Other·September 27, 2019

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. Complaint: 618552 Facility reported incident: 618234 Representing the Department: 37653, Health Facilities Evaluator Nurse The inspection was limited to the specific complaint and facility reported incident investigated and does not represent the findings of a full inspection of the facility. Two Federal deficiencies and one State Citation were written as a result of complaint 618552 and facility reported incident 618234.

F678 SS=D Cardio-Pulmonary Resuscitation (CPR) CFR(s): 483.24(a)(3)

F678 10/07/2019 §483.24(a)(3) Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure staff provided basic life support, including cardiopulmonary resuscitation (CPR), immediately to 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: MT2Z11 Facility ID: CA220000218 If continuation sheet 1 of 15 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 09/11/2019 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 sampled residents (Resident 1) while choking during meal time. Failure to follow standards of practice for medical emergencies for Resident 1 had the potential to cause significant harm or death. Findings: Review of the Admission record titled "FACESHEET" indicated Resident 1 was admitted to the facility on 12/3/15, with diagnoses of dysphagia (difficulty swallowing) following unspecified cerebral vascular disease (stroke) and dementia (loss of cognitive functioning - thinking, remembering and reasoning). Review of the POLST for Resident 1 dated 4/10/18 indicated under section A, "Cardiopulmonary Resuscitation, attempt resuscitation/CPR." Under section B, "Medical Interventions, full treatment." During an interview on 1/23/19 at 2:20pm, the Speech Pathologist (SP) stated, "(Resident 1) required a CNA (Certified Nursing Assistant) present to administer small bites and cue resident on chewing and swallowing and monitor for signs of aspiration while eating." During an interview on 1/10/19 at 2:30pm the Director of Nursing (DON) stated that an unusual occurrence happened on 1/1/19 with Resident 1 on the first floor dining room by the main entrance adjacent to unit 1. At 10am Resident 1 was escorted to the dining room to participate in a sensory activity that involved listening to music. At 11am lunch began and his food tray was placed at his table away from his reach because no one was available to assist with feeding. An Activity Assistant (AA) was walking into the dining room and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MT2Z11 Facility ID: CA220000218 If continuation sheet 2 of 15 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 09/11/2019 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 witnessed Resident 1 grabbing at his food with no CNA at the table to assist him with eating. When it appeared that Resident 1 was choking, a Certified Nursing Assistant (CNA1) retrieved the Licensed Vocational Nurse (LVN1) from the staff lounge where LVN1 was taking her lunch break. Usually there are assigned staff to the dining room. The DON further stated LVN1 received corrective action because there should always be a Licensed Vocational Nurse in the resident dining room during meal time. After returning to the dining room, LVN1 wheeled Resident 1 back to his room and initiated cardiopulmonary resuscitation (CPR basic life support). When asked if this was the facility's standard emergency response protocol, the DON stated "Ideally they should have cleared the dining room and immediately attended to the Resident's (Resident 1) choking status where he was." Staff initiated a Code Blue (medical emergency) Response, 911 was called and Resident 1 was transferred to an acute care hospital (GACH) where he passed away. During observation of the dining room on 6/25/19 at 12:00pm, accompanied by the Activity Assistant (AA), there were five tables around the perimeter of the room. One table on the south wall by the window. During concurrent interview AA stated during shift on 1/1/19 at 11:45am, Resident 1 was seated at the table next to the window by himself with his food tray in front of him. AA stated she observed Resident 1 feeding himself and had food all over his mouth and shirt. AA wiped the food from his mouth and shirt with a cloth napkin and continued to observe residents. AA observed CNA1 feeding another Resident two tables away from Resident 1. AA acknowledged Resident 1 requires assistance with feeding and stated she did not inform CNA1 of her concerns before leaving for her FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MT2Z11 Facility ID: CA220000218 If continuation sheet 3 of 15 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 09/11/2019 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 break because she assumed CNA1 was aware. During an interview on 1/10/19 at 4:45pm, The Administrative Support Staff (AdminSS) stated he usually does rounds along the whole floor during lunchtime. At 12 noon he saw food all over Resident 1 and noticed shortness of breath, patted Resident 1 on the back, and cleaned up the food on his mouth and shirt. AdminSS stated there were approximately 5-6 residents in the dining room at that time and one staff member feeding a resident. Called/signaled LVN 2 from the nursing