Other·March 9, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated standard survey. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. For Complaint no. CA00516138 regarding Admission, Transfer, & Discharge Rights, the Department identified a violation of Federal and State regulations. A Class "B" Citation no. 220013025 was issued. Representing the California Department of Public Health: ID 35817, Health Facilities Evaluator Nurse

F204 SS=D PREPARATION FOR SAFE/ORDERLY TRANSFER/DISCHRG CFR(s): 483.15(c)(7)

F204 03/24/2017 (c)(7) Orientation for Transfer or Discharge A facility must provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand. This REQUIREMENT is not met as evidenced by: Based on interview and record review the LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 699N11 Facility ID: CA220000041 If continuation sheet 1 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055188 (X3) DATE SURVEY COMPLETED 02/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BROOKSIDE SKILLED NURSING HOSPITAL 2620 Flores St San Mateo, CA 94403 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility failed to implement their Admission, Discharge, and Transfer Rights policy and procedure for Resident 1, when no notice of transfer or discharge was provided when facility denied readmission of Resident 1. This failure had the potential to result in mental and / or psychosocial discomfort for Resident 1 and the family of Resident 1. Findings: Resident 1 was admitted to the facility on 3/8/13 with diagnoses that included bi-polar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), bacteremia (bacteria in the blood stream), and urinary retention (inability to empty the bladder). During a review of the clinical record for Resident 1, the minimum data set (MDS, a resident assessment tool) dated 1/5/16 indicated a brief interview for mental status (BIMS, a brief scanner to help in detecting cognitive impairment) score of 7 (BIMS score of 0 -7 indicates severe cognitive impairment). The behavior assessment of the MDS indicated Resident 1 had delusions, exhibited verbal behaviors, such as screaming, threatening, and cursing, toward others, and rejected or refused necessary care and treatments. The care plan (a written or computerized guide that organizes information about the resident ' s care) dated 6/10/14 with update 1/26/16 indicated interventions for infectious process, such as washing hand of Resident 1 before and after meals, and consider a private room if no proper roommate is possible. On 2/5/16, Resident 1 was lethargic (drowsy having little energy) with blood pressure of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 699N11 Facility ID: CA220000041 If continuation sheet 2 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055188 (X3) DATE SURVEY COMPLETED 02/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BROOKSIDE SKILLED NURSING HOSPITAL 2620 Flores St San Mateo, CA 94403 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 100/60 and heart rate of 40. Resident 1 was diagnosed with urinary tract infection and sepsis and transferred to an acute care facility. On 5/11/16, Resident 1 was refused readmission to the first available semi-private bed after being discharged from the acute care facility. During an interview with Administrator (Admin) on 1/18/17, at 1 PM, Admin stated the previous "behaviors" of Resident 1 posed a danger to other residents if Resident 1 is admitted to a semi-private room. When asked about the previous behaviors Admin stated Resident 1 would rummage through the linen cart, throw dirty linen, clothes, and food at staff. Resident 1 would yell at roommates and their visitors. When asked how the facility handled these behaviors in the past, Admin stated Resident 1 was in a semi-private room without a roommate. Admin stated the behaviors of Resident 1 would make it hard for facility to provide the recommended "enhanced standard precautions" (integration and consolidation of Center for Disease Control (CDC) recommendations for Standard Precautions, Transmission-based Precautions, and Intensified Interventions [Joint Infection Prevention and Control Guidelines - Enhanced Standard Precautions (ESP) - California LongTerm Care Facilities, 2010] needed for residents colonized with VRE (bacteria are present but no symptoms of infection is present). Review of Interdisciplianry Team (IDT) Notes dated 5/11/16 indicated, "...After significant consideration and review of the information gathered and discussion with Infectious Disease experts, the (facility name) IDT team FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 699N11 Facility ID: CA220000041 If continuation sheet 3 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055188 (X3) DATE SURVEY COMPLETED 02/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BROOKSIDE SKILLED NURSING HOSPITAL 2620 Flores St San Mateo, CA 94403 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE concluded that we will not be able to ensure excellent clinical care