Health inspection·October 20, 2023

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Administrator, Administrator in Training (AIT), Director of Nursing (DON), Assistant Director of Nursing (ADON) 2, and Senior [NAME] President of Operations (SVPO) for facility's failure to protect Resident 8 and other female residents in the facility from Resident 1's sexually inappropriate behavior. Five (5) IJ Removal Plan were not accepted. On 10/20/23 at 11:20 AM, the IJ was removed in the presence of the Administrator after the surveyors verified onsite through observation, interview, and record review the implementation of the facility's submitted and accepted IJ Removal Plan #6 (action to correct the deficient practices). The IJ Removal Plan #6 included the following information: 1. Resident 1 was sent to the acute hospital for an evaluation due to increase sexual behavior on 10/17/23 and returned to facility with new medication order. 2. Resident 8 was visited by Social Services Assistant (SSA) and Licensed Vocational Nurse (LVN) from the day of the incident and subsequent visits resulted in no reports or evidence of emotional distress or change in daily routines. 3. The Interdisciplinary Team (IDT, a group of healthcare professionals with various areas of expertise who work together toward the goals of the residents) met on 10/17/23 and updated Resident 8's care plan. 4. The IDT reviewed Resident 1's chart on 10/17/23 to determine root cause of behaviors, possible triggers and interventions that can be used to ensure safety of all residents in the facility. Resident 1's care plan was updated on 10/17/23 to reflect these findings. 5. SSAs and Administrator in Training (AIT) conducted interviews on 10/17/23 for all alert females to see if they feel safe and if they had been touched inappropriately. All residents stated they felt safe and no inappropriate touching had taken place. 6. Director of Nursing (DON)/Designee reviewed all change of condition and behavior monitoring on 10/18/23 for all nonverbal residents from July of 2023 to present to see if there were any indications of abuse. There was no nonverbal resident identified from those with change of condition and behavior monitoring. 7. The AIT in-serviced the Health Care Partners (HCP, non-licensed staff providing one-to-one [1:1] supervision to residents) on 10/13/23 regarding procedure for one-to-one monitoring. All HCPs will pass competency evaluation by 10/19/23. After 10/19/23, they will be allowed back on the floor until the competency evaluation is completed by the AIT/Designee. 8. One-to-one sitter was in place from 7:00 AM to 10:00 PM. Every (Q) 15-minute checks from 10:00 PM to 7:00 AM by CNA/Designee while resident is in his room and 1:1 if he wants to come out of his room. 9. Night shift CNAs, LVNs and RNs (Registered Nurse) were in-serviced on monitoring and Q 15-minute checks of Resident 1 by the Administrator on 10/18/23. 10. The Administrator checked the Q 15-minute log on 10/18/23 from the time Resident 1 returned from the acute hospital on [DATE]. The log was complete, and no gaps or issues were noted. The Administrator/Designee will check the log daily. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 2 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Cross referenced to F607, F609, and F610. Level of Harm - Immediate jeopardy to resident health or safety Findings: Residents Affected - Few Review of Resident 1's admission record indicated, was admitted to facility on 8/30/22 with diagnoses including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), dementia (a group of symptoms affecting memory, thinking and social abilities), history of alcohol abuse, mild cognitive impairment (trouble remembering, learning new things, concentrating, or making decisions), and cognitive communication deficit (difficulty thinking and communicating). Further review, indicated, Resident 1 was his own responsible party (decision maker). Review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 9/1/23, indicated, Resident 1's cognition (thought process) was moderately impaired. The MDS indicated, Resident 1 did not exhibit any mood symptoms and physical behavioral symptoms directed towards others such as scratching, grabbing, and abusing others sexually. Further review of the MDS indicated, Resident 1 required supervision with set up help to one-person physical assist for bed mobility, transfer, walking, locomotion (ability to move from one place to another), eating, and toilet use. The MDS also indicated Resident 1 required extensive assistance with one-person physical assist for dressing and personal hygiene. Review of Resident 3's admission record indicated, was admitted to facility on 12/21/22 with diagnoses including hemiplegia (complete paralysis of side of the body), hemiparesis (partial weakness or paralysis of on one side of the body), dementia, and cognitive communication deficit. Review of Resident 3's MDS dated [DATE], indicated, Resident 3's cognition was severely impairment. The MDS indicated, Resident 3 did not exhibit any mood and behavioral symptoms. Further review of the MDS indicated, Resident 3 required extensive assistance with one-person physical assist for bed mobility and total dependence with one-person physical assist for transfer, walking, locomotion, eating, toilet use, and personal hygiene. Review of Resident 2's admission record indicated, was admitted to facility on 5/11/23 with diagnoses including encephalopathy (damage or disease that affects the brain), cognitive communication deficit, and catatonic disorder (a behavioral syndrome marked by an inability to moved normally). Review of Resident 2's MDS dated [DATE], indicated, Resident 2 has memory problem and moderately impaired decision-making skills under the staff assessment for mental status. The MDS indicated, Resident 2 had episodes of feeling or appearing down, depressed, or hopeless for 2 to 6 days under the staff assessment of resident mood. The MDS did not indicate any behavioral symptoms for Resident 2. Further review of the MDS indicated, Resident 2 required supervision with one-physical assist for transfer, walk in room, locomotion, and eating; limited assistance with one-physical assist for bed mobility and walk in corridor; extensive assistance with one-physical assist for dressing, toilet use, and personal hygiene. 1. Review of facility's untitled letter document dated 9/7/23, indicated, .On 8/31/2023, our resident [Resident 1] was observed in his room with a female resident (referring to Resident 2) who was touching his penis. The nurse separated the two residents. During the course of the investigation, it was found that [Resident 1] was involved in previous incident in July, in which he was seen touching (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 3 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 a different resident on the breast . Level of Harm - Immediate jeopardy to resident health or safety Review of CDPH's document titled, Complaint/Incident Intake Report, known as HS 802 indicated, the incident of Resident 1 touching Resident 3's breast was received on 9/1/23 at 5:20 PM by fax. Residents Affected - Few Review of document titled, Report of Suspected Dependent Adult/Elder Abuse, date completed on 8/31/23, indicated, date and time of the incident Resident 1 touching Resident 3's breast was sometime in July. This alleged incident was reported to the police by phone and to CDPH (California Department of Public Health) and Ombudsman by fax on 8/31/23, no time indicated. Review of Resident 3's Change in Condition dated 9/1/23, indicated, Resident was reported to have been touched in the breast area by another resident. Assessment done without issues noted. SOC 341 completed. Ombudsman and [NAME] Police Department notified. Resident unable to verbalize any information. Daughter and MD notified. During an observation on 9/14/23 at 3:07 PM, Resident 1 was wearing a pair of green socks with a hole exposing his right big toe and was pushing his wheelchair while walking by himself towards his room. During an interview on 9/14/23 at 3:11 PM, Resident 1 stated he doesn't remember an incident of touching female residents in the facility. Resident 1 then started asking for the phone to call his sister. Resident 1 was asked once again if he remembers any encounter with female residents in the facility. Resident 1 then stated, Are you criticizing me for liking women? Resident 1 then started wheeling himself towards the front desk. During concurrent observation and interview on 9/14/23 at 3:16 PM, Resident 3 was not in her room. CNA 1 stated, Resident 3 was up on her wheelchair in the dining room. CNA 1 stated she was not present when Resident 1 allegedly touched the breast of Resident 3 in July 2023 but have heard about it. CNA 1 explained, Resident 3 used gestures when communicating her needs and was total dependent with ADLs (activities of daily living). During an observation on 9/14/23 at 3:19 PM on the second-floor dining room, Resident 3 was sitting on a reclining wheelchair and was verbally responsive in Cantonese. During an interview on 9/14/23 at 3:22 PM, Licensed Vocational Nurse (LVN) 1 stated, a CNA said that one resident tried to touch the breast of Resident 3 and that there was no report or documentation of the incident in resident's chart. During an interview on 9/14/23, at 3:30 PM, CNA 2 stated, this was the first incident she witnessed that involved Resident 1 and Resident 3 in July 2023 on the second-floor dining room. CNA 2 recalled the incident and stated, [Resident 1] was wheeling himself towards the dining area. I saw [Resident 1] rubbing left breast of [Resident 3] in circular motion. CNA 2 also stated, she reported the incident immediately to LVN 1 and took Resident 1 back to his room. During an interview on 9/14/23 at 3:46 PM, LVN 1 confirmed and stated, CNA 2 reported to her regarding Resident 1 touching Resident 3's breast but cannot remember the exact date of the incident. LVN 1 stated, I reported it (referring to touching Resident 3's breast) to Resident Care Coordinator (RCC). I don't know what happened after. No investigation after. LVN 1 explained that the witness should report to RCC and Administrator (ADM) and that she doesn't do anything after reporting an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 4 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few allegation of abuse. LVN 1 added, the RCC will then report to the Administrator and complete the documentation and investigation. During further interview on 9/14/23 at 3:48 PM, LVN 1 stated, Everybody are mandated reporters. LVN 1 also stated, I don't report (to the State Agency/Ombudsman). Only (report) to RCC. Review of Resident 3's clinical record indicated, there was no progress notes in July 2023 regarding the incident of Resident 1 touching Resident 3's breast. Further review indicated, there was no documented evidence a plan of care was initiated to address the incident. Review of Resident 1's clinical record indicated, there was no progress notes in July 2023 regarding the incident of Resident 1 touching Resident 3's breast. Further review indicated, there was no documented evidence a plan of care was initiated to address Resident 1's sexually inappropriate behavior. During concurrent interview and record review on 9/14/23 at 3:53 PM, LVN 1 was unable to find documentation of the incident in Resident 1 and Resident 3's clinical record. LVN 1 stated, I don't see it here. During an interview on 9/14/23 at 4:23 PM, RCC stated, she received two reports that involved Resident 1. RCC stated, the incident of Resident 1 touching Resident 3's breast was not reported to the Administrator/Abuse Coordinator. RCC stated, the way she understood the report was that Resident 1 tap or grab Resident 3's shoulder, therefore concluded that it was not abuse. Thus, no report and no further investigation was conducted. During further interview on 9/14/23 at 4:28 PM, RCC stated, any alleged incidents should be reported directly to the Administrator and/or designee and reporting should be whoever witness the incident. RCC further stated, a change of condition and staff interview should be conducted after a report of alleged abuse was made. During an interview on 9/14/23 at 4:57 PM, Social Worker (SW) 1 stated, she learned about the incident of Resident 1 touching Resident 3's breast during her interview with CNA 2 regarding the incident between Resident 1 and Resident 2 on 8/31/23. During an interview on 9/14/23 at 4:59 PM, Assistant Director of Nursing (ADON) 2 stated, the Abuse Coordinator was not notified of the touching of the breast. ADON stated, Abuse Coordinator should have been notified immediately which did not happen. During further interview on 9/14/23 at 5:03 PM, SW 1 stated that the alleged incident of Resident 1 touching Resident 3' breast was not investigated after learning about the incident. SW 1 stated, At that time the DON and Administrator said it will be taken care of but did not happen (referring to reporting and investigation of the incident). During an interview on 9/14/23 at 5:09 PM, DON stated, There was a miscommunication between LVN 1 and RCC. RCC did not understand what LVN explained. No follow-up interview to clarify the reported incident of Resident 1 touching Resident 3's breast. During a follow-up interview on 9/14/23 at 5:14 PM, RCC stated, I should have followed up more. Get more information. RCC also stated that there was no report or documentation regarding the alleged (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 5 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 incident (referring to Resident 1 touching Resident 3's breast), I didn't do anything. No action done. Level of Harm - Immediate jeopardy to resident health or safety 2. During an interview on 9/14/23 at 3:34 PM, CNA 2 stated, a month later, she witnessed and reported two incidents that involved Resident 1 and Resident 2. CNA 2 stated, on the same month (August 2023), prior to the reported incident on 8/31/23, [Resident 1] attempted to touch [Resident 2] vagina by the social worker's office. CNA 2 added, she reported the incident to the evening nurse and was told to monitor Resident 1 since it was only an attempt. CNA 2 further stated, she did not document the incident and cannot remember the exact date it happened. Residents Affected - Few Review of Resident 1 and Resident 2's progress notes for August 2023 indicated, there was no documentation regarding Resident 1's attempt to touch Resident 2's vagina (female's private part). During an interview on 9/14/23 at 4:52 PM, SW 1 stated, she was not aware of Resident 1 attempted to touch Resident 2's vagina. During an interview on 9/14/23 at 5:19 PM, RCC stated, she did not get a report regarding Resident 1 attempted to touch Resident 2's vagina in August 2023. During a follow up telephone interview on 9/26/23 at 11:58 AM, CNA 2 stated, she reported the incident of Resident 1 attempted to touch Resident 2's vagina to the evening shift nurse (LVN 3) since the incident happened before dinner. CNA 2 added, [LVN 3] told me to monitor [Resident 1] since it was only an attempt. During a telephone interview on 9/27/23 at 10:35 AM, LVN 3 confirmed and stated, CNA 2 reported Resident 1 attempted to touch Resident 2's vagina during the evening shift and the two residents were separated immediately and monitored. LVN 3 also stated, I didn't document (referring to the incident). It was an attempt. I can't remember if I reported it. During an interview on 9/27/23 at 10:38 AM, ADON 1 stated, she was not aware of the attempt of Resident 1 touching Resident 2 that was reported by CNA 2 to LVN 3. ADON 1 added, If there's a report attempting to touch, it needs to be reported immediately. We need to do something right away. Review of Resident 2's care plan indicated, there was no documented evidence a care plan was initiated to address Resident 1's attempt to touch Resident's vagina in August 20223. 