station for assistance. LVN 2 patted Resident 1 on the back and left to go get the medical chart. During an interview on 1/11/19 at 1:35pm LVN1 stated CNA1 got her from the break room when Resident 1 was experiencing a medical emergency. LVN1 stated she ran to the dining room and saw Resident 1 slumped down, pale and his tongue sticking out of his mouth. Resident 1 did not respond to LVN1's voice or touch. LVN1 stated that due to the number of other residents in the dining room she made the decision to wheel Resident 1 down the hall to his room and then left the room to go and obtain oxygen. LVN1 stated she should not have wheeled Resident 1 from the dining room to his room and should have initiated CPR in the dining room. During an interview on 1/18/19 at 9:50 am a Licensed Vocation Nurse (LVN3) stated while in the breakroom on 1/1/19 at 12:07pm LVN3 overheard there was a medical emergency. LNV3 saw LVN1 quickly leave the breakroom and LVN3 followed LVN1 to the emergency, heading straight to Resident 1's room. Resident 1 was in his wheelchair, looked pale and his lips were white. LVN3 stated Resident 1 was not breathing and was unresponsive. LVN3 and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MT2Z11 Facility ID: CA220000218 If continuation sheet 4 of 15 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 09/11/2019 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 a Rehabilitative Nurse Aide (RNA1) moved Resident 1 from his wheelchair to the bed and attempted to give the Heimlich maneuver. LVN3 stated "If had it to do over again, would do CPR immediately at room when saw him. Lay him down of the floor from his wheelchair (sic)." During review of the "Resident Progress Notes" signed by Licensed Vocational Nurse (LVN3) for Resident 1 dated 1/1/19, indicated "...at 12:10p, a staff member (CNA1) went inside the break room and reported that a Resident (Resident 1) was having an emergency. Rushed to the Resident's (Resident 1) room and saw (Resident 1) in wheelchair. Transferred (Resident 1) to the bed. Seen (Resident 1) gasping for air. Performed Heimlich maneuver 2 times at 12:15pm. After knowing (Resident 1) was full code, me and one staff (RNA1) transferred (Resident 1) on the floor. Performed CPR, 4 cycles of chest compressions and one staff was doing ambu bag (an artificial manual breathing unit). Paramedics came in and took over and told us to leave the room". During review of the "Resident Progress Notes" signed by Registered Nurse (RN1) for Resident 1 dated 1/1/19, indicated " at around lunch time, noted a LN (Licensed Nurse - LVN1) rushing and I immediately followed her. Arrived in (Resident 1) room. (Resident 1) was in bed and RNA1 was doing the Heimlich maneuver on him. When they saw that he was no longer conscious, they started to lower the head of the bed down. Instructed staff to move him to the floor and I called the code (Code Blue - a medical emergency protocol for a life threatening circumstance) and told them to call 911, 12:15pm. (LVN3) started compressions. Crash cart came in. I went to grab the ambu bag. I tilted his head and opened his mouth FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MT2Z11 Facility ID: CA220000218 If continuation sheet 5 of 15 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 09/11/2019 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 with my finger in it, finger sweep performed. I visually did not see any food particles in his mouth or anything obstructing his airway. I did two puffs, when (RNA1) took over for me. During my two puffs, I could clearly see his chest rising. During this time (RNA1) was on the phone with 911. At 12:20pm, the paramedics arrived and a female officer. They wanted everyone out of the room except for a nurse that knew (Resident 1). (LVN1) stayed in the room close to the bathroom wall. ACLS (Advanced Cardiac Life Support) starts. At 12:31pm the Fire Department arrived followed shortly by a male officer. I am standing outside the doorway frame, with my ear pointing in, when I hear is that a glove. They brought a Lucas CPR device (a mechanical chest compression machine). I ran to the elevator and told them to hold the elevator door open. At 12:46pm (Resident 1) was on his way to the ER (Emergency Room) ..." Record review of the personnel file for RNA1 on 2/6/19 at 2:55pm, indicated the CPR certification on file was issued on 11/3/18 and expired on 11/3/2020. The CPR certification did not have a valid certification number associated with a nationally recognized organization according to standards of practice. RNA 1 stated she gave cash to a friend who paid for the certification online. When asked where she took the class, RNA1 stated "Just took the course online...no in person instruction and has not had other CPR training through any other company." During an interview on 2/6/19 at 4:30pm, the Director of Staff Development (DSD), stated "The CPR cert (for RNA1) appeared to be forged. Verification cannot be made through the website or company. CNA's (and RNA's) are not required to be CPR certified so don't ask for them...usually CPR certs will have an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MT2Z11 Facility ID: CA220000218 If continuation sheet 6 of 15 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 