Health inspection·January 14, 2022

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During a concurrent interview and record review on 1/14/22, at 9 AM, with Director of Staff Development (DSD), DSD stated, Resident 28 has an order but not clear. DSD cannot find the care plan for oxygen for Resident 28. DSD further stated, there should be a care plan as far as oxygen is concerned. During a review of the facility's policy and procedure (P P) titled, Assessments and Care Plans dated 11/1/17, the P&P indicated, Policy: .The care plan will be individualized .will consist of identified needs and problems, reasonable, measurable and time framed goals, and realistic approaches for achieving desired outcomes . Event ID: Facility ID: 055188 If continuation sheet Page 2 of 20 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 01/14/2022 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 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 provide services according to professional standards of quality for one of four sampled residents when: Residents Affected - Few The oxygen order for Resident 28 was not specified whether continuous or as needed basis. This failure had the potential to not deliver oxygen correctly and ensure safe and effective oxygen therapy, which can result to negative consequences to the resident. Findings: During a review of admission record for Resident 28, the admission record indicated resident was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included pneumonia (lung infection), pericardial effusion (buildup of too much fluid in the double layered, saclike structure around the heart), diabetes (abnormal blood sugar), chronic kidney disease and on dialysis (dialysis is a procedure to remove waste products and excess fluids from the blood when the kidneys stop working properly), and hypertension. During a review of Resident 28 physician's order dated 7/16/21, the physician order indicated, oxygen at 2 Liters/minute, may increase to 4 Liters/minute to relieve shortness of breath. During a review of Resident 28's minimum data set (MDS, a resident assessment tool) dated 11/30/21, the MDS indicated, Brief Interview Mental Status (BIMS, a short scanner to help detect cognitive impairment) score of 15 indicated no cognitive impairment. During the initial tour observation, on 1/11/22, at 9:10 AM, Resident 28 was sitting on her bed, awake and alert. A portable oxygen concentrator connected to NC was dangling by Resident 28's bedside. Resident 28 stated, she sometimes get oxygen. During a concurrent interview and record review on 1/13/22, at 11:25 AM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, there is an order of oxygen therapy for Resident 28, unsure if continuous or as needed basis. LVN 1 stated, they are checking Resident 28's oxygen saturation level (O2 saturation - the amount of oxygen traveling through the body with the red blood cells and normal oxygen saturation is usually between 95% and 100% for most healthy adults) every shift and the nurse should know that if the resident oxygen saturation level is below 90%, the resident should be given oxygen. LVN 1, acknowledged the oxygen order is not clear and needed clarification. During a concurrent interview and record review on 1/14/22, at 9 AM, with Director of Staff Development (DSD), DSD stated, the oxygen order for Resident 28 should have indicated continuous or PRN (as needed). DSD further stated, the order was not clear and should have been clarified with the physician. DSD stated, she will be educating staff. During a review of the facility's policy and procedure (P & P) titled, Oxygen Administration dated 1/1/15, the P & P indicated under Use, .orders for oxygen include .3. whether administration is to be routine or PRN 4. the percent of oxygen saturation to be maintained 5. The percent of oxygen saturation that required physician notification . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 3 of 20 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 01/14/2022 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 0658 Level of Harm - Minimal harm or potential for actual harm During a review of the article titled, Standards for specifying oxygen orders, from Health Care Quality Association on Accreditation HQAA.org, dated 5/4/17, the article indicated, O2 orders, Because it is a drug, oxygen orders must be obtained and should include the following information: .Duration - such as continuous or 12 hours/day or PRN (as needed) . [https://info.hqaa.org/hqaa-blog/o2-orders-101] Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 4 of 20 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 01/14/2022 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 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure one of 16 sampled residents (Resident 29) had weekly assessments and documentation of the pressure ulcer (localized damage to the skin and/or underlying soft tissue usually over a bony prominence) on the left buttock. Residents Affected - Few This failure had the potential to result in delayed healing, and ineffective plan of care and treatment of the resident's pressure ulcer. Findings: During a concurrent observation and interview on 1/13/22, at 10:20 AM, Resident 29 was in his bed awake and alert. Resident 29 stated, he was admitted to the facility for rehabilitation due to a fall incident. When asked about other services received, Resident 29 stated, he was treated for a wound on his buttock and said, it was slowly getting better. During a concurrent observation and interview on 1/13/22 at 3:15 PM, with RN 1, inside Resident 29's room, RN 1 inspected the resident's pressure ulcer on the left buttock. RN 1 stated, the pressure ulcer was unstageable (full thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured) and had tunneling (passageway of tissue destruction underneath the surface of the skin with an opening at the skin level from the edge of the wound). During a review of Resident 29's hospital Discharge Summary and Orders), dated 6/19/21, the hospital Discharge Summary indicated, Interagency Referral to Skilled Nursing Facility . NURSING DOCUMENTATION . TREATMENTS . Wound Left Buttock .Wound Size . Wound Left Buttock -Length (cm): 4.5 cm . Width (cm): 2 cm . Depth (cm): 0.2 cm .Wound Bed Assessment: Pink . During a review of Resident 29's facility admission Skin Risk Observation