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 complaints investigated and does not represent the findings of a full inspection of the facility. For Complaint nos. CA518875 and CA520663 regarding Admission, Transfer, & Discharge Rights, the Department identified a violation of Federal and State regulations. A Class "B" Citation no. 220013024 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 (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: HVLZ11 Facility ID: CA220000416 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: _______________ 555235 (X3) DATE SURVEY COMPLETED 02/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AHMC SETON MEDICAL CENTER 1900 Sullivan Ave Daly City, CA 94015 (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 follow Federal regulations and facility Admission, Discharge, and Transfer policy 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 6/23/16 with diagnosis that included hypertension (high blood pressure), dementia (a general term for a decline in mental ability severe enough to interfere with daily life), seizure disorder (abnormal movements or behavior due to unusual electrical activity in the brain), and aphasia (loss of ability to understand or express speech, caused by brain damage). During a review of the clinical record for Resident 1, the minimum data set (MDS, a Resident assessment tool) dated 10/26/16 set (MDS, a resident assessment tool) indicated Resident 1 had moderately impaired daily decision-making skills. Resident 1 required set up and supervision for mobility and activities pf daily living. The care plan (a written or computerized guide that organizes information about the Resident ' s care) dated 6/24/16 with updates 6/25/16, 7/20/16, 10/3/16, 10/17/16, 12/24/16/ and 12/26/16 indicated interventions to address the behaviors of Resident 1 including; eating the meals of roommates, agitation related to changes in surrounding or routine and hitting and biting staff and other residents. On 12/29/16, Resident 1 was observed hitting another resident and refused to stop hitting FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HVLZ11 Facility ID: CA220000416 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: _______________ 555235 (X3) DATE SURVEY COMPLETED 02/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AHMC SETON MEDICAL CENTER 1900 Sullivan Ave Daly City, CA 94015 (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 resident when directed. Resident 1 was placed on an involuntary psychiatric hold and transferred to an acute care facility for further evaluation. On 1/3/17, Resident 1 was refused readmission to the first available semi-private bed after being discharged from acute care facility. During an interview with Director of Nursing (DON) on 1/19/17, at 3 PM, DON stated the "behaviors" of Resident 1 posed a danger to staff and other residents. When asked about the previous behaviors Admin stated Resident 1 has caused injuries to other residents and staff members. When asked how the facility handled these behaviors in the past Admin stated Resident 1 activities and location was being monitored every hour. Admin stated the facility does not have a locked unit making it difficult to monitor Resident 1. DON stated the decision not to re-admit Resident 1 was a combined decision of Administrator (Admin), Medical Director (MD), and "senior management". During an interview with Medical Director (MD) on 1/23/17, at 4 PM, MD stated there have been multiple incidents of Resident 1 abusing other residents and residents in the facility are afraid of Resident 1. During an interview with Ombudsman on 1/19/17, at 8:45 AM, Ombudsman stated the aggressive behavior of Resident 1 increased after Resident 1 was moved to a new room. Ombudsman stated that in the two to three days before Resident 1 was transferred to acute care, he bit a care giver, tried to pull a resident out of bed, and caused another resident to sustain a broken wrist when he was pushed by Resident 1. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HVLZ11 Facility ID: CA220000416 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: _______________ 555235 (X3) DATE SURVEY COMPLETED 02/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AHMC SETON MEDICAL CENTER 1900 Sullivan Ave Daly City, CA 94015 (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 Review of acute hospital Psychiatric Evaluation Services notes indicated involuntary psychiatric hold discontinued on 1/1/17. Review of acute hospital Hospitalist Progress notes dated 1/17/17 indicated Resident 1 sleeping during the day after receiving Seroquel (a drug used to treat bi-polar disorders) 25 milligrams, temazepam (a sedative) and lorazepam (a drug to relieve anxiety). Hospitalist Progress note indicated skilled facility continued to deny re-admission of Resident 1. During an interview with DON on 2/24/17, at 12:30 PM, DON stated no notice of discharge or transfer was sent to Resident 1 or the family of Resident 1. During an interview with Admin on 2/24/17, at 1:50 PM, DON stated no notice of discharge or transfer was sent to Resident 1 or the family of Resident 1. Admin stated we missed sending the notice. The facility policy and procedure titled "Bed Hold" dated 4/12 indicated ...when a resident is resident transferred for acute hospitalization ...the resident may be readmitted to the first available bed if the resident meets the admission criteria. The facility policy and procedure titled "Admission & Discharge Criteria Subacute and Skilled Nursing dated 4/12 indicated ...Skilled Nursing a. Admission Criteria ...3. Medication being adjusted ...8. Alzheimer ' s or dementia... The facility policy and procedure titled Admission & Discharge Criteria Subacute and Skilled FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HVLZ11 Facility ID: CA220000416 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: _______________ 555235 (X3) DATE SURVEY COMPLETED 02/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AHMC SETON MEDICAL CENTER 1900 Sullivan Ave Daly City, CA 94015 (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 Nursing dated 4/12 indicated ...Skilled Nursing ...Discharge Criteria 1. Patients will be discharged or transferred when one or more of the following criteria are met: a. Minimum criteria for admission no longer met b. Minimum criteria for admission no longer met c. Acute changes in clinical status requiring a higher level of care d. Patient elects to be transferred to an alternate facility and/or home, and has the appropriate resources and support systems to do so.

