Other·September 26, 2018

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. CA00517454 regarding Quality of Care/Treatment, the Department substantiated a violation of Federal regulations. Representing the California Department of Public Health: 31983, Health Facilities Evaluator Nurse

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 10/04/2018 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on interview, observation, and record review, the facility failed to identify the risk factors and need for supervision for one of 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: RJCQ11 Facility ID: CA220000218 If continuation sheet 1 of 7 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: _______________ 555034 (X3) DATE SURVEY COMPLETED 09/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN MATEO MEDICAL CENTER D/P SNF 222 W 39th Ave 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 three residents (Resident 1), who fell on 1/6/17 and sustained a subdural hematoma (collection of blood between the layer covering the brain and the surface of the brain). The facility failed to implement interventions to reduce the risk for fall when 1) resident was placed in a room near the far end of the hallway the nursing station and not in direct line of sight of the nursing station, 2) there was a delay of at least 15 minutes in responding to his call light, and 3) no fall prevention devices or precautions were implemented. The facility's failure to plan and provide close monitoring and supervision resulted in Resident 1 falling nine hours after admission to the facility, requiring transport back to the General Acute Care Hospital (GACH) for for evaluation and treatment of a subdural hematoma and repair of a two centimeter (cm) long occipital (back of the head) scalp laceration with staples and had a direct or immediate relationship to Resident 1's health, safety, or security. Findings: Record review of the facility "Admission Orders," dated 1/5/17, indicated Resident 1 was admitted with diagnoses including Alzheimer's dementia (a progressive disorder affecting memory and physical function), after care for a right hip ORIF (open reduction internal fixation surgery to repair a fractured hip), and history of a fall within the 6 months prior to admission. Occupational Therapy and Physical Therapy evaluation and treatment were ordered. No orders for resident activity were specified. Resident 1's Physician Admission Orders dated 1/5/17, included prescriptions for Tramadol (analgesic or pain medication) 50 milligrams every six hours as needed for moderate pain. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RJCQ11 Facility ID: CA220000218 If continuation sheet 2 of 7 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: _______________ 555034 (X3) DATE SURVEY COMPLETED 09/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN MATEO MEDICAL CENTER D/P SNF 222 W 39th Ave 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 Record review of the facility's "Resident Admission Assessment," for Resident 1, dated 1/5/17, noted: weakness and pain of right hip, confused, dementia [memory disorder], and incontinent [unable to control urination or defecation] of bowel and bladder. The same assessment noted Resident 1 required extensive assistance with bathing, dressing, hygiene, and transferring. This assessment indicated Resident 1 was totally dependent on staff for toileting and ambulating, had fall risk factors of history of fall in last six months, was disoriented and confused, had poor safety judgment, and impaired balance. This assessment indicated psychotropic [used to treat psychiatric or psychological conditions] and pain medications as additional fall risk factors. Record review on 1/23/17 of Resident 1's, "Elopement Risk Assessment", dated 1/5/17, noted resident with, "Intermittent Confusion", and, "Two or More Behaviors Resident States Desire to Go Home, Wanders Aimlessly, etc.", was noted as part of, "Confounding Behaviors that Increase risk". Record review on 1/23/17 of Resident 1's, "Fall Risk Assessment form", dated 1/15/17, noted risk factors of intermittent confusion, history of falls, incontinent, impaired gait and balance, and medications that place resident at risk of fall, with a total score of 16, which indicated resident assessed as at high risk of falling. Resident 1's assessment matched the clinical profile of individuals with a high predictability of another fall. Record review on 1/23/17 of Resident 1's, "ADL [Activities of Daily Living] Flow Sheet", for 1/5/17, noted resident required extensive to limited assistance with toileting and needed either a walker or a wheelchair for mobility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RJCQ11 Facility ID: CA220000218 If continuation sheet 3 of 7 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: _______________ 555034 (X3) DATE SURVEY COMPLETED 09/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN MATEO MEDICAL CENTER D/P SNF 222 W 39th Ave 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 During an interview on 2/6/17 at 2:36 pm with the Director of Nursing (DON), she confirmed record review findings for Resident 1's, "Resident Admission Assessment", "Elopement Risk Assessment", "Fall Risk Assessment Form", "ADL Flow Sheet", "Physical Restraint Device Assessment"; and that Resident 1 had not been provided with a walker, as a physical therapy assessment was pending the day after admission. These findings indicated Resident 1 was predictably at risk for another fall, especially since he was admitted to the facility after major right hip surgery. Record review on 1/27/17 of, "Census List", noted room 104, bed 2, across the hallway from the nursing station, was marked vacant. Record review on 1/27/17 of, "Daily Staffing Schedule", for 1/6/17 night shift, noted CNA 1 had 17 residents assigned to his care when Resident 1 fell. During an