report, dated 6/19/21, the Skin Observation report indicated, Skin tear(s) was marked under the section Other Ulcers, Wounds and Skin Problems. The report further indicated, the skin tears were located on the back of l [left] foot and left elbow. There was no indication of a skin-related problem on the left buttock. During a concurrent record review of Resident 29's medical records, and interview on 1/14/22, at 2 PM, with RN 1, RN 1 stated, the nursing progress note (PN) dated 6/19/21, indicated Resident 29 had a pressure ulcer scar on the left buttock. RN 1 stated, the nursing PN dated 8/10/21 indicated an open area on the left buttock. RN 1 further stated, wound physician report dated 10/20/21, indicated left buttock stage 3 (full thickness loss of skin with possible subcutaneous fat, granulation tissue, rolled wound edges visible, and slough, eschar (dead tissue)) and tunneling. RN 1 also stated, wound assessments had to be done weekly. When asked, RN 1 was unable to present evidence of weekly wound assessments and documentation that indicated prior condition of the resident's left buttock pressure ulcer until 10/20/21 when the wound physician evaluated stage 3 pressure ulcer. RN 1 added the resident's wound care was transitioned to hospice services on 10/26/21. During a review of Resident 29's admission Minimum Data Set (MDS, an assessment tool), dated 6/25/21, Section I - Active Diagnoses indicated, Pressure ulcer of left buttock, stage 2 (partial thickness skin loss with exposed skin presenting as a shallow open ulcer). During a review of Resident 29's Skin Integrity Events report, dated 8/10/21, the Skin (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 5 of 20 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 01/14/2022 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 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Integrity Report indicated, .left buttock .skin abrasion 1.0 cm x 0.7 cm . Depth of Skin Tear/Laceration shallow (marked) . Blood Loss - Controlled Bleeding (marked) . Wound Edges - irregular (marked) . During a review of Resident 29's Skin Integrity Events report, dated 8/31/21, the Skin Integrity Report indicated, .open wound on left buttock . 1 cm x 1.5 cm . Depth of Skin Tear/Laceration - shallow (marked) . Blood Loss - Small Amount (marked) . Wound Edges - irregular (marked) . During a review of Resident 29's nursing progress note, dated 9/1/21, the nursing progress notes indicated, . on monitoring for (L) [left] buttock wound . During a review of Resident 29's nursing progress note, dated 10/4/21, the nursing progress notes indicated, . left buttock wound noted with almost 100% slough about 2.5 x 3 cm, some foul odor . During a review of Resident 29's Infection Control report, dated 10/20/21, the Infection Control Report indicated, .left buttock pressure ulcer wound infection . wound has slough, and deeper compared to last week, redness around the wound . During a review of Resident 29's Wound Management Detail Report, from 6/19/21 through 12/27/21, the wound report indicated, one entry on 8/10/21 on a left buttock wound location. During a review of the facility's policy and procedure (P&P), titled, WOUND MANAGEMENT AND SKIN INTEGRITY, dated 4/1/21, the P&P indicated, .ASSESSMENT - General Guidelines 1. Comprehensive assessment is essential for effective pressure ulcer prevention and treatment and includes . Assessments are completed during admission, weekly for the first four weeks after admission, quarterly, and when the resident experiences a significant change of condition . ASSESSMENT . PRESSURE ULCERS . Assessment Guidelines . Documentation includes type of skin injury/ulcer, location, shape, appearance of ulcer edges and wound bed, condition of surrounding tissues . Documentation Guidelines - At least weekly (or more often when indicated .) an evaluation of the pressure ulcer is documented. Documentation includes: 1. Date that wound observation is being done 2. Stage of the wound 3. Size 4. Depth 5. Presence, location and extent of undermining, tunneling or sinus tract 6. Exudate if present, including type, color, odor and approximate amount 7. Appearance of wound bed 8. Appearance of surrounding skin 9. Appearance of surrounding tissue and wound edges 10. Occurrence of pain, its nature and frequency . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 6 of 20 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 01/14/2022 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 - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure one of 16 sampled residents (Resident 165) was provided treatment, supervision and appropriate equipment and supplies to prevent accidents related to oral suctioning (a procedure to clear secretions such as mucus from the mouth). 1. There was no assessment and documentation to identify Resident 165's individual risk of an accident, including the need for supervision prior to performing oral suction on her own. 2. Resident 165's care plans did not incorporate oral suctioning procedures consistent with the resident's needs, goals, and facility standards of practice, policies and procedures. 3. There was no physician's order for Resident 165 to self-administer an oral suctioning procedure. 4. Resident 165's oral suctioning and use of suction equipment and supplies were not monitored and documented in accordance with facility standards of practice, policies, and infection prevention and control. These failures had to potential for Resident 165 to not receive proper and safe respiratory care services related to oral suctioning. Findings: During an observation on 1/12/22, at 9:43 AM, Resident 165 sat on the side of her bed and performed oral suctioning of her mouth using a yankauer (a medical suction device). Resident 165 stated, she did it herself to take out mucus. During a record review of Resident 165's history and physical (H&P), dated 12/31/21, the H&P indicated, resident was admitted to the facility on [DATE] with dysphagia (difficulty swallowing), bronchiectasis (a lung condition resulting to a build-up of excess mucus), acute stroke due to ischemia (inadequate blood supply), depressive disorder and anxiety. During a record review of Resident 165's physician order report (POR), signed by the physician on 1/14/22, the POR indicated, . Medications flow sheet . Sertraline . Start Date 12/30/21 . 