3. Review of document titled, Report of Suspected Dependent Adult/Elder Abuse, known as SOC 341, with date completed on 8/31/23, indicated, date and time of the incident of Resident 2 touching Resident 1's penis was 8/31/23 at 2:10 PM. The incident was reported to the police by phone on 8/31/23 at 4:30 PM; the facility reported to CDPH and Ombudsman by fax on 8/31/23, no time indicated. Review of Resident 2's Change in Condition dated 9/1/23, indicated, Resident was found in male resident room his [sic] hand in his penis. Resident separated from resident. Head to Toe assessment completed without issues noted. SOC 341 completed. Ombudsman and BPD ([NAME] Police Department) notified. BPD on scene and interviewed resident. Resident unable to verbalize any information. Family-Daughter and Dr [doctor] notified. Review of Resident 1's Change in Condition dated 9/1/23, indicated, At around 1410 (2:10 PM) on 08/31/2023 .the male resident on [room number] was witnessed by CNA inside [room number] with another (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 6 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few female resident [room number], the alleged victim. The alleged abuser was sitting on the wheelchair, pants was down while the alleged victim is touching the alleged abuser's penis. Both residents were separated, and the alleged victim was escorted back to her own room for safety while the alleged abuser stayed inside the room . An SOC-341 (known as Report of Suspected Dependent Adult/Elder Abuse) was completed and filed . CDPH and Ombudsman were also notified of the incident . During an interview on 9/14/23 at 3:40 PM, CNA 2 stated that on 8/31/23, she was walking by Resident 1's room towards the nursing station and noticed the door was open and saw Resident 2 standing in front of Resident 1 who was sitting on his wheelchair. CNA 2 stated, [Resident 1] pull-ups (disposable brief) were down. [Resident 2] was touching his penis. CNA 2 further stated, she called Resident Care Coordinator (RCC) and was told to separate the two residents and bring Resident 2 back to her room. During further interview, CNA 2 stated, she was suspended during the investigation of the incident on 8/31/23 (Resident 1 and Resident 2) because she did not report the July 2023 (breast) incident directly to the Administrator. CNA 2 added that she reported the incident immediately to the charge nurse. CNA 2 then stated, It doesn't make sense to suspend me. Now I'm afraid to report. I might get suspended again. During an interview on 9/14/23 at 4:19 PM, RCC stated, CNA 2 called her to go to Resident 1's room whose sitting on a wheelchair with his pants down while Resident 2 was standing in front holding his penis. RCC stated, the two residents were separated immediately and told CNA 2 to assist Resident 2 to her room. RCC also stated that she brought CNA 2 to the ADON to report the incident. During an interview on 9/14/23 at 4:52 PM, SW 1 stated, she interviewed the staff regarding the incident and assisted the ADON in completing form SOC 341. SW 1 then stated, the DON and Administrator did the reporting and investigation of the incident. Review of Resident 2's care plan for At risk for decline in psychosocial well-being due to sexual contact instigated by male resident, initiated on 9/1/23, indicated, Resident 2 will express/demonstrate feeling safe in facility through the review date. The care plan indicated the following interventions: observe resident for occurrence of or changes in sleep pattern, depression, anxiety, anger, confusion, behavior, and appetite changes. Refer the resident to psych evaluation for a psychosocial wellbeing assessment. Report s/s (signs/symptoms) of psychosocial distress to nurse. Review the daily routine of the facility with the resident and accommodate wishes. Review the resident's coping skills and support the use of the coping mechanism as much as possible. Review of Resident 1's Interdisciplinary Team (IDT, a group of healthcare professionals with various areas of expertise who work together toward the goals of the residents) Note dated 9/7/23, indicated, Staff reported this resident (Resident 1) was with a female resident (Resident 2) in his room, touching his penis on 8/31/23 . Upon investigation of this incident on 8/31/23, we found that this same resident (Resident 1) was involved with another incident of touching the breast area of a female resident (Resident 3) in the dining hall in the month of July . The IDT Note indicated, Administrator, Abuse Coordinator, DON (Director of Nursing), MD (Medical Doctor), RP (responsible party), police, CDPH and Ombudsman were notified of the incident. Further review of the IDT Note indicated, the alleged perpetrator (Resident 1) was placed on 15-minute monitoring for signs and symptoms of adverse effects from the alleged incident, was transferred to another floor and room, referred for psych evaluation, and olanzapine (medication used to treat (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 7 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few mental disorders) was increased to 10 mg (milligrams, a unit of measurement). The IDT Note did not indicate the incident of Resident 1 touching Resident 3's breast was further discussed and investigated. Review of Resident 1's Psych Assessment dated 9/1/23, indicated, Resident 1 was referred for psych evaluation due to the following targeted symptoms: sexually pre-occupied, impulsivity, and poverty of thought. The Psych Assessment indicated a diagnostic impression of schizophrenia with interventions including supportive psychotherapy (a type of therapy that primarily focuses on providing emotional support, encouragement, and validation during difficult life circumstances or psychological challenges), discontinue olanzapine 7.5 mg, start with olanzapine 10 mg 1 tablet per orem (po, per mouth) at hours of sleep (hs), and refer accordingly. Review of Resident 1's care plan for The resident was involved in alleged sexual abuse, initiated on 9/3/23, three days after the incident, indicated, the alleged abuser was sitting on the wheelchair, pants were down while the alleged victim is touching the alleged abuser's penis. The care plan indicated Resident 1 will have no evidence of behavior problems or will not display the same behavior until the next review. The care plan indicated the following interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Anticipate and meet the resident's needs. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove form situations. Document behavior and potential causes. Observed the behavior and report any abnormal findings. Separate/transfer the room of the abuser to [room number/unit]. SOC-341 was completed and filed. Further review of Resident 1's care plan indicated, there was no documented evidence a care plan was initiated to address Resident 1 touching Resident 3's breast and attempt to touch Resident 2's vagina. During an interview on 9/14/23 at 5:20 PM, ADON 1 stated, a plan of care was put in place after the reported incident on 8/31/23 between Resident 1 and Resident 2 and no other plan of care initiated after the incident in July 2023 between Resident 1 and Resident 3. During a joint interview on 9/14/23 at 5:27 PM, ADM and Regional Quality Management Consultant (RQMC) stated, the two staff (CNA 2 and LVN 1) were suspended for not reporting immediately to the Administrator. During an interview on 9/19/23 at 1:54 PM, Activity Assistant (AA) 2 stated, she observed Resident 1 winking at female residents during group activities and when he's out in the hallway. AA 2 also stated Resident 1 was just friendly and did not think of it as sexually inappropriate. During a concurrent interview and record review on 9/27/23 at 10:44 AM, ADON 1 stated there was no investigation and IDT conducted regarding the two incidents of Resident 1 touching Resident 3's breast and the attempt to touch Resident 2's vagina. During an interview on 9/27/23 at 1:08 PM, ADM stated, any allegations of abuse need to be reported by phone right away and faxed SOC 341 to SSA within two hours of the incident. ADM also stated, a 5-day follow-up or written result of the investigation should be faxed to the State Agency within five days from the incident or up to seven days including weekends, which did not happen. Review of facility's untitled letter document dated 9/7/23, indicated, This letter is to inform you (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 8 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the results of our investigation regarding a resident-to-resident sexual interaction that was reported to you on 8/31/23. Since the date of that report, there has been a change in two key positions which resulted in this letter not being completed within the five day time frame. Thank you for your understanding in this matter . During the course of the investigation, it was found that [Resident 1] was involved in previous incident in July, in which he was seen touching a different resident on the breast . [Resident 1] has been placed on increased monitoring to observe for behaviors and for psychosocial well-being. He was also moved to the first floor of the building near the nurse's station, away from the two female residents. he was evaluated by a psychiatrist who ordered a medication change. There have been no further incidents of inappropriate behavior . During further review, the untitled letter document did not indicate the result of the facility's investigation of the incident. 4. Review of Resident 8's admission record indicated, was admitted to facility on 3/17/21 with diagnoses including heart disease, stroke, functional quadriplegia (complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord), and anxiety disorder (persistent and excessive worry that interferes with daily activities). Review of Resident 8's MDS dated [DATE] indicated, Resident 8 has a BIMS (Brief Interview of Mental Status, a brief screener that aids in detecting cognitive impairment) score of 15, a score of 15 means no cognitive impairment. The MDS also indicated, Resident 8 was non-ambulatory and required extensive assistance with two-person assist for bed mobility, transfer, and locomotion on and off the unit; and one-person assist for dressing, eating, toilet use, and personal hygiene. Review of document titled, Report of Suspected Dependent Adult/Elder Abuse, known as SOC 341, with date completed on 10/12/23, indicated, date and time of the incident was on 10/12/23 at 4:55 PM, Staff heard Resident in room [number] who was in the hallway by her room in her wheelchair crying loudly. Staff asked resident what was wrong she stated a 'male resident down the hall was passing her and touched her on her right breast.' Resident stated that she wasn't in any pain from the incident. Male resident relocated to a different room and hallway. Continue current interventions in place. During an interview on 10/16/23 at 2:38 PM, the ADM stated, on 10/12/23 at 4:55 PM, Resident 8 was heard crying loudly in the hallway saying, He touched my boob (breast). Resident 8 was asked who touched and claimed it was Resident 1. The ADM further stated, CNA 5 was going to give a shower to Resident 1 however, CNA 5 left Resident 1 in his room unaccompanied to check if the shower room was available. The ADM stated, CNA walked away from resident. The ADM added, Resident 1 was transferred to another room in the same Unit as Resident 8 but in a different hallway. Resident 1 continued to have a one-to-one sitter in the morning and evening shift while every 15 minutes monitoring during night shift. During an interview on 10/16/23 at 2:56 PM, ADON 1 stated, she went to check on Resident 8 after she heard her yelling in the hallway he touched me on the breast. ADON 1 then stated, she asked and wheeled Resident 8 to Resident 1's room, which was one room away from her, to show and confirm if it was Resident 1 who touched her on the breast. Resident 8 confirmed it was Resident 1 who touched her on the breast. During further interview, ADON 1 explained that CNA 5 brought the shower chair in Resident 1's room and informed him it was his shower time. ADON 1 added, CNA 5 stepped out of the