09/11/2019 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 instructor number and cortication number printed on them and if need be verification can be done through the website or through the telephone much like it can be done for nursing. These cards look odd. All CPR certs, if done on-line also must have an in person practical application of the skills as part of the certification requirements". Review of the "(Name of Ambulance Company) Patient Care Report" dated 1/1/2019 at 12:31:00 (12:31pm) indicated "Removed an entire medical glove from the patient's (Resident 1) mouth covered in blood." During an interview on 1/10/19 at 12:20pm the Physician (MD) from the GACH stated "Patient (Resident 1) was in full arrest when he got here. He was already gone. Several minutes of no oxygen is all it takes. Once the pupils are already fixed and dilated you are faced with potential brain death." Review of the General Acute Care Hospital (GACH) discharge summary dated 1/2/19 2350 (11:50pm) indicated "(Resident 1) remained critically ill despite Ventilator support and chest tube and vasopressors and antibiotics. (Resident 1) had fixed and dilated pupils. Therefore after discussions with family ...it was decided to transition to comfort care on 1/2/19 and the terminal extubation was done at 2017 hrs (8:17pm) and (Resident 1) promptly expired at 1/2/19 @ 2253 (10:53pm)". Review of the Policy and Procedure titled "Medical Emergencies - Code Blue" dated January 1, 2012 indicated "Procedure I. First responder ...ii. Respond to resident immediately and ... iii. Commence one-person CPR, according to current practice. Review of the Pathology from the County's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MT2Z11 Facility ID: CA220000218 If continuation sheet 7 of 15 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 09/11/2019 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 Coroner's Office dated 2/10/19 indicated the cause of death was "Disease or Condition leading to death: A. Asphyxiation due to laryngeal blockage by a foreign object ...".

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 10/07/2019 §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 observation, interview and record review the facility failed to provide adequate supervision during mealtime for one of three sampled residents (Resident 1) in accordance with Resident 1's assessment and plan of care. Resident 1, who had difficulty swallowing, was left unsupervised while eating in the dining room. This failure resulted in Resident 1 choking on a glove during mealtime and being transferred to the emergency room for medical treatment on 1/1/19. Resident 1 expired on 1/2/19 due to asphyxiation(choking) caused by a laryngeal (throat) blockage by a foreign object. Findings: Review of the admission record titled, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MT2Z11 Facility ID: CA220000218 If continuation sheet 8 of 15 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 09/11/2019 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 "FACESHEET," indicated Resident 1 was admitted to the facility on 12/3/15, with diagnoses of dysphagia (difficulty swallowing) following unspecified cerebral vascular disease (stroke) and dementia (loss of cognitive functioning - thinking, remembering and reasoning). Review of his quarterly Minimum Data Set (MDS - an assessment tool) dated 11/5/18, indicated Resident 1 had long-term and shortterm memory problems. Resident 1 had unclear speech, required total dependence with one-person assistance during meals. Resident 1 had functional limitation in range of motion to one upper extremity. Resident 1 had difficulty swallowing requiring a mechanically altered and therapeutic diet. Resident 1 had a POLST (Physicians Order for Life Sustaining Treatment) indicating attempt resuscitation/CPR (Basic Life Support). Review of the POLST for Resident 1, dated 4/10/18, indicated under section A, "Cardiopulmonary Resuscitation, attempt resuscitation/CPR". Under section B, "Medical Interventions, full treatment". Review of Physician Orders, dated 8/8/18, indicated, "Mechanical soft diet with honey thick liquids, renal diet and high protein". Review of the care plan titled, "Nutrition Swallowing Impairment," dated 11/18, indicated a problem related to drooling, intolerance to thin liquids, dementia and dysphagia with written interventions around food intake to include: instruct/cue resident to swallow after each bite, double swallow to clear throat and monitor for signs and symptoms of aspiration (choking). During record review of the swallowing FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MT2Z11 Facility ID: CA220000218 If continuation sheet 9 of 15 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 09/11/2019 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 assessment by the Speech Pathologist (SP), dated 8/8/18 at 9:31 am, SP indicated Resident 1 was a moderate aspiration risk due to dysphagia resulting in coughing intermittently during food intake and coughing with residual food in mouth after swallowing. Certified Nursing Assistant (CNA) staff were "Educated and advised on safety awareness with monitoring oral food intake, administering small bites, alternating consistencies of mechanical soft texture foods with nectar thick liquids". During an interview on 1/23/19 at 2:20 pm, the SP stated, "He (Resident 1) has a moderate swallowing deficit and requires close monitoring and supervision". Review of the ADL (Activities of Daily Living) Flow sheet for Resident 1 dated 1/1/19 indicated "D/1" for eating and drinking during the AM shift. During a concurrent interview on 6/27/19 at 4 pm, the DON stated "Staff code the sections of the ADL Flow Sheet to represent the most help they provided to care for the Resident at that time. 