1 tab (tablet) . once a day . For anxiety . Sertraline Use - Observe resident closely for significant side effects . sedation . drowsiness . Lorazepam . Start Date . 12/30/21 . 1 tab (tablet) . Three Times A Day . PRN (as needed) . Monitor for Side Effects . Lorazepam Use . Observe resident closely for significant side effects . Sedation, Drowsiness . Dizziness . Confusion . Monitor Sedation . Sedation Level . Sleepy Easily aroused . Awake, Alert . Occasionally drowsy, easily aroused . Frequently drowsy, drifts to sleep . Somnolent, Minimal or No response to stimuli . Every shift . During an interview on 1/12/22 at 3:29 PM, with Certified Nursing Assistant (CNA) 1, CNA 1 stated, Resident 165 was admitted about a week ago and had told CNA 1, she [Resident 1] wants to do it (oral (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 7 of 20 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 01/14/2022 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 - Minimal harm or potential for actual harm Residents Affected - Few suction) herself. CNA 1 stated, she had notified Licensed Vocational Nurse (LVN) 2. CNA 1 also stated, LVN 2 was not at the facility that day. During a concurrent interview and record review of Resident 165's medical records on 1/12/22 at 3:35 PM, with Registered Nurse (RN) 2, RN 2 stated, the resident was alert and oriented. RN 2 stated, he had not performed oral suctioning of the resident, and he was not aware that the resident had done it herself. RN 2 also confirmed the following: 1. There was no evidence Resident 165 was assessed and deemed capable by the facility's health care team prior to performing oral suction procedures properly and safely on her own. 2. Resident 165's care plans since admission did not include oral suctioning. 3. No physician orders were found related to Resident 165's oral suctioning procedure. During a concurrent observation and interview on 1/12/21, at 3:40 PM, in Resident 165's room, with RN 2 present, Resident 165 stated, the nurses had not suctioned her orally, and she had done oral suctioning on her own since admission into the facility. On inspection of the suction equipment next to the resident's bedside, RN 2 acknowledged the suction tubing attached to the suction machine was unlabeled, and undated, with the yankauer found uncovered on the bedside table. The suction canister had approximately 200 ml (milliliters) of white and cream-color liquid with green-color liquid settlement at the bottom of the canister. Resident 165 stated, suction machine and supplies did not belong to her. RN 2 stated, he did not find extra oral suction supplies inside the resident's bedside table and drawer. RN 2 was unable to provide information as to who brought and set up the suction equipment and supplies in Resident 165's room including when the suction equipment and supplies were checked, used, replaced and cleaned. RN 2 stated, the suction canister had to be changed and cleaned every shift, with contents measured and documented by the staff. RN 2 also stated, suction supplies had to be labeled and replaced every three days by the staff. During a follow up interview on 1/13/22 at 3:45 PM, with RN 2, RN 2 stated, LVN 2 admitted Resident 165 into the facility and put the suction machine and supplies in the resident's room. During an interview on 1/13/22 at 3:55 PM, with LVN 2, LVN 2 stated, she had not performed oral suction to Resident 165 but had seen the resident suction herself. LVN 2 stated, she did not inform the resident's physician. LVN 2 stated, she should have notified the physician. During a concurrent interview and record review of Resident 165's medical records on 1/14/22 at 10:44 AM, with RN 3, RN 3 stated, she was aware Resident 165 did her own oral suctioning because the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 8 of 20 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 01/14/2022 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 - Minimal harm or potential for actual harm Residents Affected - Few resident had told her before. RN 3 stated, she should have notified the physician. RN 3 stated, there should have been a physician's order for the oral suctioning procedure. RN 3 explained that nurses were supposed to do an assessment to see if the Resident 165 was capable to do oral suction safely and correctly. RN 3 stated, she did not find any assessments done on Resident 165 on oral suctioning. RN 3 also stated, she did not think the interdisciplinary team (IDT) met and discussed Resident 165's ability to perform oral suctioning. During a record review of Resident 165's Baseline Resident-Centered Plan of Care (BRCP), dated 1/3/22, the BRCP indicated, the following sections were left unmarked or unchecked, . A. Resident and/or Resident Representative (RR) Interview . Cognition . Communication . B. Health and Safety History .C. Activities of Daily Living .Equipment in Use . D. Goals of Care . III. Rehabilitative Services .Attendees [attendees to the baseline care plan meeting] . Printed Baseline Care Plan and Physicians Orders . Vitals . Notes . During a record review of Resident 165's Care Plan (CP), dated 1/1/22, the CP indicated, . Category: Respiratory - Alteration in Respiratory Function R/T (related to) Bronchiectasis . Goal . Approach . There was no information indicated in the CP regarding oral suctioning. During a record review of Resident 165's Care Plan (CP), dated 1/1/22, the CP indicated, . Category: Mobility & Safety . Strengths and abilities [specify] blank . There was no information indicated in the CP regarding the resident's risks and/or ability to perform oral suctioning. During a record review of Resident 165's Care Plan (CP), dated 1/1/22, the CP indicated, . Category . At risk for Aspiration r/t (related to) Dysphagia . Goal . Will not have episodes of Aspiration . Approach . Assess breath sounds and breathing patterns . Follow Aspiration Risk Precautions . During a record review of Resident 165's Care Plan (CP), dated 1/3/22, the CP indicated, . Category: Mood State . Altered Mood State R/T Depression, Anxiety, Manifested by Restlessness . Approach . Anti-Anxiety S.E. (side effects). Medication: Lorazepam . Observe for and report side effects: sedation .dizziness, confusion . Special Attention if given with other sedatives .Anti-Depressant S.E. Zoloft . Observe and report for side effects: Common- sedation . weakness, dizziness, confusion, agitation, tremor, . During a review of the facility's policy and procedure (P&P) titled, ASSESSMENT POLICY AND PROCEDURE, dated 11/1/17, the P&P indicated, STANDARD - . expansion of the interdisciplinary team's role in providing care and services to the elderly in skilled nursing facilities . Providing care to the individuals residing in skilled nursing facilities utilizes clinical competence, observational skills and assessment expertise from all disciplines to develop individualized plans of care . POLICY . The assessment is completed by the interdisciplinary team and coordinated by a Registered Nurse. This assessment is the basis for each resident's plan of care . All of the data available to the interdisciplinary team is assessed and analyzed. Determinations regarding, but not limited, the following are made . Capacity to perform ADLs and impairment in same . Medically defined conditions . Physical and mental functional status . Sensory and physical impairments . Special treatments or procedures . During a review of the facility's policy and procedure (P&P) titled, CARE PLANS, dated 11/1/17, the P&P indicated, STANDARD - The resident care plan is the vehicle employed by the interdisciplinary team for achieving desirable resident outcomes. The plan is the result of the interdisciplinary assessment, analysis and diagnosis. It addresses the actual and potential physical, environmental, and psychosocial needs and problems identified by the interdisciplinary team in conjunction with the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 9 of 20 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 01/14/2022 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 - Minimal harm or potential for actual harm Residents Affected - Few resident and significant others in the resident's life. The care plan identifies the individual needs and problems of the resident, states the resident's goal in measurable terms, and documents realistic approaches that the interdisciplinary team will employ to achieve the desired outcomes. POLICY - Upon admission, an initial care plan will be initiated for the resident. This care plan will address the immediate needs of the resident. Immediate needs will be identified using but not limited to the physician's evaluation, the medical plan of care, physician's orders, transfer information, information provided by the resident and the significant others in the resident's life, outcome of risks assessments, and the observations made by staff related to presenting symptoms and significant functional dependencies . The care plan will be reviewed and revised as necessary to reflect the changes in the resident's status. Any professional who recognizes the need for changing the care plan will initiate the change . PROCEDURE: 1. Initial Care Plan Initiated within 24 hours of admission of the resident, Reflects the immediate needs of the resident (i.e. treatments . safety issues .) All disciplines enter appropriate problems, goals and approaches based on their assessments prior to the Comprehensive Care Plan Conference . CARE PLANNING CONFERENCE PROCEDURE: admission CARE PLANNING CONFERENCE . The interdisciplinary team evaluates the resident and reviews the resident's care plan for appropriateness. Necessary changes are made on the care plan and pertinent notes are made in the medical record .Areas reviewed and discussed including follow-ups will be documented in the SMS Interdisciplinary Team Resident Care Conference Notes during the care planning conference . INTERDISCIPLINARY TEAM PROCESS - STANDARD - The Interdisciplinary Team (IDT) process is used in assessing major issues that impact the physical, mental and psychosocial health of a resident . POLICY - when conditions arise that impact the health and welfare of a resident, the IDT meets to assess the circumstances and develop methods for resolving or minimizing the problem. The assessment is documented and signed by the members of the team. A new plan of care is developed or the current one is updated to reflect the changes in care. GUIDELINES 1. Conditions such as . other occurrences that affect the resident's health and well-being should be considered for completion of the IDT process. 2. Assessment should identify history surrounding the problem, risk factors that may impact the decline or lack of improvement and causal factors that trigger the problem 3. Documentation includes: a. history of problem, b. pre-disposing and risk factors involved c. level of ability to avoid the problem d. past attempts at resolution e. plan to prevent or minimize future incidents . During a review of the facility's policy and procedure (P&P) titled, .SELF-ADMINISTRATION BY RESIDENT, dated 2007, the P&P indicated, POLICY: Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe and the medications are appropriate and safe for self-administration. PROCEDURES . If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive, physical, and visual ability to carry out this responsibility, during the care planning process . The interdisciplinary team determines the resident's ability to self-administer medications by means of a skill assessment conducted as part of the care plan process . The results of the interdisciplinary team assessment are recorded on the Medication Self-Administration Assessment, which is placed in the resident's medical record . The resident is instructed in the proper cleaning . where applicable, proper storage . The completion of this instruction is documented in the resident's medical record. The nursing staff, as deemed necessary, undertakes periodic review of these instructions with the resident .The decision that a resident has the ability to self-administer medication is subject to periodic assessment by the IDT, based on changes in the resident's medical and decision-making status . 