room to check if the shower room was available. ADON 1 further stated, The sitter (a person who looks after or takes care of someone) left resident unfortunately. She thought the CNA was with him. During an observation on 10/16/23 at 3:04 PM, in Unit 1 hallway, Resident 1's room was located next to the Administrator's office and one room/door away from Resident 8's room, which was located on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 9 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the same side of the hallway. Resident 8 was inside her room, sitting on a wheelchair next to her bed watching television (TV). Resident 8 was alert, verbally responsive, oriented to time, place, and person. During an interview on 10/12/23 at 3:05 PM, Resident 8 recalled the incident with Resident 1 on 10/12/23 and stated, I was sitting on the chair outside the room and then there's this man [Resident 1's Name was mentioned], wheeling. I thought he's just gonna (going to) wave at me. He squeezed my right breast. I was screaming out loud, crying. I screamed for help, 'maniac'. Resident 8 also stated, the social worker and supervisor came to asked what happened. Resident 8 then asked if Resident 1 can be in jail or moved somewhere. Resident 8 further stated, I was shocked. I was already crying. They (referring to supervisor and social worker) didn't ask me how I feel. During an observation on 10/16/23 at 3:12 PM, the shower room where CNA 5 went to check was located in Unit 2 hallway, across room [ROOM NUMBER], and back end of Unit 1 hallway. During an[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 10 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 9), was free from misappropriation of resident's property when Former Director of Nursing (FDON) took Resident 9's Ozempic medication and kept it in his office. Residents Affected - Few This failure resulted in Resident 9 not receiving his Ozempic medication. Findings: Resident 9 was admitted on [DATE], with diagnoses including Multiple sclerosis (Disabling disease of the brain and spinal cord), Diabetes mellitus (Disease that affect how the body uses blood sugar), Heart Failure (heart can't pump blood well enough to meet body's need). Resident 9 Brief interview for mental status indicated 15, which means intact cognitive response. During an Interview on 10/5/23, at 2:05 PM., with Resident 9, Resident 9 stated FDON took and kept my Ozempic pen for a week and did not return it. I noticed when it was returned to me that 1 needle was missing. After a few weeks it was then that I found out that one dose was missing. I have no idea why he took it. Resident 9 also added I don't want him working at other facilities where he can do the same thing. I am vocal and my mind is working fine but what if he does this with other patients that doesn't know any better. During an Interview on 10/5/23, at 2:40 PM., with Interim Director of Nursing (ADON) 1, ADON 1 stated . I don't know why it was in the FDON's office. Usually, it would be in the med cart or with patient if they self-administer. The medication was not given when it was due at around 2 PM. During an Interview on 10/5/2023 at 2:50 PM., with Registered Nurse (RN) 2, RN 2 stated FDON at the time, asked to see the medication, he texted me on June 21, 2023. 10:30 AM, I grabbed the box and gave it to FDON. I don't know why he wanted to see it. He didn't return it. Several nurses attempted to retrieve the pen after that day, but he didn't return it. During an interview on 10/11/23 at 3:47 PM, with Licensed Vocational Nurse (LVN) 11, LVN 11 stated Medication was due 2 PM -3 PM. I had 12 hours shift that day from 7AM to 7 PM. It was not given within my shift. I called Former Administrator (FADM) around 5 PM because the resident was really upset and informed him about the incident. FADM informed me that FDON will bring the pen back. Review of E-mail sent on 10/13/23 at 1:03 PM from Assistant Administrator (AADM) indicated Rockport and [NAME] Skilled Nursing let FDON go on September 5, 2023. During review of Policy and Procedure (P&P), revised date January 08, 2014, titled Abuse and Neglect, indicated iv. Upon an allegation of abuse by a Facility Staff member, the Facility Staff member will be suspended and removed from the premises. During review of P&P, date revised July 2018, Titled Abuse-Prevention, Screening, & Training Program indicated Misappropriation of resident property and financial abuse are defined as the deliberate misplacement, exploitation, or wrongful, temporary, or permanent use of a resident's belongings or money without the resident's consent. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 11 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide process oversight and ensure effective implementation of its abuse policies and procedures to protect three of three sampled residents (Resident 2, Resident 3, and Resident 8) when: Residents Affected - Few 1. Facility did not ensure three allegations of sexual abuse (non-consensual sexual contact of any type with a resident) were reported to the State Survey Agency (SSA) within the required timeframe of two (2) hours for Resident 2 and Resident 3. Additionally, Certified Nursing Assistant (CNA) 2 and Licensed Vocational Nurse (LVN) 1 who witnessed and reported the sexual abuse allegations to the nurse-in-charge were placed on suspension. 2. Facility did not conduct a thorough investigation of the three allegations of sexual abuse for Resident 3 in July 2023 and two incidents for Resident 2 in August 2023. In addition, the facility did not report the results of the investigation for all three allegations of sexual abuse to the SSA within five (5) working days. 3. Facility did not identify triggers of Resident 1 to manifest the sexually abusive behavior which resulted to another incident of inappropriate touching of Resident 8's right breast on 10/12/23. The cumulative effects of these failures resulted in delayed identification of Resident 1's sexually inappropriate behavior towards Resident 2 and Resident 3; did not prevent further sexual abuse towards Resident 2 and Resident 8; and staff including CNA 2 and LVN 1, being afraid to report witnessed abuse incidents. Additionally, these failures placed other vulnerable residents in the facility to experience sexual abuse and the potential to compromise resident's safety from unreported and uninvestigated allegations of abuse. On 10/17/23 at 4:44 PM, an Immediate Jeopardy (IJ, a situation in which the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause serious injury, harm, impairment, or death to a resident) situation was identified in the presence of the Administrator, Administrator in Training (AIT), Director of Nursing (DON), Assistant Director of Nursing (ADON) 2, and Senior [NAME] President of Operations (SVPO) for facility's failure to provide process oversight and ensure effective implementation of the facility's abuse policies and procedures during the provision of care and services for Resident 2, Resident 3, and Resident 8. Five (5) IJ Removal Plan were not accepted. On 10/20/23 at 11:20 AM, the IJ was removed in the presence of the Administrator after the surveyors verified onsite through observation, interview, and record review the implementation of the facility's submitted and accepted IJ Removal Plan #6 (action to correct the deficient practices). The IJ Removal Plan #6 included the following information: 1. CNA 2 and LVN 1 were both placed on suspension on 9/1/23 for 10 days and were given in-service on 9/1/23 regarding their duty as mandated reporter. 2. In-services were started by the Director of Staff Development (DSD) on 10/18/23 for all staff on abuse prevention and reporting. Any staff who did not receive training by 10/19/23 were not allowed back on the floor until they have received training and completed a Post Test and an Acknowledgement of Abuse and Neglect Training. In-services by the DSD will continue until all staff have been retrained. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 12 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 3. The DSD/Designee started a weekly audit of all employees' file to ensure they received training on prohibiting and preventing abuse, identifying what constitutes abuse, recognizing signs of abuse, reporting abuse, and understanding resident behavioral symptoms that may increase the risk of abuse and neglect and how to respond. 4. SSAs and Administrator in Training (AIT) conducted interviews on 10/17/23 of all alert female residents to see if they feel safe and if they had been touched inappropriately. All residents stated they felt safe and no inappropriate touching had taken place. 5. Director of Nursing (DON)/Designee reviewed all change of condition and behavior monitoring on 10/18/23 for all nonverbal residents from July of 2023 to present to see if there were any indications of abuse. There was no nonverbal resident identified from those with change of condition and behavior monitoring. 6. The IDT reviewed Resident 1's chart on 10/17/23 to determine root cause of behaviors, possible triggers and interventions that can be used to ensure safety of all residents in the facility. Resident 1's care plan was updated on 10/17/23 to reflect these findings. Cross referenced to F600, F609, and F610. Findings: Review of Resident 1's admission record indicated, was admitted to facility on 8/30/22 with diagnoses including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), dementia (a group of symptoms affecting memory, thinking and social abilities), history of alcohol abuse, mild cognitive impairment (trouble remembering, learning new things, concentrating, or making decisions), and cognitive communication deficit (difficulty thinking and communicating). Review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 9/1/23, indicated, Resident 1's cognition (thought process) was moderately impaired. The MDS indicated, Resident 1 did not exhibit any mood symptoms and physical behavioral symptoms directed towards others such as scratching, grabbing, and abusing others sexually. Further review of the MDS indicated, Resident 1 required supervision with set up help to one-person physical assist for bed mobility, transfer, walking, locomotion (ability to move from one place to another), eating, and toilet use. The MDS also indicated Resident 1 required extensive assistance with one-person physical assist for dressing and personal hygiene. Review of Resident 2's admission record indicated, was admitted to facility on 5/11/23 with diagnoses including encephalopathy (damage or disease that affects the brain), cognitive communication deficit, and catatonic disorder (a behavioral syndrome marked by an inability to moved normally). Review of Resident 2's MDS dated [DATE], indicated, Resident 2 has memory problem and moderately impaired decision-making skills under the staff assessment for mental status. The MDS indicated, Resident 2 had episodes of feeling or appearing down, depressed, or hopeless for 2 to 6 days under the staff assessment of resident mood. The MDS did not indicate any behavioral symptoms for Resident 2. Further review of the MDS indicated, Resident 2 required supervision with one-physical assist for transfer, walk in room, locomotion, and eating; limited assistance with one-physical assist for bed mobility and walk in corridor; extensive assistance with one-physical assist for dressing, toilet use, and personal hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 13 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Review of resident 3's admission record indicated, was admitted to facility on 12/21/22 with diagnoses including hemiplegia (complete paralysis of side of the body), hemiparesis (partial weakness or paralysis of on one side of the body), dementia, and cognitive communication deficit. Review of Resident 3's MDS dated [DATE], indicated, Resident 3's cognition was severely impairment. The MDS indicated, Resident 3 did not exhibit any mood and behavioral symptoms. Further review of the MDS indicated, Resident 3 required extensive assistance with one-person physical assist for bed mobility and total dependence with one-person physical assist for transfer, walking, locomotion, eating, toilet use, and personal hygiene. Review of Resident 8's admission record indicated, was admitted to facility on 3/17/21 with diagnoses including heart disease, stroke, functional quadriplegia (complete immobility due to severe disability or frailty from another medical condition without injury to the brain or spinal cord), and anxiety disorder (persistent and excessive worry that interferes with daily activities). Review of Resident 8's MDS dated [DATE] indicated, Resident 8 has a BIMS (Brief Interview of Mental Status, a brief screener that aids in detecting cognitive impairment) score of 15, a score of 15 means no cognitive impairment. The MDS also indicated, Resident 8 was non-ambulatory and required extensive assistance with two-person assist for bed mobility, transfer, and locomotion on and off the unit; and one-person assist for dressing, eating, toilet use, and personal hygiene. 1a. Review of facility's untitled letter document dated 9/7/23, indicated, .On 8/31/2023, our resident [Resident 1] was observed in his room with a female resident who was touching his penis. The nurse separated the two residents. During the course of the investigation, it was found that [Resident 1] was involved in previous incident in July, in which he was seen touching a different resident on the breast . Review of California Department of Public Health (CDPH) document titled, Complaint/Incident Intake Report, known as HS 802 indicated, the incident of Resident 1 touching Resident 3's breast was received on 9/1/23 at 5:20 PM by fax. Review of document titled, Report of Suspected Dependent Adult/Elder Abuse, known as SOC 341, with date completed on 8/31/23, indicated, date and time of the incident Resident 1 touching Resident 3's breast was sometime in July. This alleged incident was reported to the police by phone on 8/31/23, no time indicated; and to CDPH and Ombudsman by fax on 8/31/23, no time indicated. Review of facility document titled, Transmission Result Report, indicated, the facility faxed to CDPH on 8/31/23 at 8:03 PM. 1b. Review of CDPH's document titled, Complaint/Incident Intake Report, known as HS 802 indicated, the incident of Resident 2 touching Resident 1's penis was received on 9/1/23 at 10:39 AM by fax. Review of document titled, Report of Suspected Dependent Adult/Elder Abuse, known as SOC 341, with date completed on 8/31/23, indicated, date and time of the incident of Resident 2 touching Resident 1's penis was 8/31/23 at 2:10 PM. The incident was reported to the police by phone on 8/31/23 at 4:30 PM; the facility reported to CDPH and Ombudsman by fax on 8/31/23, no time indicated. Review of facility document titled, Transmission Result Report, indicated, the facility faxed to CDPH on 8/31/23 at 6:10 PM and to Ombudsman on 8/31/23 at 6:11 PM (4 hours after the incident). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 14 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 1c. During an interview on 9/14/23, at 3:30 PM, CNA 2 stated, she witnessed the first incident involving Resident 1 and Resident 3 in July 2023 on the second-floor dining room. CNA 2 recalled the incident and stated, [Resident 1] was wheeling himself towards the dining area. I saw [Resident 1] rubbing left breast of [Resident 3] in circular motion. CNA 2 also stated, she reported the incident immediately to Licensed Vocation Nurse (LVN) 1 and took Resident 1 back to his room. During further interview, CNA 2 stated, she was suspended during the investigation of the incident on 8/31/23 (Resident 1 and Resident 2) because she did not report the July 2023 (breast) incident directly to the Administrator. CNA 2 added that she reported the incident immediately to the charge nurse. During an interview on 9/14/23 at 3:34 PM, CNA 2 stated, a month later, she witnessed and reported two incidents that involved Resident 1 and Resident 2. CNA 2 stated, on the same month (August 2023), prior to the reported incident on 8/31/23, [Resident 1] attempted to touch [Resident 2] vagina by the social worker's office. CNA 2 added, she reported the incident to the evening nurse and was told to monitor Resident 1 since it was only an attempt. CNA 2 further stated, she did not document the incident and cannot remember the exact date it happened. During an interview on 9/14/23 at 3:40 PM, CNA 2 stated, she was suspended during the investigation of the incident on 8/31/23 (Resident 1 and Resident 2) because she did not report the July 2023 (breast) incident directly to the Administrator. CNA 2 added that she reported the incident immediately to the charge nurse. CNA 2 then stated, It doesn't make sense to suspend me. Now I'm afraid to report. I might get suspended again. Review of Resident 1 and Resident 2's progress notes for August 2023 indicated, there was no documentation regarding Resident 1's attempt to touch Resident 2's vagina. During an interview on 9/14/23 at 3:46 PM, LVN 1 confirmed and stated, CNA 2 reported to her regarding Resident 1 touching Resident 3's breast but cannot remember the exact date of the incident. LVN 1 stated, I reported it (referring to touching Resident 3's breast) to Resident Care Coordinator (RCC). I don't know what happened after. No investigation after. LVN 1 explained that the witness should report to RCC and Administrator (ADM) and that she doesn't do anything after reporting an allegation of abuse. LVN 1 added, the RCC will then report to the Administrator and complete the documentation and investigation. During further interview on 9/14/23 at 3:48 PM, LVN 1 stated, Everybody are mandated reporters. LVN 1 also stated, I don't report (to the State Agency/Ombudsman). Only (report) to RCC. During an interview on 9/14/23 at 4:23 PM, RCC stated, she received two reports that involved Resident 1. RCC stated, the incident of Resident 1 touching Resident 3's breast was not reported to the Administrator/Abuse Coordinator. RCC stated, the way she understood the report was that Resident 1 tap or grab Resident 3's shoulder, therefore concluded that it was not abuse. Thus, no report and no further investigation was conducted. During further interview on 9/14/23 at 4:28 PM, RCC stated, any alleged incidents should be reported directly to the Administrator and/or designee and reporting should be whoever witness the incident. RCC further stated, a change of condition and staff interview should be conducted after a report of alleged abuse was made. During an interview on 9/14/23 at 4:52 PM, Social Worker (SW) 1 stated, she learned about the incident of Resident 1 touching Resident 3's breast during her interview with CNA 2 regarding the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 15 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few incident between Resident 1 and Resident 2 on 8/31/23. SW 1 further stated, the CNA, LVN, or RCC were expected to report the alleged incident of Resident 1 touching Resident 2's breast immediately or within two hours from the time they knew about the incident. During an interview on 9/14/23 at 4:59 PM, Assistant Director of Nursing (ADON) stated, the Abuse Coordinator was not notified of the touching of the breast. ADON stated, Abuse Coordinator should have been notified immediately which did not happen. During further interview on 9/14/23 at 5:03 PM, SW 1 stated that the alleged incident of Resident 1 touching Resident 3' breast was not investigated after learning about the incident. SW 1 stated, At that time the DON and Administrator said it will be taken care of but did not happen (referring to reporting and investigation of the incident). During an interview on 9/14/23 at 5:19 PM, RCC stated, she did not get a report regarding Resident 1 attempted to touch Resident 2's vagina in August 2023. During a joint interview on 9/14/23 at 5:27 PM, ADM and RQMC stated, the two staff (CNA 2 and LVN 1) were suspended for not reporting immediately to the Administrator. Review of CNA 2's employee file indicated, Corrective Action Memo dated 9/12/23 was given to and signed by CNA 2 on 9/12/23 indicating, .Employer Statement: Staff did not follow policy in properly reporting an alleged sexual abuse case to the abuse coordinator. On 8/31/23, [CNA 2] notified us about the alleged abuse case that happened in July, but the abuse coordinator was not informed . Employee Statement (Optional): I did notify the nurse in-charge and it was [LVN 1] and the nurse reported to the supervisor [RCC] and did mention to [LVN 3]. Review of LVN 1's employee file indicated, Corrective Action Memo dated 9/12/23 was given to and signed by LVN 1 on 9/12/23 indicating, .Employer Statement: [LVN 2] did not follow policy in properly reporting an alleged sexual abuse case to the abuse coordinator on time . Under the Employee Statement (Optional) indicated LVN 1 did not write her statement. Review of CNA 2 and LVN 1's timesheet dated 9/1/23 to 9/15/23 indicated, CNA 2 and LVN 1 were taken off the schedule from 9/1/23 through 9/8/23. During a follow up telephone interview on 9/26/23 at 11:58 AM, CNA 2 stated, she reported the incident of Resident 1 attempted to touch Resident 2's vagina to the evening shift nurse (LVN 3) since the incident happened before dinner. CNA 2 added, [LVN 3] told me to monitor [Resident 1] since it was only an attempt. During a telephone interview on 9/27/23 at 10:35 AM, LVN 3 confirmed and stated, CNA 2 reported Resident 1 attempted to touch Resident 2's vagina during the evening shift and the two residents were separated immediately and monitored. LVN 3 also stated, I didn't document (referring to the incident). It was an attempt. I can't remember if I reported it. During an interview on 9/27/23 at 10:38 AM, DON stated, she was not aware of the attempt of Resident 1 touching Resident 2 that was reported by CNA 2 to LVN 3. DON added, If there's a report attempting to touch, it needs to be reported immediately. We need to do something right away. During an interview on 9/27/23 at 1:08 PM, ADM stated, any allegations of abuse need to be reported (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 16 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 by phone right away and faxed SOC 341 to SSA within two hours of the incident. Level of Harm - Immediate jeopardy to resident health or safety 2. Review of Resident 3's clinical record indicated, there was no progress notes in July 2023 regarding the incident of Resident 1 touching Resident 3's breast. Further review indicated, there was no documented evidence a plan of care was initiated to address the incident. Residents Affected - Few Review of Resident 1's clinical record indicated, there was no progress notes in July 2023 regarding the incident of Resident 1 touching Resident 3's breast. Further review indicated, there was no documented evidence a plan of care was initiated to address Resident 1's sexually inappropriate behavior. Review of Resident 1 and Resident 2's progress notes for August 2023 indicated, there was no documentation regarding Resident 1's attempt to touch Resident 2's vagina. During an interview on 9/14/23 at 3:46 PM, LVN 1 stated, I reported it (referring to touching Resident 3's breast) to Resident Care Coordinator (RCC). I don't know what happened after. No investigation after. LVN 1 explained that the witness should report to RCC and Administrator (ADM) and that she doesn't do anything after reporting an allegation of abuse. LVN 1 added, the RCC will then report to the Administrator and complete the documentation and investigation. During concurrent interview and record review on 9/14/23 at 3:53 PM, LVN 1 was unable to find documentation of the incident in Resident 1 and Resident 3's clinical record. LVN 1 stated, I don't see it here. During an interview on 9/14/23 at 4:23 PM, RCC stated, she received two reports that involved Resident 1. RCC stated, the incident of Resident 1 touching Resident 3's breast was not reported to the Administrator/Abuse Coordinator. RCC stated, the way she understood the report was that Resident 1 tap or grab Resident 3's shoulder, therefore concluded that it was not abuse. Thus, no report and no further investigation was conducted. During further interview on 9/14/23 at 4:28 PM, RCC stated, a change of condition and staff interview should be conducted after a report of alleged abuse was made. During an interview on 9/14/23 at 4:52 PM, SW 1 stated that the alleged incident of Resident 1 touching Resident 3' breast was not investigated after learning about the incident. During a concurrent interview and record review on 9/27/23 at 10:44 AM, DON stated there was no investigation and IDT conducted regarding the two incidents of Resident 1 touching Resident 3's breast and the attempt to touch Resident 2's vagina. Review of facility's untitled letter document dated 9/7/23, indicated, This letter is to inform you of the results of our investigation regarding a resident-to-resident sexual interaction that was reported to you on 8/31/2023. Since the date of that report, there has been a change in two key positions which resulted in this letter not being completed within the five-day time frame . During an interview on 9/27/23 at 1:08 PM, ADM stated, any allegations of abuse need to be reported by phone right away and faxed SOC 341 to SSA within two hours of the incident. ADM also stated, a 5-day follow-up or written result of the investigation should be faxed to the State Agency within five days from the incident or up to seven days including weekends, which did not happen. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 17 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 3. Review of Resident 1's Interdisciplinary Team (IDT, a group of healthcare professionals with various areas of expertise who work together toward the goals of the residents) Note dated 9/7/23, indicated, Staff reported this resident (Resident 1) was with a female resident (Resident 2) in his room, touching his penis on 8/31/23 . Upon investigation of this incident on 8/31/23, we found that this same resident (Resident 1) was involved with another incident of touching the breast area of a female resident (Resident 3) in the dining hall in the month of July . The IDT Note indicated, Administrator, Abuse Coordinator, DON (Director of Nursing), MD (Medical Doctor), RP (responsible party), police, CDPH and Ombudsman were notified of the incident. Further review of the IDT Note indicated, the alleged perpetrator (Resident 1) was placed on 15-minute monitoring for signs and symptoms of adverse effects from the alleged incident, was transferred to another floor and room, referred for psych evaluation, and olanzapine (medication used to treat mental disorders) was increased to 10 mg (milligrams, a unit of measurement). The IDT Note did not indicate the incident of Resident 1 touching Resident 3's breast was further discussed and investigated. Review of Resident 1's Psych Assessment dated 9/1/23, indicated, Resident 1 was referred for psych evaluation due to the following targeted symptoms: sexually pre-occupied, impulsivity, and poverty of thought. The Psych Assessment indicated a diagnostic impression of schizophrenia with interventions including supportive psychotherapy (a type of therapy that primarily focuses on providing emotional support, encouragement, and validation during difficult life circumstances or psychological challenges), discontinue olanzapine 7.5 mg, start with olanzapine 10 mg 1 tablet per orem (po, per mouth) at hours of sleep (hs), and refer accordingly. Review of Resident 1's care plan for The resident was involved in alleged sexual abuse, initiated on 9/3/23, three days after the incident, indicated, the alleged abuser was sitting on the wheelchair, pants were down while the alleged victim is touching the alleged abuser's penis. The care plan indicated Resident 1 will have no evidence of behavior problems or will not display the same behavior until the next review. The care plan indicated the following interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Anticipate and meet the resident's needs. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a clam manner. Divert attention. Remove form situations. Document behavior and potential causes. Observed the behavior and report any abnormal findings. Separate/transfer the room of the abuser to [room number/unit]. SOC-341 was completed and filed. Further review of Resident 1's care plan indicated, there was no documented evidence a care plan was initiated to address Resident 1 touching Resident 3's breast and attempt to touch Resident 2's vagina. During an interview on 9/14/23 at 5:20 PM, ADON 1 stated, a plan of care was put in place after the reported incident on 8/31/23 between Resident 1 and Resident 2 and no other plan of care initiated after the incident in July 2023 between Resident 1 and Resident 3. Review of document titled, Report of Suspected Dependent Adult/Elder Abuse, known as SOC 341, with date completed on 10/12/23, indicated, date and time of the incident was on 10/12/23 at 4:55 PM, Staff heard Resident in room [number] who was in the hallway by her room in her wheelchair crying loudly. Staff asked resident what was wrong she stated a 'male resident down the hall was passing her and touched her on her right breast.' Resident stated that she wasn't in any pain from the incident. Male resident relocated to a different room and hallway. Continue current interventions in place. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 18 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few During an observation on 10/16/23 at 3:04 PM, in Unit 1 hallway, Resident 1's room was located next to the Administrator's office and one room/door away from Resident 8's room, which was located on the same side of the hallway. Resident 8 was inside her room, sitting on a wheelchair next to her bed watching television (TV). Resident 8 was alert, verbally responsive, oriented to time, place, and person. During an interview on 10/12/23 at 3:05 PM, Resident 8 recalled the incident with Resident 1 on 10/12/23 and stated, I was sitting on the chair outside the room and then there's this man [Resident 1's Name was mentioned], wheeling. I thought he's just gonna (going to) wave at me. He squeezed my right breast. I was screaming out loud, crying. I screamed for help, 'maniac'. Resident 8 also stated, the social worker and supervisor came to asked what happened. Resident 8 then asked if Resident 1 can be in jail or moved somewhere. Resident 8 further stated, I was shocked. I was already crying. They (referring to supervisor and social worker) didn't ask me how I feel. During an interview on 10/16/23 at 3:59 PM, RN 1 stated, [Resident 1] likes waving both hands like reaching out to you. Has a habit of reaching out. RN 1 further stated, Resident 1's habit of waving both hands and reaching out were not part of the behavior monitoring. During an interview on 10/16/23 at 4:47 PM, ADM stated that after the incident, new interventions were implemented for Resident 1 including room transfer close to the nurse's station, reminded staff not to leave resident alone, and to continue one-to-one sitter in the morning and evening shift, and Q 15 minutes check at night shift. During concurrent interview and record review on 10/16/23 at 5:06 PM, AIT reviewed and provided copies of Resident 1's Every 15 minutes Resident Monitoring for October 2023 and was unable to find documented evidence of Q 15 minutes monitoring on 10/12/23. Further review of the provided copies of Resident 1's Every 15 minutes Resident Monitoring for October 2023 indicated, monitoring sheets were missing on 10/1/23, 10/3/23, 10/6/23, 10/7/23, 10/8/23, 10/10/23, 10/11/23, 10/12/23, and 10/16/23. AIT stated, That's all of October's monitoring sheet. Review of Resident 1's care plan for A female resident claimed [Resident 1] allegedly touched her on the breast., initiated on 10/12/23, indicated, The resident will not exhibit any sexually inappropriate behavior problems until next review. The care plan indicated the following interventions: Continue with line sight supervision during the day and frequent checks while in room at night. Transfer to a different room . Monitor the resident for nay sexually inappropriate behavior and immediately intervene as necessary to protect the rights and safety of others. Approach/speak in a calm manner. Divert attention. Immediately remove from situation and take to alternate location as needed. Review of the facility's policy and procedure titled, Abuse - Prevention, Screening, & Training Program, revised July 2018, indicated, .Policy - The Facility does not condone any form of resident abuse .The Administrator as abuse prevention coordinator is responsible for the coordination and implementation of the Facility's abuse prevention, screening, and training program policies . Procedure 'Sexual abuse' is defines as non-consensual contact of any type, sexual harassment, sexual coercion, or sexual assault . III. Screening residents - A. The Facility conducts resident pre-admission, admission, and ongoing assessments (screening) and care planning for appropriate interventions and monitoring of residents with needs and behaviors which might lead to conflict or neglect. IV. Training - A. The facility conducts mandatory staff training programs during orientation, annually and as needed on: i. Prohibiting and preventing abuse . ii. Identifying what constitutes abuse . iii. Recognizing signs of abuse . iv. Reporting abuse . v. Understanding resident behavioral symptoms that may (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 19 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few increase the risk of abuse and neglect and how to respond . V. Prevention . I. As appropriate, the Facility involves qualified psychiatrists, psychologists and other mental health professionals to help staff manage challenging or aggressive residents. J. The Facility establishes a safe environment that reasonably supports resident to the extent possible including, but not limited to, consensual sexual activity. K. The Facility identifies, corrects, and intervenes in situations in which abuse .is more likely to occur . M. The Facility conducts resident pre-admission, admission and ongoing assessments (screening) and care planning for appropriate interventions and monitoring of residents with needs and behaviors that might lead to conflict or neglect . Review of the facility's policy and procedure titled, Abuse Reporting and Investigations, revised 7/31/23 with effective date of 8/18/23, indicated, .The Facility promptly reports and thorough investigates allegations of resident abuse, mistreatment, neglect, exploitation, abuse facilitated or enabled by the use of technology, misappropriation of resident property, or injuries of unknown source, and suspicions of crimes . 1. Administrator as Abuse Prevention Coordinator . a. Allegations of abuse, neglect, mistreatment, exploitation, or reasonable suspicion of a crime to be reported to the Administrator or designated representative immediately. b. When the Administrator or designated representative receives a report of an incident or suspected incident of resident abuse, mistreatment, neglect, abuse facilitated or enabled technology, exploitation, or injuries of unknow source, or suspicion of a crime, the Administrator or designated representative will initiate an investigation immediately . ii. The facility will not inhibit facility staff/covered individuals from their mandated reporting obligations. iii. Facility staff/covered individuals will not be disciplined or retaliated against for good-faith reporting . 2. Immediate Action . b. The administrator or designated representative conducting the investigation will interview individuals who may have information relevant to the allegation or suspected crime . 3. Notification of Outside Agencies of Allegations of Abuse . b. Administrator or designed representative will notify the LTC (Long Term Care) Ombudsman, and CDPH (California Department of Public Health) by telephone and in writing (SOC 341) within two (2) hours of an initial report. 4. Notification of Outside Agencies of Allegations of Abuse Caused by a Resident with Dementia Diagnosed by a Physician . i. The Administrator or designated representative will notify within two (2) hours, notify by telephone, CDPH, the Ombudsman and Law Enforcement. ii. The Administrator or designated representative will send a written SOC 341 report to the Ombudsman and Law Enforcement and CDPH Licensing and Certification within 2 hours. 5. Notification of Outside Agencies of Allegation of Abuse With No Serious Bodily Injury - [TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 20 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure three allegations of sexual abuse (non-consensual sexual contact of any type with a resident) were reported to the State Survey Agency (SSA) within the required timeframe of two (2) hours for three of 3 sampled residents (Resident 1, Resident 2, and Resident 3). 1. Certified Nursing Assistant (CNA) 2 witnessed Resident 1 touched Resident 3's breast in July 2023, alleged incident was not reported to SSA until 8/31/23. 2. A month later, CNA 2 had witnessed same resident (Resident 1) attempted to touch inappropriately another female resident's (Resident 2) vagina in August 2023, the alleged incident was not reported to SSA. 3. On 8/31/23 at 2:10 PM, CNA 2 witnessed Resident 1 in his room sitting on his wheelchair, with pants down while Resident 2 was touching Resident 1's penis, the alleged incident was reported at 6:10 PM (4 hours after the incident). These failures resulted in delayed identification and implementation of interventions to address Resident 1's sexually inappropriate behavior towards Resident 3 and Resident 2. In addition, these failures eventually resulted in further sexual abuse on 8/31/23 when Resident 1 continued to have access to Resident 23. Furthermore, these failures had the potential to compromise the safety of all residents in the facility from unreported and uninvestigated allegations of abuse. Findings: Review of Resident 1's admission record indicated, was admitted to facility on 8/30/22 with diagnoses including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), dementia (a group of symptoms affecting memory, thinking and social abilities), history of alcohol abuse, mild cognitive impairment (trouble remembering, learning new things, concentrating, or making decisions), and cognitive communication deficit (difficulty thinking and communicating). Further review, indicated, Resident 1 was his own responsible party (decision maker). Review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 9/1/23, indicated, Resident 1's cognition (thought process) was moderately impaired. The MDS indicated, Resident 1 did not exhibit any mood symptoms and physical behavioral symptoms directed towards others such as scratching, grabbing, and abusing others sexually. Further review of the MDS indicated, Resident 1 required supervision with set up help to one-person physical assist for bed mobility, transfer, walking, locomotion (ability to move from one place to another), eating, and toilet use. The MDS also indicated Resident 1 required extensive assistance with one-person physical assist for dressing and personal hygiene. Review of Resident 2's admission record indicated, was admitted to facility on 5/11/23 with diagnoses including encephalopathy (damage or disease that affects the brain), cognitive communication deficit, and catatonic disorder (a behavioral syndrome marked by an inability to moved normally). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 21 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Actual harm Review of Resident 2's MDS dated [DATE], indicated, Resident 2 has memory problem and moderately impaired decision-making skills under the staff assessment for mental status. The MDS indicated, Resident 2 had episodes of feeling or appearing down, depressed, or hopeless for 2 to 6 days under the staff assessment of resident mood. The MDS did not indicate any behavioral symptoms for Resident 2. Residents Affected - Few Further review of the MDS indicated, Resident 2 required supervision with one-physical assist for transfer, walk in room, locomotion, and eating; limited assistance with one-physical assist for bed mobility and walk in corridor; extensive assistance with one-physical assist for dressing, toilet use, and personal hygiene. Review of Resident 3's admission record indicated, was admitted to facility on 12/21/22 with diagnoses including hemiplegia (complete paralysis of side of the body), hemiparesis (partial weakness or paralysis of on one side of the body), dementia, and cognitive communication deficit. Review of Resident 3's MDS dated [DATE], indicated, Resident 3's cognition was severely impairment. The MDS indicated, Resident 3 did not exhibit any mood and behavioral symptoms. Further review of the MDS indicated, Resident 3 required extensive assistance with one-person physical assist for bed mobility and total dependence with one-person physical assist for transfer, walking, locomotion, eating, toilet use, and personal hygiene. 