and services for ALL the residents entrusted to our care. On 5/11/15 (Administrator) notified the hospital that we would not be able to consider (Resident 1) for readmission." Review of the facility census record printed 1/18/17 indicated from 3/8/13 until 2/5/17, Resident 1 was in the same semi-private room. Review of California Association of Health Facilities document titled Joint Infection Prevention and Control Guidelines - Enhanced Standard Precautions (ESP) - California LongTerm Care Facilities, 2010 indicated ... Process Measures - Admission Assessment: 1. No request for long term care facility admission or readmission should be refused based on knowledge of a positive test for any multi-drug resistant organism (such as VRE) 2. No request for negative tests prior to interfacility transfer should be made. New or returning residents should be admitted based on the ability of the facility to provide supportive and restorative care. 3. Develop a resident care plan, which takes into consideration the individual ' s risk of transmission or acquisition of infectious agents. Review of acute hospital Progress Record Infectious Disease consult note dated 5/6/16, entered by Infectious Disease Physician indicated Resident 1 likely colonized with VRE and may grow this organism in the future, note indicated no treatment needed at this time. Review of Office of Administrative Hearings and Appeals - California Department of Health Care Services Summary of Proceedings dated 12/23/16 and signed by Administrative Law Judge (ALJ) indicated ...Decision and Order FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 699N11 Facility ID: CA220000041 If continuation sheet 4 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055188 (X3) DATE SURVEY COMPLETED 02/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BROOKSIDE SKILLED NURSING HOSPITAL 2620 Flores St San Mateo, CA 94403 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE ...the skilled facility must readmit Resident 1 to its first available female bed ...This is the final decision and order of the Department, and there are no future administrative remedies available. The Summary of Proceedings indicated that the facility's failure to readmit Resident 1 was tantamount (equal) to an involuntary transfer. During an interview with Admin on 2/2/17 at 10:25 AM, when Admin was asked for a copy of notice of transfer or discharge provided to Resident 1, Admin stated the facility notified the acute care hospital. When asked if family of Resident 1 received a notice of transfer or discharge, Admin stated no notice was provided to resident or family members. Review of the facility policy and procedure titled, "Admission, Transfer, and Discharge Rights" dated 5/1/15, indicated under section titled Transfer and Discharge "...Before the facility transfers or discharges a resident, the facility shall notify the resident and, if appropriate, a family or legal representative of the resident of the transfer or discharge and the reason. The facility shall also notify the Department of Public Health as required ... The resident has the right to be notified, in writing 30-days before the transfer or discharge."

F206 SS=D POLICY TO PERMIT READMISSION BEYOND BED-HOLD CFR(s): 483.15(e)(1)(2)

F206 03/24/2017 (e)(1) Permitting residents to return to facility. A facility must establish and follow a written FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 699N11 Facility ID: CA220000041 If continuation sheet 5 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055188 (X3) DATE SURVEY COMPLETED 02/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BROOKSIDE SKILLED NURSING HOSPITAL 2620 Flores St San Mateo, CA 94403 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following. (i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semiprivate room if the resident(A) Requires the services provided by the facility; and (B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services. (ii) If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges. (e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to permit one Resident (Resident 1) to return to facility after Resident 1 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 699N11 Facility ID: CA220000041 If continuation sheet 6 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055188 (X3) DATE SURVEY COMPLETED 02/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BROOKSIDE SKILLED NURSING HOSPITAL 2620 Flores St San Mateo, CA 94403 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE hospitalized on 2/5/16. This failure had the potential to cause significant humiliation, indignity, anxiety or other emotional trauma for Resident 1 and the family of Resident 1. Findings: Resident 1 was admitted to the facility on 3/8/13 with diagnoses that included bi-polar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs), bacteremia (bacteria in the blood stream), and urinary retention (inability to empty the bladder). During a review of the clinical record for