'D' stands for total dependence and '1' stands for minimal one person assist". During an interview on 1/10/19 at 2:30 pm, the Director of Nursing (DON) stated that an unusual occurrence happened on 1/1/19 with Resident 1 on the first floor dining room by the main entrance adjacent to unit 1. At 10am, Resident 1 was escorted to the dining room to participate in a sensory activity that involved listening to music. At 11am lunch began and his food tray was placed at his table away from his reach because no one was available to assist with feeding. An Activity Assistant (AA) was walking into the dining room and witnessed Resident 1 grabbing at his food with no CNA at the table to assist him with eating. When it appeared that Resident 1 was choking, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MT2Z11 Facility ID: CA220000218 If continuation sheet 10 of 15 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 09/11/2019 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 a Certified Nursing Assistant (CNA) 1 retrieved the Licensed Vocational Nurse (LVN) 1 from the staff lounge where LVN 1 was taking her lunch break. Usually there are assigned staff to the dining room. The DON further stated LVN 1 received corrective action because there should always be a Licensed Vocational Nurse in the resident dining room during meal time. After returning to the dining room, LVN 1 wheeled Resident 1 back to his room and initiated cardiopulmonary resuscitation (CPR basic life support). When asked if this was the facility's standard emergency response protocol, the DON stated "Ideally they should have cleared the dining room and immediately attended to the Resident's (Resident 1) choking status where he was." Staff initiated a Code Blue (medical emergency) Response, 911 was called and Resident 1 was transferred to an acute care hospital where he passed away. During observation of the dining room on 6/25/19 at 12:00 pm, accompanied by the Activity Assistant (AA), there were five tables around the perimeter of the room. One of the tables was on the south wall by the window. During concurrent interview AA stated during shift on 1/1/19 at 11:45 am, Resident 1 was seated at the table next to the window by himself with his food tray in front of him. AA stated she observed Resident 1 feeding himself and had food all over his mouth and shirt. AA wiped the food from his mouth and shirt with a cloth napkin and continued to observe residents. AA observed CNA 1 feeding another resident two tables away from Resident 1. AA acknowledged Resident 1 required assistance with feeding and stated she did not inform CNA 1 of her concerns before leaving for her break because she assumed CNA 1 was aware. During an interview on 1/10/19 at 4:45pm, the Administrative Support Staff (AdminSS) stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MT2Z11 Facility ID: CA220000218 If continuation sheet 11 of 15 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 09/11/2019 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 he usually does rounds along the whole floor during lunchtime. At 12 noon he saw food all over Resident 1 and noticed he was short of breath and patted Resident 1 on the back. Admin SS cleaned up the food on Resident 1's mouth and shirt. AdminSS stated there were approximately 5-6 residents in the dining room at that time and one staff member feeding a resident. Called/signaled LVN 2 from the nursing station for assistance. LVN 2 patted Resident 1 on the back and left to go get the medical chart. AdminSS stated there were approximately 5-6 residents in the dining room at that time and one staff member feeding a resident. Called/signaled LVN 2 from the nursing station for assistance. LVN 2 patted Resident 1 on the back and left to go get the medical chart. During an interview on 1/11/19 at 1:35 pm, LVN 1 stated CNA1 got her from the break room when Resident 1 was experiencing a medical emergency. LVN1 stated she ran to the dining room and saw Resident 1 slumped down, pale and his tongue sticking out of his mouth. Resident 1 did not respond to LVN 1's voice or touch. LVN 1 stated that due to the number of other residents in the dining room she made the decision to wheel Resident 1 down the hall to his room and then left the room to go and obtain oxygen. LVN 1 stated she should not have wheeled Resident 1 from the dining room to his room and should have initiated CPR in the dining room. During an interview on 1/18/19 at 9:50 am, Licensed Vocation Nurse (LVN) 3 stated while in the breakroom on 1/1/19 at 12:07pm, LVN 3 overheard there was a medical emergency. LVN 3 saw LVN1 quickly leave the breakroom and LVN 3 followed LVN 1 to the emergency, heading straight to Resident 1's