1. Review of facility's untitled letter document dated 9/7/23, indicated, .On 8/31/2023, our resident [Resident 1] was observed in his room with a female resident who was touching his penis. The nurse separated the two residents. During the course of the investigation, it was found that [Resident 1] was involved in previous incident in July, in which he was seen touching a different resident on the breast . Review of CDPH's document titled, Complaint/Incident Intake Report, known as HS 802 indicated, the incident of Resident 1 touching Resident 3's breast was received on 9/1/23 at 5:20 PM by fax. Review of document titled, Report of Suspected Dependent Adult/Elder Abuse, known as SOC 341, with date completed on 8/31/23, indicated, date and time of the incident Resident 1 touching Resident 3's breast was sometime in July. This alleged incident was reported to the police by phone on 8/31/23, no time indicated; and to CDPH and Ombudsman by fax on 8/31/23, no time indicated. Review of facility document titled, Transmission Result Report, indicated, the facility faxed to CDPH on 8/31/23 at 8:03 PM. During an interview on 9/14/23, at 3:30 PM, CNA 2 stated, she witnessed the first incident involving Resident 1 and Resident 3 in July 2023 on the second-floor dining room. CNA 2 recalled the incident and stated, [Resident 1] was wheeling himself towards the dining area. I saw [Resident 1] rubbing left breast of [Resident 3] in circular motion. CNA 2 also stated, she reported the incident immediately to Licensed Vocation Nurse (LVN) 1 and took Resident 1 back to his room. During an interview on 9/14/23 at 3:46 PM, LVN 1 confirmed and stated, CNA 2 reported to her regarding Resident 1 touching Resident 3's breast but cannot remember the exact date of the incident. LVN 1 stated, I reported it (referring to touching Resident 3's breast) to Resident Care Coordinator (RCC). I don't know what happened after. No investigation after. LVN 1 explained that the witness should report to RCC and Administrator (ADM) and that she doesn't do anything after reporting an allegation of abuse. LVN 1 added, the RCC will then report to the Administrator and complete the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 22 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 documentation and investigation. Level of Harm - Actual harm During further interview on 9/14/23 at 3:48 PM, LVN 1 stated, Everybody are mandated reporters. LVN 1 also stated, I don't report (to the State Agency/Ombudsman). Only (report) to RCC. Residents Affected - Few During concurrent interview and record review on 9/14/23 at 3:53 PM, LVN 1 was unable to find documentation of the incident in Resident 1 and Resident 3's clinical record. LVN 1 stated, I don't see it here. During an interview on 9/14/23 at 4:23 PM, RCC stated, she received two reports that involved Resident 1. RCC stated, the incident of Resident 1 touching Resident 3's breast was not reported to the Administrator/Abuse Coordinator. RCC stated, the way she understood the report was that Resident 1 tap or grab Resident 3's shoulder, therefore concluded that it was not abuse. Thus, no report and no further investigation was conducted. During further interview on 9/14/23 at 4:28 PM, RCC stated, any alleged incidents should be reported directly to the Administrator and/or designee and reporting should be whoever witness the incident. RCC further stated, a change of condition and staff interview should be conducted after a report of alleged abuse was made. During an interview on 9/14/23 at 4:52 PM, Social Worker (SW) 1 stated, she learned about the incident of Resident 1 touching Resident 3's breast during her interview with CNA 2 regarding the incident between Resident 1 and Resident 2 on 8/31/23. SW 1 further stated, the CNA, LVN, or RCC were expected to report the alleged incident of Resident 1 touching Resident 2's breast immediately or within two hours from the time they knew about the incident. During an interview on 9/14/23 at 4:59 PM, Assistant Director of Nursing (ADON) stated, the Abuse Coordinator was not notified of the touching of the breast. ADON stated, Abuse Coordinator should have been notified immediately which did not happen. During further interview on 9/14/23 at 5:03 PM, SW 1 stated that the alleged incident of Resident 1 touching Resident 3' breast was not investigated after learning about the incident. SW 1 stated, At that time the DON and Administrator said it will be taken care of but did not happen (referring to reporting and investigation of the incident). During an interview on 9/14/23 at 5:09 PM, Director of Nursing (DON) stated, There was a miscommunication between LVN 1 and RCC. RCC did not understand what LVN explained. No follow-up interview to clarify the reported incident. During a follow-up interview on 9/14/23 at 5:14 PM, RCC stated, I should have followed up more. Get more information. RCC also stated that there was no report or documentation regarding the alleged incident (referring to Resident 1 touching Resident 3's breast), I didn't do anything. No action done. 2. During an interview on 9/14/23 at 3:34 PM, CNA 2 stated, a month later, she witnessed and reported two incidents that involved Resident 1 and Resident 2. CNA 2 stated, on the same month (August 2023), prior to the reported incident on 8/31/23, [Resident 1] attempted to touch [Resident 2] vagina by the social worker's office. CNA 2 added, she reported the incident to the evening nurse and was told to monitor Resident 1 since it was only an attempt. CNA 2 further stated, she did not document (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 23 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 the incident and cannot remember the exact date it happened. Level of Harm - Actual harm Review of Resident 1 and Resident 2's progress notes for August 2023 indicated, there was no documentation regarding Resident 1's attempt to touch Resident 2's vagina. Residents Affected - Few During an interview on 9/14/23 at 4:52 PM, SW 1 stated, she was not aware of Resident 1 attempted to touch Resident 2's vagina. During an interview on 9/14/23 at 5:19 PM, RCC stated, she did not get a report regarding Resident 1 attempted to touch Resident 2's vagina in August 2023. During a follow up telephone interview on 9/26/23 at 11:58 AM, CNA 2 stated, she reported the incident of Resident 1 attempted to touch Resident 2's vagina to the evening shift nurse (LVN 3) since the incident happened before dinner. CNA 2 added, [LVN 3] told me to monitor [Resident 1] since it was only an attempt. During a telephone interview on 9/27/23 at 10:35 AM, LVN 3 confirmed and stated, CNA 2 reported Resident 1 attempted to touch Resident 2's vagina during the evening shift and the two residents were separated immediately and monitored. LVN 3 also stated, I didn't document (referring to the incident). It was an attempt. I can't remember if I reported it. During an interview on 9/27/23 at 10:38 AM, DON stated, she was not aware of the attempt of Resident 1 touching Resident 2 that was reported by CNA 2 to LVN 3. DON added, If there's a report attempting to touch, it needs to be reported immediately. We need to do something right away. 3. Review of CDPH's document titled, Complaint/Incident Intake Report, known as HS 802 indicated, the incident of Resident 2 touching Resident 1's penis was received on 9/1/23 at 10:39 AM by fax. Review of document titled, Report of Suspected Dependent Adult/Elder Abuse, known as SOC 341, with date completed on 8/31/23, indicated, date and time of the incident of Resident 2 touching Resident 1's penis was 8/31/23 at 2:10 PM. The incident was reported to the police by phone on 8/31/23 at 4:30 PM; the facility reported to CDPH and Ombudsman by fax on 8/31/23, no time indicated. Review of facility document titled, Transmission Result Report, indicated, the facility faxed to CDPH on 8/31/23 at 6:10 PM and to Ombudsman on 8/31/23 at 6:11 PM (4 hours after the incident). During an interview on 9/14/23 at 3:40 PM, CNA 2 stated that on 8/31/23, she was walking by Resident 1's room towards the nursing station and noticed the door was open and saw Resident 2 standing in front of Resident 1 who was sitting on his wheelchair. CNA 2 stated, [Resident 1] pull-ups (disposable brief) were down. [Resident 2] was touching his penis. CNA 2 further stated, she called Resident Care Coordinator (RCC) and was told to separate the two residents and bring Resident 2 back to her room. During further interview, CNA 2 stated, she was suspended during the investigation of the incident on 8/31/23 (Resident 1 and Resident 2) because she did not report the July 2023 (breast) incident directly to the Administrator. CNA 2 added that she reported the incident immediately to the charge nurse. CNA 2 then stated, It doesn't make sense to suspend me. Now I'm afraid to report. I might get suspended again. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 24 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Actual harm During an interview on 9/14/23 at 4:19 PM, RCC stated, CNA 2 called her to go to Resident 1's room whose sitting on a wheelchair with his pants down while Resident 2 was standing in front holding his penis. RCC stated, the two residents were separated immediately and told CNA 2 to assist Resident 2 to her room. RCC also stated that she brought CNA 2 to the ADON to report the incident. Residents Affected - Few During an interview on 9/14/23 at 4:52 PM, SW 1 stated, she interviewed the staff regarding the incident and assisted the ADON in completing form SOC 341. SW 1 then stated, the DON and Administrator did the reporting and investigation of the incident. Review of Resident 1's Interdisciplinary Team (IDT, a group of healthcare professionals with various areas of expertise who work together toward the goals of the residents) Note dated 9/7/23, indicated, Staff reported this resident (Resident 1) was with a female resident (Resident 2) in his room, touching his penis on 8/31/23 . Upon investigation of this incident on 8/31/23, we found that this same resident (Resident 1) was involved with another incident of touching the breast area of a female resident (Resident 3) in the dining hall in the month of July . The IDT Note indicated, Administrator, Abuse Coordinator, DON (Director of Nursing), MD (Medical Doctor), RP (responsible party), police, CDPH and Ombudsman were notified of the incident. The IDT Note did not indicate the incident of Resident 1 touching Resident 3's breast and attempt to touch Resident 2's vagina was further discussed and investigated. During a joint interview on 9/14/23 at 5:27 PM, ADM and Nurse Consultant stated, the two staff (CNA 2 and LVN 1) were suspended for not reporting immediately to the Administrator. During a concurrent interview and record review on 9/27/23 at 10:44 AM, DON stated there was no investigation and IDT conducted regarding the two incidents of Resident 1 touching Resident 3's breast and the attempt to touch Resident 2's vagina. During an interview on 9/27/23 at 1:08 PM, ADM stated, any allegations of abuse need to be reported by phone right away and faxed SOC 341 to SSA within two hours of the incident. Review of the facility's policy and procedure titled, Abuse Reporting and Investigations, revised 7/31/23 with effective date of 8/18/23, indicated, .The Facility promptly reports and thorough investigates allegations of resident abuse, mistreatment, neglect, exploitation, abuse facilitated or enabled by the use of technology, misappropriation of resident property, or injuries of unknown source, and suspicions of crimes . a. Allegations of abuse, neglect, mistreatment, exploitation, or reasonable suspicion of a crime to be reported to the Administrator or designated representative immediately. b. When the Administrator or designated representative receives a report of an incident or suspected incident of resident abuse, mistreatment, neglect, abuse facilitated or enabled technology, exploitation, or injuries of unknow source, or suspicion of a crime, the Administrator or designated representative will initiate an investigation immediately . ii. The facility will not inhibit facility staff/covered individuals from their mandated reporting obligations. iii. Facility staff/covered individuals will not be disciplined or retaliated against for good-faith reporting . 3. Notification of Outside Agencies of Allegations of Abuse . b. Administrator or designed representative will notify the LTC (Long Term Care) Ombudsman, and CDPH (California Department of Public Health) by telephone and in writing (SOC 341) within two (2) hours of an initial report. 4. Notification of Outside Agencies of Allegations of Abuse Caused by a Resident with Dementia Diagnosed by a Physician . i. The Administrator or designated representative will notify within two (2) hours, notify by telephone, CDPH, the Ombudsman and Law Enforcement. ii. The Administrator or designated representative will send a written SOC 341 report to the Ombudsman and Law Enforcement and CDPH Licensing and Certification within (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 25 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete 2 hours. 5. Notification of Outside Agencies of Allegation of Abuse With No Serious Bodily Injury - a. The Administrator or designated representative will notify within two (2) hours notify, by telephone, CDPH, the Ombudsman and Law Enforcement. b. The Administrator or designated representative will send a written SOC 341 report to the Ombudsman and Law Enforcement and CDPH Licensing and Certification within two (2) hours . Event ID: Facility ID: 555034 If continuation sheet Page 26 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Respond appropriately to all alleged violations. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2a. A review of the face sheet indicated Resident 5 was admitted with diagnoses including stroke, seizure disorder (epilepsy) and dementia (decline in memory or other thinking skills). Residents Affected - Some A review of MDS dated [DATE], BIMS indicated Resident 5 has severe cognitive impairment. Under functional status Resident 5 totally dependent ADL's including mobility, transfer, eating, and toileting. A review of the nurses 'notes dated 5/24/23, addressing Resident 5 ' s Change in Condition indicated, .Certified Nurse Assistant (CNA, caregiver) reported to Licensed Nurse (LN) that the resident 's right thigh looked bigger than the left one .LN noted the resident with internal rotation of the right hip and swelling to the right thigh. With slight discomfort when right thigh was touched . A review of the Physician (Medical doctor) notes dated 5/24/23, indicated, .Patient (Resident 5) reported to have a possible fracture of which an x-ray was done on 5/24/23, showing right intertrochanteric fracture, staff reports no fall . During a review of the clinical record for Resident 5 and interview on 9/14/23, at 3:05 PM, ADON 1 stated, There was no IDT notes for the incident. I don ' t see any IDT charting. She ' s conserved. The conservator transferred her to another facility. The conservator has another resident here. Both residents were transferred to another facility after both had a fracture. 