interview with the DON on 1/25/17 at 11:05 am, DON was asked why Resident 1 was not placed in room 104 2 on admission, which is closer to the nursing station, yet, "transferred to 104 2", was noted in careplan, "Fall Risk Prevention and Management", in, "Approaches" on 1/6/17, after Resident 1's fall with injury on the night shift beginning at 11 pm on 1/5/17. DON stated, "I'm not sure why there was a decision for him to move... there might be some room changes they would have done. DON confirmed Resident 1 was high risk for falls, had received Tramadol during the admission, and had a history of a fall within 6 months of admission. Record review on 1/20/17 of, "Intra Agency Referral Form," dated 1/6/17, noted Resident 1 was, " ...found lying on the floor at near [sic] FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RJCQ11 Facility ID: CA220000218 If continuation sheet 4 of 7 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: _______________ 555034 (X3) DATE SURVEY COMPLETED 09/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN MATEO MEDICAL CENTER D/P SNF 222 W 39th Ave 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 bathroom. sustain [sic] laceration right occipital with 3 cm [centimeters, a metric measure] length 1 cm depth with moderate amount of bleeding." Record review on 1/20/17 of, "Resident Progress Notes", for Resident 1, noted on 1/6/17 at 3:15 4:25 am, "Resident was found lying on the floor near bathroom with blood on his body.", and noted Resident 1 was transported by ambulance to a GACH on 1/6/17. During an interview with CNA 1 on 1/23/17 at 8:30 am: when asked how long it took for him to answer the call light on the 1/6/17 night shift when Resident 1 fell, he stated, "15 minutes." Record review on 1/27/17 of facility policy and procedure, "Communication Call System" (revision 1.0, dated 1/1/12), stated, "Nursing Staff will answer call bells promptly, in a courteous manner." During an interview on 2/6/17 at 2:36 pm with DON, she was asked if 15 minutes to answer a call light/bell met the facility's policy and procedure to, " ...answer call bells promptly.", she replied, "No." During an observation on 1/20/17 at 10:09 am, the Administrator confirmed Resident 1 fell in room 124 near the opposite end of the hallway shared by the nursing station and across from room 104. Concurrent interview with the Administrator confirmed room 124 was not in direct line of sight of the nursing station, which was seven resident rooms away from room 124, and located near the opposite end of the hallway. During an interview on 1/27/17 at 2:45 PM with RN Supervisor (RNS), she stated for residents FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RJCQ11 Facility ID: CA220000218 If continuation sheet 5 of 7 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: _______________ 555034 (X3) DATE SURVEY COMPLETED 09/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN MATEO MEDICAL CENTER D/P SNF 222 W 39th Ave 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 identified as high risk for falls on admission before a care plan is written, common nursing actions included placing resident in a room that is closest to the nursing station, staff would be alerted that resident is at high risk for falls and to check on the resident frequently, "...at least every 2 hours...". RNS stated these nursing actions came from experience and training. Record review on 2/8/17 of, "Hospitalist History and Physical [H & P]", from GACH, dated 1/16/17, noted, 'Active problems: Subdural hematoma [collection of blood between the layer covering the brain and the surface of the brain]... ", and, "#Fall resulting in small subdural/subarachnoid [bleeding in to the protective tissue layers surrounding the brain] hematoma [bruise]", and, " ...regarding recurrent falls, suspect multifactorial (st p [status post or state after] orthopedic surgeries, suboptimal environment, presyncope or syncope [change in consciousness related to a fall in blood pressure], orthostatic [changes in blood pressure secondary to body position], metabolic abnormalities, visual impairment etc)". Document review on 2/8/17 of, "Subdural hematoma", accessed at https://medlineplus.gov/ency/article/0000713 .htm , noted, "A subdural hematoma is most often the result of a severe head injury. This type of subdural hematoma is among the deadliest of all head injuries. The bleeding fills the brain area very rapidly, compressing brain tissue. This often results in brain injury and may lead to death." Subdural hematomas can also occur after a minor head injry. The amount of bleeding is smaller and occurs more slowly. This type of subdural hematoma is often seen in older adults. Record review on 2/8/17 of same GACH FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RJCQ11 Facility ID: CA220000218 If continuation sheet 6 of 7 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: _______________ 555034 (X3) DATE SURVEY COMPLETED 09/25/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN MATEO MEDICAL CENTER D/P SNF 222 W 39th Ave 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 History and Physical noted, "CT [three dimensional imaging] Brain WO [without] Contrast, Edited Result Final", in, "Impression: 1. Acute trace left parietal [lobe of brain on upper lateral region] subdural hematoma... 2. Acute trace posterior falx [layer of tissue in the brain] subdural hematoma... ", and, "Evidence of intracranial hemorrhage [bleeding within the brain]... Yes". Document review on 1/25/17 of, "Evidence Based Falls Management Program in the Nursing Home", accessed at http://scholarworks.bellarmine.edu/cgi/viewcont ent.cgi?article=1008&context=tdc , noted an unfamiliar environment, sedating medications, weakness, and cognitive impairment as common precursors to falls. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RJCQ11 Facility ID: CA220000218 If continuation sheet 7 of 7