4. During a concurrent interview and record (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 10 of 20 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 01/14/2022 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 - Minimal harm or potential for actual harm Residents Affected - Few review of Resident 165's medical records on 1/13/22, at 3:35 PM, with RN 1, RN 1 confirmed she did not find evidence that the staff monitored and documented the resident performed oral suction on her own and used suction equipment and supplies. During a review of the facility's policy and procedure (P&P) titled, Suctioning a resident, dated 11/2009, the P&P indicated, Policy: It is the policy of this facility to provide suction services to residents on respiratory care. Suctioning is provided when: Resident is unable to clear their secretions by coughing, Coarse sounds known as rhonchi or wheezing are heard in the chest. Supplies needed: An oxygen source, A suction device and a tonsil tip or yankauer suction device, Sterile normal saline water. Procedure: Obtain or check physician orders for type of suction tubing/catheter or tip to be used, Assemble the supplies . Turn on the suction and check the pressure. Open the package containing the suction catheter and the gloves. Open a vial of sterile saline . Put the clean gloves . Pre-oxygenate the resident . Advance the catheter only to the appropriate depth . Stop advancing the suction tubing once you meet resistance . Apply suction .If the secretions are thick, sterile water can be suctioning through the catheter to clear it. During suction event, oxygenate residents and give him/her time to recover before repeating. If the resident goes into distress, stop suctioning, provide oxygen and call additional help such as staff . Document amount, consistency, color of suction contents in the resident's clinical record . During a review of the facility's policy and procedure (P&P) titled, SUCTION EQUIPMENT, undated, the P&P indicated, POLICY: When a suction machine is in constant use by one resident, clean the equipment after each shift . PROCEDURE TO CLEAN SUCTION MACHINE - the following is the procedure to clean suction machines after each shift when used by a single resident . Empty contents of suction jar at end of shift, or more often . Rinse suction jar with water and empty it out. Suction clean water through suction tubing. If there is mucous build up in the tubes, replace before re-using. Replace the suction catheter after each use . NOTE: Always wash hands before and after each procedure . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 11 of 20 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 01/14/2022 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 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, prepare, and distribute food in a safe and sanitary manner. Residents Affected - Many 1. Opened food items were not properly dated and stored. 2. Fresh produce in the refrigerator had mold-like substance. 3. Thawed, uncooked poultry in the refrigerator was not properly dated and stored. 4. [NAME] (C) 2 did not follow proper sanitation and food handling practices during tray line service and did not perform hand hygiene after removing gloves. 5. Temperature and storage conditions for emergency food kits were not monitored. 6. Food Service Manager (FSM) wore jewelry in the kitchen. 7. Kitchen tools and patient food trays were not maintained in good condition. 8. Coffee mugs belonging to facility staff were stored in the kitchen cabinets. These deficient practices had the potential to put residents at risk for foodborne illnesses. Findings: 1. During an initial kitchen tour observation and concurrent interview on 1/11/22, at 9:14 AM, with [NAME] (C) 1 present, the following food items were found inside the kitchen cabinet next to the hand washing station. 1.1 an opened container of mashed potato granules with no open and use by date. 1.2 an opened bottle of hot sauce with no open and use by date. 1.3 an opened bottle of imitation vanilla extract with no open and use by date. 1.4 a small, opened box of baking soda inside an opened Ziploc bag. C 1 confirmed the findings and stated, the food items had to be dated once opened. C 1 stated, the Ziploc bag that contained the opened box of baking soda box had to be sealed. During a review of the facility's policy and procedure (P&P) titled, SANITATION AND INFECTION CONTROL, dated 2018, the P&P indicated, CANNED AND DRY GOOD STORAGE - POLICY: All the food and non-food items purchased by the Department of Food and Nutrition services will be stored properly. All open food items will have an open date and use-by-date . During a review of the facility's document titled, DRY STORAGE QUICK REFERENCE GUIDE, dated 2016, the document indicated, DRY STORAGE: (Staples; Mixes and Packaged Foods; Canned and Dried Foods; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 12 of 20 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 01/14/2022 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Spices, Herbs, Condiments and Extracts; Other) . Food . Potatoes, Instant . Recommended storage . Unopened 6-12 months, Opened - Same as unopened . SPICES, HERBS, CONDIMENTS, AND EXTRACTS Catsup/Chili Sauce . Recommended storage . Opened - 1 month . Handling Hints - Refrigerate for longer storage . Vanilla . Recommended storage . Opened - 12 months . Other Extracts . Recommended storage . Unopened - 12 months . Opened - Same as unopened . Baking Soda . Handling Hints - Keep dry and covered . 2. During a concurrent observation of the walk-in refrigerator and interview on 1/11/22, at 10:16 AM, with the Food Services Manager (FSM) present, several pieces of lemons inside a box had a mold-like substance. Five plastic packages of strawberries also had mold-like substances. FSM stated, the lemons and strawberries had mold in them. During a review of the facility's policy and procedure (P&P) titled, SANITATION AND INFECTION CONTROL, dated 2018, the P&P indicated, SUBJECT: FOOD RECEIVING AND STORAGE OF COLD FOODS - POLICY: All the perishable food items purchased by the department of food and dining services will be stored properly . SUGGESTED REFRIGERATED STORAGE GUIDELINES . FRUIT - Check Quality . FRESH VEGETABLES - Check Quality . 