the care plan regarding the resident's right clavicle fracture sustained after an unwitnessed fall included, approaches such as placing the resident in a fall prevention program and providing a floor mat. During an interview on 1/16/20, at 9:24 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated, Resident 47 had confusion and balancing issues and was at risk for falls. CNA 1 stated, She [Resident 47] could walk in her room by herself [time frame not provided], except when going to the bathroom . now she needs more physical help. When asked about Resident 47's fall on 10/8/19, CNA 1 responded she wasn't there [did not witness] when Resident 47 was falling, but saw the resident after the fall. CNA 1 stated she was unable to provide details on where the resident's items were, or the height of the resident's bed, at the time of the fall. When asked how was the staff preventing Resident 47 from falling, CNA 1 gave responses such as keeping the bed and wheel chair locked, placing the resident's objects within reach, and having the resident's bed in the lowest position. During a concurrent interview and observation on 1/16/20, at 9:36 a.m., with CNA 1, in the bedroom of Resident 47, CNA 1 asked for the type of bed Resident 47 had, CNA 1 responded a regular bed. After lowering Resident 47's bed to the lowest position, CNA 1 stated the height of Resident 47's bed was not lower than a regular bed. CNA 1 stated, Resident 47 had not been using an ultra low bed at the time of the fall, on 10/8/19. When asked where was Resident 47's floor mat, CNA 1 was unable to find a floor mat in the resident's bedroom. CNA 1 then stated, the resident had not been using a floor mat, adding she can't remember when the floor mat was provided for Resident 47. When asked how using ultra low bed and a floor mat affected a resident's fall, she stated the ultra low beds and a floor (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 9 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookside Skilled Nursing Hospital 2620 Flores Street San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm mat reduced the impact from a resident's fall. When asked for a description of anti-slid guards, CNA 1 replied, They were used on a floor to reduce sliding. CNA 1 added, there were no anti-slid guards in the Resident 47's bedroom. When asked were anti-slid guards used at the time of Resident 47's fall (on 10/8/19), CNA 1 responded, No . Residents Affected - Few Note: The nursing home is disputing this citation. During a concurrent record review and interview on 1/16/20, at 2:33 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, Resident 47 was at risk for falls and was in a fall prevention program. LVN 1 stated, Resident 47 needs more assistance than what was needed a year ago. LVN 1 further stated, Resident 47 had unwitnessed fall resulting in a fracture. When asked for details about the fall. LVN 1 stated Resident 47 was found on the floor in her bedroom. LVN 1 stated, the certified nursing assistant entered the resident's bedroom and helped the resident before she arrived, so she was unable to describe where the resident's equipment was, or whether the call light was on or off, at the time of the fall. LVN 1 added, she was unable to provide further information, except that Resident 47 had a history of not using the call light. When asked to provide any care plans with information on falls, at the time of resident's fall, on 10/8/19, LVN 1 reviewed the comprehensive care plan in place at the time of resident's fall, on 10/8/19, and was only able to provide the resident's fall risk the care plan. LVN 1 stated, the care plan shows the resident needed an ultra low bed mattress and anti-slid guards on the floor, at the time of the fall, on 10/8/19. LVN 1 was then asked to review Resident 47's most current (as of 1/16/20) comprehensive care plan for any care plans with information on falls. LVN 1 provided the resident's fall risk care plan and stated the care plan's approaches we're not edited after 4/30/19 and the approaches needs to be edited. LVN 1 then provided the care plan regarding the resident's right clavicle fracture sustained after an unwitnessed fall, and stated this care plan was created after the resident's fall on 10/8/19. LVN 1 could not provide any other care plans with information on falls in Resident 47's most current (as of 1/16/20) comprehensive care plan. LVN 1 reviewed Resident 47's progress notes, between 8/1/19 and 1/16/20, and Resident 47's post fall investigation report, dated 10/8/19. LVN 1 stated, there was no documentation which indicated Resident 47 had been provided an ultra low bed mattress and anti-slid guards on her bedroom floor. During