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

F206 (e)(1) Permitting residents to return to facility. A facility must establish and follow a written 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HVLZ11 Facility ID: CA220000416 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: _______________ 555235 (X3) DATE SURVEY COMPLETED 02/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AHMC SETON MEDICAL CENTER 1900 Sullivan Ave Daly City, CA 94015 (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 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 hospitalized on 12/29/16. This failure had the potential to result in significant decline in former social patterns preventing Resident 1 from maintaining or reaching his highest practible level of wellbeing. Findings: Resident 1 was admitted to the facility on 6/23/16 with diagnosis that included hypertension (high blood pressure), dementia (a general term for a decline in mental ability severe enough to interfere with daily life), seizure disorder (abnormal movements or behavior due to unusual electrical activity in the brain), and aphasia (loss of ability to understand or express speech, caused by brain damage). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HVLZ11 Facility ID: CA220000416 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: _______________ 555235 (X3) DATE SURVEY COMPLETED 02/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AHMC SETON MEDICAL CENTER 1900 Sullivan Ave Daly City, CA 94015 (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 a review of the clinical record for Resident 1, the minimum data set (MDS, a Resident assessment tool) dated 10/26/16 set (MDS, a Resident assessment tool) indicated Resident 1 had moderately impaired daily decision-making skills. Resident 1 required set up and supervision for mobility and activities pf daily living. The care plan (a written or computerized guide that organizes information about the Resident's care) dated 6/24/16 with updates 6/25/16, 7/20/16, 10/3/16, 10/17/16, 12/24/16/ and 12/26/16 indicated interventions to address the behaviors of Resident 1 including; eating the meals of roommates, agitation related to changes in surrounding or routine and hitting and biting staff and other Residents. On 12/29/16, Resident 1 was observed hitting another Resident and refused to stop hitting the other Resident when directed. Resident 1 was placed on an involuntary psychiatric hold and transferred to an acute care facility for further evaluation. On 1/3/17, Resident 1 was refused readmission to the first available semi-private bed after being discharged from acute care facility. During an interview with Director of Nursing (DON) on 1/19/17, at 3 PM, DON stated the "behaviors" of Resident 1 posed a danger to staff and other Residents. When asked about the previous behaviors Admin stated Resident 1 has caused injuries to other Residents and staff members. When asked how the facility handled these behaviors in the past Admin stated Resident 1 activities and location was being monitored every hour. Admin stated the facility does not have a locked unit making it difficult to monitor Resident 1. DON stated the decision not to re-admit FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HVLZ11 Facility ID: CA220000416 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: _______________ 555235 (X3) DATE SURVEY COMPLETED 02/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AHMC SETON MEDICAL CENTER 1900 Sullivan Ave Daly City, CA 94015 (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 Resident 1 was a combined decision of Administrator (Admin), Medical Director (MD), and "senior management". During an interview with Medical Director (MD) on 1/23/17, at 4 PM, MD stated there have been multiple incidents of Resident 1 abusing other Residents and Residents in the facility are afraid of Resident 1. During an interview with Ombudsman on 1/19/17, at 8:45 AM, Ombudsman stated the "aggressive" behavior of Resident 1 increased after Resident 1 was moved to a new room. Ombudsman stated that in the two to three days before Resident 1 was transferred to acute care, he bit a care giver, tried to pull a Resident out of bed, and caused another Resident to sustain a broken wrist when he was pushed by Resident 1. Review of acute hospital Psychiatric Evaluation Services notes indicated involuntary psychiatric hold discontinued on 1/1/17. Review of acute hospital Hospitalist Progress notes dated 1/17/17 indicated Resident 1 sleeping during the day after receiving Seroquel (a drug used to treat bi-polar disorders), temazepam (a sedative), and lorazepam (a drug to relieve anxiety). Hospitalist Progress notes indicated skilled facility continued to deny re-admission of Resident 1. The facility's policy and procedure titled "Bed Hold" dated 4/12 indicated ...when a Resident is transferred for acute hospitalization ...the Resident may be readmitted to the first available bed if the Resident meets the admission criteria. The facility's policy and procedure titled FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HVLZ11 Facility ID: CA220000416 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: _______________ 555235 (X3) DATE SURVEY COMPLETED 02/24/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE AHMC SETON MEDICAL CENTER 1900 Sullivan Ave Daly City, CA 94015 (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 "Admission & Discharge Criteria Subacute and Skilled Nursing dated 4/12 indicated ...Skilled Nursing a. Admission Criteria ...3. Medication being adjusted ...8. Alzheimer's or dementia... Review of clinical record of Resident 1 indicated a diagnosis of dementia. Review of acute hospital notes indicated Resident 1 receiving the following medications Seroquel, temazepam, and lorazepam. The facility's policy and procedure titled Admission & Discharge Criteria Subacute and Skilled Nursing dated 4/12 indicated ...Skilled Nursing ...Discharge Criteria 1. Residents will be discharged or transferred when one or more of the following criteria are met: a. Minimum criteria for admission no longer met b. Minimum criteria for admission no longer met c. Acute changes in clinical status requiring a higher level of care d. Resident elects to be transferred to an alternate facility and/or home, and has the appropriate resources and support systems to do so. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: HVLZ11 Facility ID: CA220000416 If continuation sheet 9 of 9