3. During a concurrent observation of the walk-in refrigerator and interview on 1/11/22, at 10:23 AM, with the Food Services Manager (FSM) present, a large container pan contained three sealed bags of thawed chicken breasts. The pan had two attached stickers. One sticker indicated, Item Chicken Lunch . Date 1/6/22 . Use By 1/10/22 . There were no times written on the sticker. The second sticker indicated, Item Chicken . Date 1/6/22 . Time DIN . Use By 1/11/22 Time [blank]. FSM explained 1/6/22 was the date when the chicken was pulled to thaw. FSM confirmed both stickers indicated the items were pulled on the same date 1/6/22 but had two different use-by-dates. FSM stated, it's confusing. FSM stated, the chicken had to be used within three days from the date it was pulled to thaw. FSM confirmed the use-by-dates indicated on both stickers were beyond three days from the date the items were pulled and thawed. During a review of the facility's policy and procedure (P&P) titled, SANITATION AND INFECTION CONTROL, dated 2018, the P&P indicated, SUBJECT: REFRIGERATED STORAGE - POLICY: All the perishable food will be stored in refrigerated storage . PROCEDURES . All frozen uncooked meat, poultry . should be placed on the bottom shelf for proper thawing, with pull by date and use by date . During a review of the facility's policy and procedure (P&P) titled, SANITATION AND INFECTION CONTROL, dated 2018, the P&P indicated, SUBJECT: FOOD RECEIVING AND STORAGE OF COLD FOODS . Procedures . All meat and perishable food . placed in the refrigerator for thawing must be labeled on pull date and used by date when item was transferred to the refrigerator . During a review of the facility's policy and procedure (P&P) titled, SANITATION AND INFECTION CONTROL, dated 2018, the P&P indicated, SUBJECT: FREEZER STORAGE . PROCEDURES . All frozen food that is perishable, especially frozen meat . must be defrosted in the refrigerator . Frozen food that has been thawed in the refrigerator should be used within 72 hours or cooked thoroughly . During a review of the facility's policy and procedure (P&P) titled, SANITATION AND INFECTION CONTROL, dated 2018, the P&P indicated, SUBJECT: FOOD DEFROSTING METHODS . PROCEDURES . The preferable method of defrosting frozen perishable food is to defrost in the refrigerator and kept refrigerated until completely thawed. Foods must be labeled and dated with item name, pull date and use by date no more three days past use by date . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 13 of 20 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 01/14/2022 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 0812 Level of Harm - Minimal harm or potential for actual harm 4. During a tray line observation on 1/12/22, at 11:57 AM, in the kitchen, C 2 directly handled a portion of cooked, chopped cauliflower with a gloved hand and returned it from a plate back to the original cauliflower container dish on the steam table. With the soiled gloves worn, C 2 then opened a drawer where portioning utensils were kept and attempted to grab a clean utensil. The surveyor intervened and C 2 removed her gloves and performed hand hygiene. Residents Affected - Many During an interview on 1/12/22 at 11:59 AM, with C 2, C 2 acknowledged she did not follow proper food handling and hand hygiene practices. During a follow-up interview on 1/13/22, at 9:02 AM, with C 2, C 2 stated, she returned the cauliflower from the plate back to the original dish on the steam table because she heard no cauliflower called out from a resident's dietary ticket. C 2 stated, she should have started with a new plate and placed the plate with the cauliflower on the side. C 2 stated, she should have used a spoon and not handled the food directly with her gloved hand to prevent cross contamination of food and equipment. C 2 stated, she should have removed her soiled gloves and washed her hands prior to opening the utensil drawer. During a review of the facility's policy and procedure (P&P) titled, ORIENTATION, INSERVICE, & PERSONNEL MANAGEMENT, dated 2018, the P&P indicated, SUBJECT: COOK JOB DESCRIPTION POLICY . The [NAME] assists in assuring proper . preparation, serving, sanitation and cleaning procedures are followed . RESPONSIBILITIES . Prepares, portions, and/or serves food using proper measuring equipment and serving utensils, while maintaining quality-control standards . Assures all food items are handled properly to meet safety and sanitation standards . During a review of the facility's policy and procedure (P&P) titled, SANITATION AND INFECTION CONTROL, dated 2018, the P&P indicated, SUBJECT: HANDWASHING . Policy . Hands must be properly and frequently washed to prevent cross contamination of food supplies and equipment . PROCEDURES . When to wash hands . Before and after handling foods . 5. During an inspection of the emergency food supply storage area on 1/13/21, at 9:36 AM, with the Food Services Manager (FSM) present, in an office located at the back entrance of the facility, FSM stated, the emergency meal kits were purchased about two to three years ago. FSM stated, temperature storage conditions of the meal kit boxes were monitored by the Maintenance Manager (MM). The meal kit boxes, indicated, STORAGE CONDITIONS - Store this product properly to ensure maximum shelf life. Store in a cool, dry area, avoid long-term storage above 75°F . During an interview on 1/13/21, at 9:57 AM, with the MM, the surveyor asked MM to show evidence the temperature requirements to store emergency meal kit boxes were monitored. MM stated, the facility did not monitor temperature storage conditions for the emergency meal kits. 6. During an initial tour of the kitchen on 1/11/22, at 8:50 AM, with the Food Services Manager (FSM), FSM stated, one dietary staff assigned in the dishwashing area had a test done for COVID-19 that morning and tested positive. As a result, FSM said, we are short staffed. FSM was observed assisting with dietary and dishwashing responsibilities in the kitchen. During a concurrent observation and interview on 1/11/22, at 9:39 AM, with FSM, in the kitchen, FSM wore a fully exposed, gold-color necklace with a cross pendant. FSM stated, staff were not allowed to wear dangling jewelry in the kitchen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 14 of 20 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 01/14/2022 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview on 1/14/22, at 9:05 AM, with the Registered Dietitian (RD), RD stated, jewelry that was hanging and loosely worn was considered dangling. During a review of the facility's policy and procedure (P&P) titled, SANITATION AND INFECTION CONTROL, dated 2018, the P&P indicated, SUBJECT: PERSONAL HYGIENE . Procedures . No dangling jewelry . should be worn . 