room. Resident 1 was in his wheelchair, looked pale and his FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MT2Z11 Facility ID: CA220000218 If continuation sheet 12 of 15 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 09/11/2019 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 lips were white. LVN 3 stated Resident 1 was not breathing and was unresponsive. LVN3 and a Rehabilitative Nurse Aide (RNA1) moved Resident 1 from his wheelchair to the bed and attempted to give the Heimlich maneuver. LVN 3 stated "If had it to do over again, would do CPR immediately at room when saw him. Lay him down of the floor from his wheelchair (sic) ". During review of the "Resident Progress Notes" signed by Licensed Vocational Nurse (LVN3) for Resident 1, dated 1/1/19 and untimed, indicated "...at 12:10p, a staff member (CNA1) went inside the break room and reported that a Resident (Resident 1) was having an emergency. Rushed to the Resident's (Resident 1) room and saw (Resident 1) in wheelchair. Transferred (Resident 1) to the bed. Seen (Resident 1) gasping for air. Performed Heimlich maneuver 2 times at 12:15pm. After knowing (Resident 1) was full code, me and one staff (RNA1) transferred (Resident 1) on the floor. Performed CPR, 4 cycles of chest compressions and one staff was doing ambu bag (an artificial manual breathing unit). Paramedics came in and took over and told us to leave the room." During review of the "Resident Progress Notes," signed by Registered Nurse (RN1) for Resident 1 dated 1/1/19 and untimed, indicated " at around lunch time, noted a LN (Licensed Nurse - LVN1) rushing and I immediately followed her. Arrived in (Resident 1) room. (Resident 1) was in bed and RNA1 was doing the Heimlich maneuver on him. When they saw that he was no longer conscious, they started to lower the head of the bed down. Instructed staff to move him to the floor and I called the code (Code Blue - a medical emergency protocol for a life threatening circumstance) and told them to call 911, 12:15 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MT2Z11 Facility ID: CA220000218 If continuation sheet 13 of 15 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 09/11/2019 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 pm. (LVN 3) started compressions. Crash cart came in. I went to grab the ambu bag. I tilted his head and opened his mouth with my finger in it, finger sweep performed. I visually did not see any food particles in his mouth or anything obstructing his airway. I did two puffs, when (RNA 1) took over for me. During my two puffs, I could clearly see his chest rising. During this time (RNA 1) was on the phone with 911. At 12:20 pm, the paramedics arrived and a female officer. They wanted everyone out of the room except for a nurse that knew (Resident 1). (LVN 1) stayed in the room close to the bathroom wall. ACLS (Advanced Cardiac Life Support) starts. At 12:31 pm the Fire Department arrived followed shortly by a male officer. I am standing outside the doorway frame, with my ear pointing in, when I hear is that a glove. They brought a Lucas CPR device (a mechanical chest compression machine). I ran to the elevator and told them to hold the elevator door open. At 12:46 pm (Resident 1) was on his way to the ER (Emergency Room) ..." Review of the "(Name of Ambulance Company) Patient Care Report" dated 1/1/19 at 12:31 pm indicated, "Removed an entire medical glove from the patient's (Resident 1) mouth covered in blood." During an interview on 1/10/19 at 12:20 pm the Physician (MD) from the GACH stated "Patient (Resident 1) was in full arrest when he got here. He was already gone. Several minutes of no oxygen is all it takes. Once the pupils are already fixed and dilated you are faced with potential brain death." Review of the General Acute Care Hospital (GACH) discharge summary dated 1/2/19 2350 (11:50 pm) indicated "(Resident 1) remained critically ill despite Ventilator support and chest FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MT2Z11 Facility ID: CA220000218 If continuation sheet 14 of 15 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 09/11/2019 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 tube and vasopressors and antibiotics. (Resident 1) had fixed and dilated pupils. Therefore, after discussions with family ...it was decided to transition to comfort care on 1/2/19 and the terminal extubation (removal of breathing tube) was done at 2017 hrs (8:17 pm) and (Resident 1) promptly expired at 1/2/19 @ 2253 (10:53pm)." Review of the Policy and Procedure titled "Dining Program" dated January 1, 2012 indicated "Procedure ...IV. Distribution of Trays ...C. Residents will be monitored by RNAs/CNAs through their meal to ensure assistance is provided ...VI. Staff Assignments ...A. RNAs/CNAs ...ii. Assist in transporting residents to their assigned dining programs and with distribution of trays, and then report to feeding/supervision assignments." Review of the County Coroner's Office dated 2/10/19 indicated "Anatomical diagnoses; 1. Latex glove in airway...Disease or Condition leading to death: A. Asphyxiation due to laryngeal blockage by a foreign object.... ." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MT2Z11 Facility ID: CA220000218 If continuation sheet 15 of 15