2b.A review of the face sheet indicated Resident 6 was admitted with diagnoses including dementia, heart failure, and diabetes. A review of the MDS, dated [DATE], BIMS score of 2 indicated severe cognitive impairment. Under functional status Resident 6 was dependent requiring one-person physical assistance with ADL's including mobility, transfer, dressing, and toilet use. A review of the nurses' notes, dated 5/24/23, indicated, CNA reported that the resident has bruising on her right thigh .notes scattered yellowish, greenish discoloration on the right groin, extending to the right hip to entire posterior (back) thigh .No fall incident reported during the past week . Resident has cognitive impairment related to dementia, and unable to provide description on the origin of bruising . A review of the ER visit notes dated 5/25/23, indicated, Resident 6 had .Diagnosis: closed fracture of the right hip. A review of the facility investigation dated 5/30/23, indicated, .Conclusion: Resident has not experienced any falls or any unusual incidents in the past two weeks. She was found to have a spontaneous fracture which the leading cause is decreased bone mass which has a propensity to affect older female adults . The facility was not able to provide evidence of documentation that indicated Resident 6 had, decreased bone mass. 2c. A review of the face sheet indicated Resident 7 was admitted with diagnoses including dementia, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 27 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 diabetes, and hypertension (abnormally high blood pressure). Level of Harm - Actual harm A review of the MDS dated [DATE], BIMS score of 4 indicated severe cognitive impairment. Under functional status Resident 7 was totally dependent and required one-person physical assistance with activities of daily living including mobility, transfer, eating and toileting. Residents Affected - Some A review of care plan addressing ADLs initiated 3/7/23, indicated, Resident needs assistance with ADL's. At risk for declining self-performance of ADL's r/t weakness, depression, aging, impaired cognitive function, communication, mood, and behavior problem due to dementia . Noted sometimes talking to self-nonsense when awake. Goal: ADL and safely needs will be anticipated and met by staff daily . refer rehab consult as needed. Turn and reposition as ordered. Provide assistance with ADL's care as needed . During an observation on 10/5/23 at 3:48 PM, Resident 7 was asleep in bed on side lying position. During an interview on 10/5/23, at 3:49 PM, LVN 4 stated, Resident (Resident 7) barely speak, does not understand her condition and is totally dependent to staff with all her ADL needs. A review of the Change in Condition Evaluation dated 3/31/23, indicated . CNA reported .new skin issue . New onset of swelling and tenderness 4/10. Pain with touch . A review of change in condition ff up note dated 4/4/23, indicated, .Still noted with large yellowish discoloration to the right knee with swelling. Resident was sent to the ER (emergency room) . A review of the ER notes dated 4/3/23, indicated .Resident was sent in from the nursing home due to concern of a right-side femur fracture .X-ray resuilts: displaced distal femoral fracture .called nurses at (facility) .States that the patient is immobile . The facility was not able to provide evidence of documentation of a completed investigation of Resident 7's injury. Based on observation, interview, and record review, the facility failed to conduct a thorough investigation for six of 7 sampled residents (Resident 1, Resident 2, Resident 3, Resident 5, Resident 6, and Resident 7) when: 1. Three allegations of sexual abuse (non-consensual sexual contact of any type with a resident) were not thoroughly investigated for Resident 1, Resident 2, and Resident 3. In addition, there was no documented evidence Resident 1's sexually inappropriate behavior towards Resident 2 and Resident 3 was addressed and measures were not implemented to prevent further sexual abuse towards Resident 2. Furthermore, the facility failed to report the results of all investigations of three allegations of sexual abuse to the administrator or designee and State Survey Agency (SSA) within 5 working days of the alleged incidents. 1a. Resident 1 was seen in the dining room touching Resident 3's breast in July 2023. 1b. Resident 1 attempted to touch inappropriately Resident 2's vagina in August 2023. 1c. On 8/31/23, CNA 2 witnessed Resident 1 in his room sitting on his wheelchair, with pants down while Resident 2 was touching Resident 1's penis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 28 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Actual harm The cumulative effects of these failures resulted in delayed identification of Resident 1's sexually inappropriate behavior towards Resident 2 and Resident 3; and did not prevent further sexual abuse towards Resident 2. Additionally, these failures had the potential to compromise the safety of all residents in the facility from unreported and uninvestigated allegations of abuse. Residents Affected - Some 2. The facility did not conduct a thorough investigation to determine the probable cause of injury for Resident 5, Resident 6, and Resident 7, who were totally dependent to staff for activities of daily living, were found with fracture (broken bone) of the femur (thigh bone). In addition, the facility did not report the results of the investigation related to Resident 5, Resident 6, and Resident 7's fracture to the administrator or his designee and to the SSA within 5 working days of the incident. These failures resulted in Resident 5, Resident 6, and Resident 7's delayed identification of fracture, diagnosis and treatment. In addition, these failures placed Resident 5, Resident 6, Resident 7, and all other residents with fracture at risk for untreated pain and further injury. 3. The facility failed to report the result of the abuse investigation to the California Department of Public Health (CDPH) within 5 working days in accordance with Federal requirements for one of three sampled abuse incidents (Resident 9). The alleged abuse incident for Resident 9 occurred on 6/26/23 and there was no result of facility investigation upon request on 10/5/23,10/6/23, 10/9/23 and 10/11/23. The facility's failure to report abuse according to the required time frame had the potential to delay the identification and implementation of appropriate corrective action that may place the resident at risk for abuse. Findings: 1. Review of Resident 1's admission record indicated, was admitted to facility on 8/30/22 with diagnoses including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), dementia (a group of symptoms affecting memory, thinking and social abilities), history of alcohol abuse, mild cognitive impairment (trouble remembering, learning new things, concentrating, or making decisions), and cognitive communication deficit (difficulty thinking and communicating). Further review, indicated, Resident 1 was his own responsible party (decision maker). Review of Resident 1's Minimum Data Set (MDS, a resident assessment tool) dated 9/1/23, indicated, Resident 1's cognition (thought process) was moderately impaired. The MDS indicated, Resident 1 did not exhibit any mood symptoms and physical behavioral symptoms directed towards others such as scratching, grabbing, and abusing others sexually. Further review of the MDS indicated, Resident 1 required supervision with set up help to one-person physical assist for bed mobility, transfer, walking, locomotion (ability to move from one place to another), eating, and toilet use. The MDS also indicated Resident 1 required extensive assistance with one-person physical assist for dressing and personal hygiene. Review of Resident 2's admission record indicated, was admitted to facility on 5/11/23 with diagnoses including encephalopathy (damage or disease that affects the brain), cognitive communication deficit, and catatonic disorder (a behavioral syndrome marked by an inability to moved normally). Review of Resident 2's MDS dated [DATE], indicated, Resident 2 has memory problem and moderately impaired decision-making skills under the staff assessment for mental status. The MDS indicated, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 29 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Resident 2 had episodes of feeling or appearing down, depressed, or hopeless for 2 to 6 days under the staff assessment of resident mood. The MDS did not indicate any behavioral symptoms for Resident 2. Level of Harm - Actual harm Residents Affected - Some Further review of the MDS indicated, Resident 2 required supervision with one-physical assist for transfer, walk in room, locomotion, and eating; limited assistance with one-physical assist for bed mobility and walk in corridor; extensive assistance with one-physical assist for dressing, toilet use, and personal hygiene. Review of Resident 3's admission record indicated, was admitted to facility on 12/21/22 with diagnoses including hemiplegia (complete paralysis of side of the body), hemiparesis (partial weakness or paralysis of on one side of the body), dementia, and cognitive communication deficit. Review of Resident 3's MDS dated [DATE], indicated, Resident 3's cognition was severely impairment. The MDS indicated, Resident 3 did not exhibit any mood and behavioral symptoms. Further review of the MDS indicated, Resident 3 required extensive assistance with one-person physical assist for bed mobility and total dependence with one-person physical assist for transfer, walking, locomotion, eating, toilet use, and personal hygiene. 1a. Review of CDPH's document titled, Complaint/Incident Intake Report, known as HS 802 indicated, the incident of Resident 1 touching Resident 3's breast was received on 9/1/23 at 5:20 PM by fax. Review of document titled, Report of Suspected Dependent Adult/Elder Abuse, known as SOC 341, with date completed on 8/31/23, indicated, date and time of the incident Resident 1 touching Resident 3's breast was sometime in July. This alleged incident was reported to the police by phone on 8/31/23, no time indicated; and to CDPH and Ombudsman by fax on 8/31/23, no time indicated. Review of facility document titled, Transmission Result Report, indicated, the facility faxed to CDPH on 8/31/23 at 8:03 PM. During an interview on 9/14/23, at 3:30 PM, CNA 2 stated, she witnessed the first incident involving Resident 1 and Resident 3 in July 2023 on the second-floor dining room. CNA 2 recalled the incident and stated, [Resident 1] was wheeling himself towards the dining area. I saw [Resident 1] rubbing left breast of [Resident 3] in circular motion. CNA 2 also stated, she reported the incident immediately to Licensed Vocation Nurse (LVN) 1 and took Resident 1 back to his room. During an interview on 9/14/23 at 3:46 PM, LVN 1 confirmed and stated, CNA 2 reported to her regarding Resident 1 touching Resident 3's breast but cannot remember the exact date of the incident. LVN 1 stated, I reported it (referring to touching Resident 3's breast) to Resident Care Coordinator (RCC). I don't know what happened after. No investigation after. LVN 1 explained that the witness should report to RCC and Administrator (ADM) and that she doesn't do anything after reporting an allegation of abuse. LVN 1 added, the RCC will then report to the Administrator and complete the documentation and investigation. Review of Resident 3's Change in Condition dated 9/1/23, indicated, Resident was reported to have been touched in the breast area by another resident. Assessment done without issues noted. SOC 341 completed. Ombudsman and [NAME] Police Department notified. Resident unable to verbalize any information. Daughter and MD notified. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 30 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Actual harm Residents Affected - Some Review of Resident 3's clinical record indicated, there was no progress notes in July 2023 regarding the incident of Resident 1 touching Resident 3's breast. Further review indicated, there was no documented evidence a plan of care was initiated to address the incident. Review of Resident 1's clinical record indicated, there was no progress notes in July 2023 regarding the incident of Resident 1 touching Resident 3's breast. Further review indicated, there was no documented evidence a plan of care was initiated to address Resident 1's sexually inappropriate behavior. During concurrent interview and record review on 9/14/23 at 3:53 PM, LVN 1 was unable to find documentation of the incident in Resident 1 and Resident 3's clinical record. LVN 1 stated, I don't see it here. During an interview on 9/14/23 at 4:23 PM, RCC stated, she received two reports that involved Resident 1. RCC stated, the incident of Resident 1 touching Resident 3's breast was not reported to the Administrator/Abuse Coordinator. RCC stated, the way she understood the report was that Resident 1 tap or grab Resident 3's shoulder, therefore concluded that it was not abuse. Thus, no report and no further investigation was conducted. During further interview on 9/14/23 at 4:28 PM, RCC stated, any alleged incidents should be reported directly to the Administrator and/or designee and reporting should be whoever witness the incident. RCC further stated, a change of condition and staff interview should be conducted after a report of alleged abuse was made. During an interview on 9/14/23 at 4:52 PM, Social Worker (SW) 1 stated, she learned about the incident of Resident 1 touching Resident 3's breast during her interview with CNA 2 regarding the incident between Resident 1 and Resident 2 on 8/31/23. SW 1 further stated, the CNA, LVN, or RCC were expected to report the alleged incident of Resident 1 touching Resident 2's breast immediately or within two hours from the time they knew about the incident. During