7. During a concurrent observation and interview on 1/11/21, at 9:23 AM, with C 1 present, in the kitchen, C 1 confirmed the material component of the bread knife handle was significantly degraded and had rough, uneven surfaces, openings, and cracks. C 1 stated, the knife had to be replaced. During an observation on 1/11/22, at 9:49 AM, the patient food trays were inspected in the shelving unit located in the middle section of the kitchen. From a stack of pink-colored patient food trays, there were four trays that had multiple chip marks, cracks and metal-like edges that were exposed. During an interview on 1/14/22, at 8:45 AM, with the RD regarding the condition of patient food trays noted during the initial kitchen tour on 1/11/22, RD stated, ideally, we would want trays to not have them . RD stated replacement of kitchen utensils and trays were up to the FSM's discretion and deferred to the FSM's decision. During an interview on 1/14/21, at 10:56 AM, with FSM, FSM stated, the bread knife handle had a silicone or rubber type material. FSM stated, they did not have a written policy and procedure related to maintenance and replacement of kitchen and food service utensils, dishes, and equipment. During a review of the facility's policy and procedure (P&P) titled, ORIENTATION, INSERVICE, & PERSONNEL MANAGEMENT, dated 2018, the P&P indicated, SUBJECT: DEPARTMENT OF FOOD AND NUTRITION SERVICES CONSULTANT (CONSULTANT DIETITIAN) JOB DESCRIPTION . POLICY . The Registered Dietitian provides consultation to the facility for . oversight of the operations of the Department of Food and Nutrition Services . Monitors and recommends food service standards for sanitation, safety, and infection control . Advises and counsels Director of Food and Nutrition Services in all areas of food service . According to the 2017 Federal Food Code, food-contacted surfaces are to be smooth and free of pits and similar imperfections. Also, nonfood-contact surfaces that are exposed to food soiling, splash and spillage or require frequent cleaning are to be constructed of corrosion-resistant and smooth material. Nonfood-contact surfaces are also to be free of crevices to allow easy cleaning and are to be free of residue. 8. During a concurrent observation and interview on 1/11/21, at 9:31 AM, with C 1 present, the shelving cabinet next to refrigerator # 3 was inspected. There were eight various-colored coffee mugs stored in the shelves next to a rolling pin, mesh strainer, bowls, glass cruet and a stainless-steel measuring container. Two of the mugs were covered in transparent, plastic food-wrap. C 1 stated, the coffee mugs belonged to staff members. C 1 stated, the coffee mugs should not be kept in the kitchen. During an interview on 1/14/21, at 10:56 AM, with FSM, FSM stated, they did not have a written policy and procedure related to storage of facility staff personal belongings. According to the 2017 Federal Food Code, lockers or other suitable facilities should be provided for the orderly storage of employee personal possessions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 15 of 20 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 01/14/2022 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 0880 Provide and implement an infection prevention and control program. 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 infection control practices when: Residents Affected - Some 1. One staff did not perform hand hygiene in between resident care activities. 2. One staff was not wearing personal protective equipment (PPE- protective clothing, helmets, gloves, face shields, goggles, facemasks and/or respirators or other equipment designed to protect the wearer from injury or the spread of infection or illness) properly. 3. One of 16 sampled residents (Resident 16) was using a nasal cannula (NC - a flexible tubing that sits inside the nostrils and delivers oxygen) that was not changed weekly. 4. One of 16 sampled residents (Resident 32) was using an unlabeled NC. These failures had the potential for cross-contamination and spread of infectious diseases that could jeopardize the health of the residents, staff, and visitors. Findings: 1. During an observation on 1/11/22 at 10:20 AM, Certified Nursing Assistant (CNA) 2 donned (put on) gloves and assisted Resident 24 to bed. At 10:23 AM, CNA 2 exited Resident 24's room and went to Resident 61's room without performing hand hygiene. While still wearing the same gloves, CNA 2 touched Resident 61's privacy curtain. At 10:24 AM, CNA 2 removed her gloves, and stepped out of the room without performing hand hygiene. In a concurrent interview, CNA 2 stated, . I should change gloves (in between resident care) . use gel (hand sanitizer) after removing them (gloves) . During an interview on 1/13/22 at 9:54 AM, the Infection Preventionist (IP) stated, that staff should perform hand hygiene in between resident care and after glove removal. During a concurrent review of the facility policy and procedure (P&P), titled Infection Control Standards (ICS) . for use through December 31, 2021, and interview with the Administrator (ADM), on 01/14/22 09:25 AM, the ADM stated, the facility follows the ICS. Review of the ICS indicated, . 1. Standard Precautions . Hand hygiene is performed during patient care activities. Hands should be washed after any patient contact . after removing gloves, when soiled and when otherwise indicated. Unless hands are visibly soiled use of alcohol based hand gels is encouraged . 2. During an observation and concurrent interview on 1/11/22 at 10:27 AM, with CNA2, CNA 2 was observed wearing a N-95 respirator (a type of PPE used to protect the wearer from particles or from liquid contaminating the face) with the lower elastic strap of the respirator hanging under her chin. CNA 2 stated, . It (respirator) should be around the head . I can't breathe when it's (lower strap) around (pointing to the back of her neck) . During an interview on 1/13/22 at 9:54 AM, with the IP, IP stated, staff were expected to wear the respirator with the straps placed around the head and neck, not hanging under the chin. IP stated, .If hanging under the chin . it's loose .They're not protected (from infectious diseases). During a concurrent review of the undated facility document titled, Sequence for Putting on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 16 of 20 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 01/14/2022 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Personal Protective Equipment (SPPE), published by the Centers for Disease Control and Prevention (CDC), and interview with the Administrator (ADM) on 1/13/22 at 11:05 AM, the SPPE indicated, .2. Mask or Respirator . Secure ties or elastic bands at middle of head and neck . The ADM stated, that the facility follows the guidelines indicated on the SPPE. 3. During a review of Resident 16's clinical health record, the Resident Face Sheet indicated, Resident 16 was admitted on [DATE]. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 2, on 1/11/21 at 12:09 PM, Resident 16 was awake, sitting in a wheelchair in her room. Resident 16 had a NC, with a label indicating 12/7/21, inserted in her nostrils. The NC was connected to an oxygen concentrator (a medical device used for delivering oxygen to individuals in need of supplemental oxygen), set at two liters per minute (LPM). LVN 2 stated, . It's (referring to the NC) already one month . supposed to be changed on a weekly basis. for infection control . 4. During a review of Resident 32's clinical health record, the Resident Face Sheet indicated, Resident 32 was admitted on [DATE]. During a concurrent observation and interview with LVN 2, on 1/11/21 at 12:12 PM, Resident 32 was in bed, using an oxygen concentrator set to two LPM. An unlabeled NC, connected to the oxygen concentrator, was inserted in Resident 32's nostrils. LVN 2 stated, . We should label it with the date when it was first used . it's for infection control . During a review of the facility P&P, titled, Oxygen Humidifier Use (OHU), dated 5/1/15, the OHU indicated, . Procedure . 7. Open sealed bag of cannula or oxygen mask. Label mask or cannula with date opened. 11. Change mask or cannula tubing every week . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 17 of 20 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 01/14/2022 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 interview on 1/11/22 at 9:30 AM, with the Administrator, Administrator stated, 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. During a review of the room waiver form completed by the Administrator, the waiver indicated, the following floor measurements: Rooms 101 had 581 total square feet, and room [ROOM NUMBER] had 581 total square feet. During an observation on 1/11/22 at 9 AM in room [ROOM NUMBER], there were no concerns about space and the room. 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 an observation on 1/11/22 at 9:50 AM in room [ROOM NUMBER], there were no concerns about the space and the room. 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 18 of 20 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 01/14/2022 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure an effective pest control program. Residents Affected - Many 1. [NAME] 1 did not report sighting of a roach in the kitchen counter. 2. Recommendations made by the pest control company were not followed. These failure had the potential to not eradicate and contain common household pests in the facility to prevent contamination, transmission or spread of disease to patients. Findings: 1. During an initial kitchen tour on 1/11/22 at 9:24 AM, a small insect crawled on the counter where the blender, toaster, and chopping boards were located. [NAME] (C) 1 noted the observation and confirmed that the insect was a roach. C1 got a paper towel and squashed the insect with her hand. During an interview on 1/12/22 at 10:22 AM, with the Maintenance Manager (MM), MM stated, he was aware of pest sightings in the facility from monthly reports issued by the pest control company including from verbal reports made by facility staff. MM stated, the facility did not have a pest sighting log. During an interview on 1/12/22 at 3:14 PM, with the Food Services Manager (FSM), FSM stated, any pest sightings would be reported to him by kitchen staff. FSM stated, C1 did not inform him of the roach found in the kitchen counter on 1/11/21. FSM stated, they do not have a pest sighting log in the kitchen. FSM stated, he was aware of prior roach sightings in the kitchen. 2. During a review of the pest control company service reports (SR) on 10/8/21, 11/5/21 and 12/21/21, the SRs indicated the following: .Observation Information . Observation: Cracks and Crevices Status: Pending Responsibility: Customer Date Entered: 9/23/20 Zone Name: Kitchen an employee break room (kitchen and employee break rooms) . Recommendation: Patch Small Holes . Observation: Hole In The Wall Status: Pending Responsibility: Customer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 19 of 20 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 01/14/2022 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 0925 Date Entered: 9/23/20 Level of Harm - Minimal harm or potential for actual harm Zone Name: Kitchen an employee break room (kitchen and employee break rooms) . Recommendation: Seal Hole In Wall . Residents Affected - Many During a concurrent observation and interview on 1/14/21 at 9:51 AM, with the Maintenance Manager (MM), the surveyor asked MM to show evidence of actions taken by the facility on recommendations indicated in the reports issued by the pest control company. MM accompanied the surveyor and inspected the employee break room and kitchen. During an observation of the employee break room on 1/14/21 at 10:12 AM, with MM present, MM opened the cabinet below the sink and noted an opening on the wall where the faucet drain was connected. There was also an insect trap next to the opening. MM acknowledged the finding. During a review of the facility's policy and procedure (P&P), titled, Sanitation and Infection Control, dated 2018, the P&P indicated, SUBJECT: PEST CONTROL - POLICY: The facility will ensure a pest control prevention program provides monthly inspection, treatment, and prevention of vermin and insect infestation. All Department of Food and Nutrition Services personnel will be instructed on evidence of vermin and insect infestation, and promptly report such problems to the Director of Food and Nutrition Services . Pest control is designed to maintain a sanitary environment, which prevents contamination, transmission or spread of disease, by insects or rodents. PROCEDURES . The kitchen will be .protected from rodents, roaches, flies and other insects . It is recommended that a pest control company be retained on a monthly basis, or more often if necessary . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055188 If continuation sheet Page 20 of 20