Resident 1, the minimum data set (MDS, a Resident assessment tool) dated 1/5/16 indicated a brief interview for mental status (BIMS, a brief scanner to help in detecting cognitive impairment) score of 7 (BIMS score of 0 -7 indicates severe cognitive impairment). The behavior assessment of the MDS indicated Resident 1 had delusions, exhibited verbal behaviors, such as screaming, threatening, and cursing, toward others, and rejected or refused necessary care and treatments. The care plan (a written or computerized guide that organizes information about the Resident ' s care) dated 6/10/14 with update 1/26/16 indicated interventions for infectious process, such as washing hands of Resident 1 before and after meals, and consider a private room if no proper roommate is possible. On 2/5/16, Resident 1 was lethargic (drowsy having little energy) with blood pressure of 100/60 and heart rate of 40. Resident 1 was diagnosed with urinary tract infection and sepsis and transferred to an acute care facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 699N11 Facility ID: CA220000041 If continuation sheet 7 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055188 (X3) DATE SURVEY COMPLETED 02/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BROOKSIDE SKILLED NURSING HOSPITAL 2620 Flores St San Mateo, CA 94403 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 5/11/16, Resident 1 was refused readmission to the first available semi-private bed after being discharged from acute care facility. Review of Interdisciplianry Team (IDT) Notes dated 5/11/16 indicated, "... After significant consideration and review of the information gathered and discussion with Infectious Disease experts, the (facility name) IDT team concluded that we will not be able to ensure excellent clinical care and services for ALL the (Residents) entrusted to our care. On 5/11/15 (Administrator) notified the hospital that we would not be able to consider (Resident 1) for readmission." During an interview with Administrator (Admin) on 1/18/17, at 1 PM, Admin stated the "behaviors" of Resident 1 posed a danger to other Residents if Resident 1 is admitted to a semi-private room. When asked about the previous behaviors Admin stated Resident 1 would rummage through the linen cart, throw dirty linen, clothes, and food at staff in addition Resident 1 would yell at roommates and their visitors. When asked how the facility handled these behaviors in the past Admin stated Resident 1 was in a semi-private room without a roommate. Admin stated the behaviors of Resident 1 would make it hard for facility to provide the recommended "enhanced standard precautions" (integration and consolidation of Center for Disease Control (CDC) recommendations for Standard Precautions, Transmission-based Precautions, and Intensified Interventions [Joint Infection Prevention and Control Guidelines - Enhanced Standard Precautions (ESP) - California LongTerm Care Facilities, 2010] needed for Residents colonized with VRE (bacteria are present but no symptoms of infection is FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 699N11 Facility ID: CA220000041 If continuation sheet 8 of 9 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055188 (X3) DATE SURVEY COMPLETED 02/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE BROOKSIDE SKILLED NURSING HOSPITAL 2620 Flores St San Mateo, CA 94403 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE present). Review of the facility census record printed 1/18/17 indicated from 3/8/13 until 2/5/16 Resident 1 was in the same semi-private room. Review of California Association of Health Facilities document titled Joint Infection Prevention and Control Guidelines - Enhanced Standard Precautions (ESP) - California LongTerm Care Facilities, 2010 indicated ...Process Measures - Admission Assessment 1. No request for long term care facility admission or readmission should be refused based on knowledge of a positive test for any multi-drug resistant organism (such as VRE) 2. No request for negative tests prior to interfacility transfer should be made. New or returning Residents should be admitted based on the ability of the facility to provide supportive and restorative care. 3. Develop a Resident care plan, which takes into consideration the individual ' s risk of transmission or acquisition of infectious agents. Review of acute hospital Progress Record Infectious Disease consult note dated 5/6/16, entered by Infectious Disease Physician indicated Resident 1 likely colonized with VRE and may grow this organism in the future, note indicated no treatment needed at this time. Review of the facility policy and procedure titled "Admission, Transfer, and Discharge Rights" dated 5/1/15, indicated under section titled Bed Hold Rights" ..."When the Resident is ready for readmission to the facility ...the facility shall offer the next appropriate bed to the Resident." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 699N11 Facility ID: CA220000041 If continuation sheet 9 of 9