a concurrent interview and observation on 1/16/20, at 2:46 p.m., with LVN 1, in the hallway, Resident 47 sat in her wheel chair while LVN 1 tested the locks on the wheel chair brakes LVN 1 stated, Resident 47's wheelchair brakes were unlocked. LVN 1 added, the brakes on the bed and wheel chair needed to be locked too. LVN 1 added, locking the brakes on the bed and the wheel chair was a standard nursing practice which prevents the bed or wheel chair from rolling or sliding when force or pressure was applied to the bed or wheel chair, e.g. during transferring. During a concurrent interview and observation on 1/16/20, at 2:47 p.m., with LVN 1, in the bedroom of Resident 47, LVN 1 stated, there was no floor mat, ultra low bed, or anti-slid guards in the resident's bedroom. LVN 1 was asked to describe the anti-slid guards, LVN 1 replied, They are used on the floor to prevent falls . [because] it prevents sliding . LVN 1 lowered Resident 47's bed to the lowest position and stated the resident's bed was not lower than a normal resident's bed. When asked when was the last time Resident 47 used an ultra low bed or had anti-slid guards in the resident's bedroom, LVN 1 stated, Never. LVN 1 stated, she did not remember when the floor mat was last used for Resident 47. LVN 1 was asked how a floor mat and ultra low beds affects a resident's fall. LVN 1 replied the use of an ultra low bed and/or a floor mat (or floor mats) reduces the impact of fall which in turn lessened the damage or injury from a fall. During a concurrent interview and observation on 1/16/20, at 3 p.m., with CNA 5, in the bedroom of Resident 47, CNA 5 was unable to find an ultra low bed, the anti-slid guards, or a floor mat in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 10 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookside Skilled Nursing Hospital 2620 Flores Street San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few Note: The nursing home is disputing this citation. resident's bedroom. CNA 5 stated Resident 47 had not previously used an ultra low bed or the anti-slid guards. CNA 5 added he did not see the floor mat and was unable to remember when the floor mat was last used. During an interview on 1/17/20, at 8:38 a.m., Rehabilitation Director (Rehab Director) and Physical Therapist (PT), Rehab Director and PT were instructed to describe how to prevent falls and reduce an injury from a fall. Rehab Director stated, . lower the bed . lock the bed . lock the wheel chair .[using] floor mats . PT stated, he agreed with Rehab's answers and added keeping frequently used objects within reach. When asked what anti-slid guards were used for, Rehab Director stated, .To prevent falls by reducing sliding . Rehab Director added sliding results from not enough friction between the floor and another surface; sliding raises the likelihood of slipping and the loss of balance, increasing the risk for falls. PT stated It [anti-slid guards] adds traction. PT added, traction reduced or prevented the sliding motion that often causes a loss of balance and a fall. Rehab Director and PT were asked had Resident 47 been using an ultra low bed, a floor mat, or had anti-slid guards in the resident's bedroom. Rehab Director answered, no. PT denied Resident 47 had been using an ultra low bed or anti-slid guards. Rehab Director further stated, she was unsure if Resident 47 used a floor mat. PT also stated he did not know if Resident 47 used a floor mat. Rehab Director added, Nursing does [the placing and removal of] the floor mats . During a concurrent interview and observation on 1/17/20, at 9:53 a.m., with PT, in the bedroom of Resident 47, Resident 47 laid in bed without a floor mat on the ground. PT could not find a floor mat in the resident's bedroom. When asked about Resident 47's bed, PT stated the resident was using a regular bed, and not an ultra low bed. PT added the height of the resident's bed needs to be lowered to prevent falls. After lowering the height of the bed, PT stated there wasn't a difference between the height of Resident 47's bed and a standard bed in the facility. When instructed to find where Resident 47's bedroom had anti-slid guards, PT stated there were none. During a review of the facility's policy and procedure (P&P) on accident prevention, revised 9/1/16, the P&P indicated, . the facility strives to provide an environment that is free from hazards The P&P added the care and services provided are designed to maximize the safety of the environment, identify residents who are risk of accidents and/or falls and to plan care and implement procedures to prevent avoidable accidents and/or falls; in addition, the facility's care and services are also designed to provide to identified residents who present risks for unavoidable accidents and/or falls and to plan care and implement procedures to minimize unavoidable accidents and/or falls. The P&P continued, Any resident receiving a fall risk score of 10 or above is considered at high risk for potential falls. The resident is placed on a prevention program and the program is care planned[.] The P&P further indicated the interdisciplinary will review, assess, and develop the care plan after a fall occurred. During a review of Resident 47's MDS, dated [DATE], indicated Resident 47 needed only supervision transfers and walking in the room; whereas the MDS dated [DATE] and onwards indicated the resident needed physical assistance with walking and transferring; for example, Resident 47's Significant Change of Status MDS, dated [DATE] (most recent MDS prior the resident's fall on 10/8/19), indicated Resident 47 needed physical assist from two people to transfer and assistance from one person to walk in the room. MDS dated [DATE] and 8/26/19, included a completed care area assessment summary. Both of which included, falls as a triggered care area and that was documented to be addressed in the care plan. During a review of Resident 47's fall risk care plan and resident's right clavicle fracture (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 11 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookside Skilled Nursing Hospital 2620 Flores Street San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few sustained after an unwitnessed fall, on 1/17/20, included, no documentation of the fall prevention program was added to either of the two care plans prior to 10/8/19. The care plan regarding the resident's right clavicle fracture sustained after an unwitnessed fall had not included a goal involving the resident's falls. The approaches in the resident's fall risk care plan also indicated Resident 47 needed supervision with transfers which was inconsistent with the level of assistance and support Resident 47 required, per the documentation in the post fall investigation, dated 10/8/19 and the MDS dated [DATE] and afterwards. Note: The nursing home is disputing this citation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 12 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookside Skilled Nursing Hospital 2620 Flores Street San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not ensure a gradual dose reduction (GDR) was attempted for use of Celexa (an anti-depressant medication) on 1 of 4 sampled residents, Resident 33. This failure had the potential to result in unnecessary use of psychotropic medications which can lead to untoward effects on the resident. Findings: Resident 33 was admitted on [DATE] with diagnoses that included heart disease, chronic kidney disease, and anxiety disorder. During a review of the physician's orders dated 1/1/20, the physician's orders indicated Resident 33 was prescribed Celexa (an anti-depressant medication) with start date of 10/30/18, for 20 milligrams once a day; and Lorazepam (an anti-anxiety medication), 0.25 milligrams twice a day, with start date of 12/11/19. During a concurrent interview and review of Resident 33's medical record, on 1/17/20 at 1:46 PM, with the Assistant Director of Nursing (ADON), ADON stated there was no gradual dose reduction attempted on Celexa. The ADON was unable to provide evidence that the facility implemented a GDR on Resident 33's use of Celexa. During a review of the facility policy and procedure titled, Medication Management, dated 2007, indicated, Policy - Each resident's drug regimen is reviewed to ensure it is free from unnecessary drugs . Additional specific guidelines are applied to Psychotropic drugs which are defined as any drug that affects brain activities associated with mental processes and behavior. This includes, but are not limited to: Antipsychotics; Antidepressants; Anti-anxiety; and Hypnotics . Gradual Dose Reduction for Psychotropic Medications - The regulation addressing the use of psychotropic medications identifies the process of tapering as a GDR and requires a GDR, unless clinically contraindicated. Within the first year in which a resident is admitted on a psychotropic medication or after the prescribing practitioner has initiated a psychotropic medication, the facility must attempt a GDR in two separate quarters (with at least one month between the attempts), unless clinically contraindicated. After the first year, a GDR must be attempted annually, unless clinically contraindicated . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 13 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookside Skilled Nursing Hospital 2620 Flores Street San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0808 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. During a review of the facility Daily Spreadsheet, dated 1/14/20, the Daily Spreadsheet indicated, the protein serving (braised beef tips) for regular portion of the modified diet are as follows: Puree #6 (white scoop = 2/3 cup or 5 oz), Gravy 1 oz; Mechanical Soft Ground #8 (gray scoop = 1/2 cup or 4 oz), Gravy 1 oz; CCHO (consistent or controlled carbohydrate diet) Mechanical Soft Ground # 8 (gray scoop = 1/2 cup or 4oz), Gravy 1 oz. The daily spreadsheet did not indicate direction for serving small portions of the modified diet. During an interview on 1/16/20, at 10:08 am, with Registered Dietitian (RD), RD stated, the spreadsheet did not provide the correct protein serving on the modified diet. Based on observation, interview and record review, the facility failed to ensure the recommended daily protein allowance was provided for 6 residents receiving small portion servings of a modified diet (foods are mechanically altered, can be chopped, ground or pureed). This failure had the potential to result in inadequate protein intake for residents on small portion servings. Findings: During a concurrent observation and interview of tray line, on 1/14/20, at 11:53 AM, with the dietary staff (DS) in the kitchen, DS was serving a small portion of mechanical soft diet. The DS was scooping the braised beef tips using a red handle scoop. The DS acknowledged using a red handle scoop, #24 (scoop size), for the braised beef tips for small portion serving. During a concurrent interview and record review, on 1/16/20, at 9:05 AM, with the Dietary Director (DD), the Daily Spreadsheet dated Tuesday, 1/14/20, was reviewed. The Daily Spreadsheet indicated, braised beef tips, mechanical soft, ground #8. The DD stated that small portions are scaled down based on the regular portion serving size. The DD further stated, a small portion serving size (equivalent to 2 oz) is half of the regular portion (equivalent to 4 oz). During a review of the Scoop Equivalent Chart, [undated], the Scoop Equivalent Chart indicated, scoop size #24 = red, measure 2 2/3 tablespoon (tbsp, unit of measurement) or weight 1 1/3 ounces (oz, unit of weight). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 14 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055188 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookside Skilled Nursing Hospital 2620 Flores Street San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0911 Level of Harm - Potential for minimal harm Residents Affected - Some Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure resident rooms accommodated no more than four residents in each room when two rooms (rooms [ROOM NUMBERS]) had six residents in each room. This failure had the potential to negatively impact the safety and well-being of residents. Findings: During a concurrent interview and record review on 1/14/20 at 8:33 AM, the Administrator stated that she had written a letter to the Centers for Medicare & Medicaid Services (CMS) requesting a waiver for rooms [ROOM NUMBERS] which had six residents in each room. A review of the facility letter dated 1/14/20, addressed to the CMS San Francisco Regional Office, Western Division of Survey and Certification, indicated a written request by the facility for the continuation of the waiver for rooms [ROOM NUMBERS] with a total bed occupancy of six residents per room. During a review of the Facility Diagram (FD) dated 2017, the FD indicated the following floor measurements: Rooms 101 had 581 total square feet, and room [ROOM NUMBER] had 608 total square feet. During an interview on 1/16/20 at 9:37 AM with the residents in room [ROOM NUMBER], they stated there were no concerns about the space and the room. During an interview on 1/16/20 at 9: 42 AM with the residents in room [ROOM NUMBER], they stated there were no concerns about the space and the room. During a concurrent observation and interview on 1/16/20 at 9:53 AM, with the Maintenance Supervisor (MS), the MS confirmed that room [ROOM NUMBER] had six residents. room [ROOM NUMBER] was divided into two sections. The right section had two beds and the left section had four beds. room [ROOM NUMBER] had a common entrance door and a shared bathroom. During a concurrent observation and interview on 1/16/20 at 9:57 AM with the MS, the MS confirmed that room [ROOM NUMBER] had six residents. room [ROOM NUMBER] was divided into two sections. The left section had four beds and the right section had two beds. room [ROOM NUMBER] had a common entrance door and a shared bathroom. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 15 of 15