further interview on 9/14/23 at 5:03 PM, SW 1 stated that the alleged incident of Resident 1 touching Resident 3' breast was not investigated after learning about the incident. SW 1 stated, At that time the DON and Administrator said it will be taken care of but did not happen (referring to reporting and investigation of the incident). During an interview on 9/14/23 at 5:09 PM, DON stated, There was a miscommunication between LVN 1 and RCC. RCC did not understand what LVN explained. No follow-up interview to clarify the reported incident of Resident 1 touching Resident 3's breast. During a follow-up interview on 9/14/23 at 5:14 PM, RCC stated, I should have followed up more. Get more information. RCC also stated that there was no report or documentation regarding the alleged incident (referring to Resident 1 touching Resident 3's breast), I didn't do anything. No action done. 1b. During an interview on 9/14/23 at 3:34 PM, CNA 2 stated, a month later, she witnessed and reported two incidents that involved Resident 1 and Resident 2. CNA 2 stated, on the same month (August 2023), prior to the reported incident on 8/31/23, [Resident 1] attempted to touch [Resident 2] vagina by the social worker's office. CNA 2 added, she reported the incident to the evening nurse and was told to monitor Resident 1 since it was only an attempt. CNA 2 further stated, she did not document (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 31 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 the incident and cannot remember the exact date it happened. Level of Harm - Actual harm Review of Resident 1 and Resident 2's progress notes for August 2023 indicated, there was no documentation regarding Resident 1's attempt to touch Resident 2's vagina. Residents Affected - Some During an interview on 9/14/23 at 4:52 PM, SW 1 stated, she was not aware of Resident 1 attempted to touch Resident 2's vagina. During an interview on 9/14/23 at 5:19 PM, RCC stated, she did not get a report regarding Resident 1 attempted to touch Resident 2's vagina in August 2023. During a follow up telephone interview on 9/26/23 at 11:58 AM, CNA 2 stated, she reported the incident of Resident 1 attempted to touch Resident 2's vagina to the evening shift nurse (LVN 3) since the incident happened before dinner. CNA 2 added, [LVN 3] told me to monitor [Resident 1] since it was only an attempt. During a telephone interview on 9/27/23 at 10:35 AM, LVN 3 confirmed and stated, CNA 2 reported Resident 1 attempted to touch Resident 2's vagina during the evening shift and the two residents were separated immediately and monitored. LVN 3 also stated, I didn't document (referring to the incident). It was an attempt. I can't remember if I reported it. During an interview on 9/27/23 at 10:38 AM, DON stated, she was not aware of the attempt of Resident 1 touching Resident 2 that was reported by CNA 2 to LVN 3. DON added, If there's a report attempting to touch, it needs to be reported immediately. We need to do something right away. 1c. Review of CDPH's document titled, Complaint/Incident Intake Report, known as HS 802 indicated, the incident of Resident 2 touching Resident 1's penis was received on 9/1/23 at 10:39 AM by fax. Review of document titled, Report of Suspected Dependent Adult/Elder Abuse, known as SOC 341, with date completed on 8/31/23, indicated, date and time of the incident of Resident 2 touching Resident 1's penis was 8/31/23 at 2:10 PM. The incident was reported to the police by phone on 8/31/23 at 4:30 PM; the facility reported to CDPH and Ombudsman by fax on 8/31/23, no time indicated. During an interview on 9/14/23 at 3:40 PM, CNA 2 stated that on 8/31/23, she was walking by Resident 1's room towards the nursing station and noticed the door was open and saw Resident 2 standing in front of Resident 1 who was sitting on his wheelchair. CNA 2 stated, [Resident 1] pull-ups (disposable brief) were down. [Resident 2] was touching his penis. CNA 2 further stated, she called Resident Care Coordinator (RCC) and was told to separate the two residents and bring Resident 2 back to her room. During further interview, CNA 2 stated, she was suspended during the investigation of the incident on 8/31/23 (Resident 1 and Resident 2) because she did not report the July 2023 (breast) incident directly to the Administrator. CNA 2 added that she reported the incident immediately to the charge nurse. CNA 2 then stated, It doesn't make sense to suspend me. Now I'm afraid to report. I might get suspended again. During an interview on 9/14/23 at 4:19 PM, RCC stated, CNA 2 called her to go to Resident 1's room whose sitting on a wheelchair with his pants down while Resident 2 was standing in front holding his penis. RCC stated, the two residents were separated immediately and told CNA 2 to assist Resident 2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 32 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 to her room. RCC also stated that she brought CNA 2 to the ADON to report the incident. Level of Harm - Actual harm During an interview on 9/14/23 at 4:52 PM, SW 1 stated, she interviewed the staff regarding the incident and assisted the ADON in completing form SOC 341. SW 1 then stated, the DON and Administrator did the reporting and investigation of the incident. Residents Affected - Some Review of Resident 1's Change in Condition dated 9/1/23, indicated, At around 1410 (2:10 PM) on 08/31/2023 .the male resident on [room number] was witnessed by CNA inside [room number] with another female resident [room number], the alleged victim. The alleged abuser was sitting on the wheelchair, pants was down while the alleged victim is touching the alleged abuser's penis. Both residents were separated, and the alleged victim was escorted back to her own room for safety while the alleged abuser stayed inside the room . An SOC-341 (known as Report of Suspected Dependent Adult/Elder Abuse) was completed and filed . CDPH and Ombudsman were also notified of the incident . Review of Resident 1's care plan for The resident was involved in alleged sexual abuse, initiated on 9/3/23, 3 days after the incident, indicated, the alleged abuser was sitting on the wheelchair, pants were down while the alleged victim is touching the alleged abuser's penis. The care plan indicated Resident 1 will have no evidence of behavior problems or will not display the same behavior until the next review. The care plan indicated the following interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness. Anticipate and meet the resident's needs. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a clam manner. Divert attention. Remove form situations. Document behavior and potential causes. Observed the behavior and report any abnormal findings. Separate/transfer the room of the abuser to [room number/unit]. SOC-341 was completed and filed. Review of Resident 2's Change in Condition dated 9/1/23, indicated, Resident was found in male resident room his hand in his penis. Resident separated from resident. Head to Toe assessment completed without issues noted. SOC 341 completed. Ombudsman and BPD ([NAME] Police Department) notified. BPD on scene and interviewed resident. Resident unable to verbalize any information. Family-Daughter and Dr [doctor] notified. Review of Resident 2's care plan for At risk for decline in psychosocial well-being due to sexual contact instigated by male resident, initiated on 9/1/23, indicated, Resident 2 will express/demonstrate feeling safe in facility through the review date. The care plan indicated the following interventions: observe resident for occurrence of or changes in sleep pattern, depression, anxiety, anger, confusion, behavior, and appetite changes. Refer the resident to psych evaluation for a psychosocial wellbeing assessment. Report s/s (signs/symptoms) of psychosocial distress to nurse. Review the daily routine of the facility with the resident and accommodate wishes. Review the resident's coping skills and support the use of the coping mechanism as much as possible. Review of Resident 1's Interdisciplinary Team (IDT, a group of healthcare professionals with various areas of expertise who work together toward the goals of the residents) Note dated 9/7/23, indicated, Staff reported this resident (Resident 1) was with a female resident (Resident 2) in his room, touching his penis on 8/31/23 . Upon investigation of this incident on 8/31/23, we found that this same resident (Resident 1) was involved with another incident of touching the breast area of a female resident (Resident 3) in the dining hall in the month of July . The IDT Note indicated, Administrator, Abuse Coordinator, DON (Director of Nursing), MD (Medical Doctor), RP (responsible party), police, CDPH and Ombudsman were notified of the incident. Further review of the IDT Note indicated, the alleged perpetrator (Resident 1) was placed on 15-minute monitoring for signs and symptoms of adverse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 33 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Actual harm effects from the alleged incident, was transferred to another floor and room, referred for psych evaluation, and olanzapine (medication used to treat mental disorders) was increased to 10 mg (milligrams, a unit of measurement). The IDT Note did not indicate the incident of Resident 1 touching Resident 3's breast and attempt to touch Resident 2's vagina was further discussed and investigated. Residents Affected - Some Review of facility's untitled letter document dated 9/7/23, indicated, This letter is to inform you of the results of our investigation regarding a resident-to-resident sexual interaction that was reported to you on 8/31/2023. Since the date of that report, there has been a change in two key positions which resulted in this letter not being completed within the five-day time frame .On 8/31/2023, our resident [Resident 1] was observed in his room with a female resident who was touching his penis. The nurse separated the two residents. During the course of the investigation, it was found that [Resident 1] was involved in previous incident in July, in which he was seen touching a different resident on the breast . During a concurrent interview and record review on 9/27/23 at 10:44 AM, DON stated there was no investigation and IDT conducted regarding the two incidents of Resident 1 touching Resident 3's breast and the attempt to touch Resident 2's vagina. During an interview on 9/27/23 at 1:08 PM, ADM stated, any allegations of abuse need to be reported by phone right away and faxed SOC 341 to SSA within two hours of the incident. ADM also stated, a 5-day follow-up or written result of the investigation should be faxed to the State Agency within five days from the incident or up to seven days including weekends, which did not happen. Review of the facility's policy and procedure titled, Abuse Reporting and Investigations, revised 7/31/23 with effective date of 8/18/23, indicated, .The Facility promptly reports and thorough investigates allegations of resident abuse, mistreatment, neglect, exploitation, abuse facilitated or enabled by the use of technology, misappropriation of resident property, or injuries of unknown source, and suspicions of crimes . 1. Administrator as Abuse Prevention Coordinator . b. When the Administrator or designated representative receives a report of an incident or suspected incident of resident abuse, mistreatment, neglect, abuse facilitated or enabled technology, exploitation, or injuries of unknow source, or suspicion of a crime, the Administrator or designated representative will initiate an investigation immediately . ii. The facility will not inhibit facility staff/covered individuals from their mandated reporting obligations. iii. Facility staff/covered individuals will not be disciplined or retaliated against for good-faith reporting . 2. Immediate Action . b. The administrator or designated representative conducting the investigation will interview individuals who may have information relevant to the allegation or suspected crime . 10. Investigator Consultation with Administrator - a. The individual who is conducting the investigation will consult daily with the Administrator concerning progress/findings of the investigation. 11. Informing Resident of Results of Investigation/Corrective Action - a. The Administrator will inform the resident and his/her representative of the results of the progress of the investigation. b. The Administrator will inform the resident and his/her representative of the results of the investigation and corrective action taken within five (5) working days of the reported incident. 12. Providing State Survey Agency and Other Agencies of the Results - a. The Administrator will provide a written report the results of all abuse investigations and appropriate action taken to CDPH Licensing and Certification and others that may be required state or local laws, within five (5) working days of the reported allegation . 3. Resident 9 was admitted on [DATE], with diagnoses including Multiple sclerosis (Disabling disease of the brain and spinal cord), Diabetes mellitus (Disease that affect how the body uses blood sugar), Heart Failure (heart can't pump blood well enough to meet body's need). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 34 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Review of SOC 341 Report of suspected Dependent Adult /Elder Abuse dated 7/17/23, Indicated Resident claims there is one half dose missing of my Ozempic. Level of Harm - Actual harm Residents Affected - Some During an interview on 10/11/2023 at 9:10AM, with Interim director of nursing (ADON) 1, ADON 1 stated The new administration is still looking for the investigation summary but there is nothing we can find, that's why we have new administration. During review of Policy and Procedure, revised 7/31/23, titled ANOZ Abuse - Reporting and Investigations indicated a. The Administrator will provide a written report of the results of all abuse investigations and appropriate action taken to CDPH Licensing and Certification and others that may be required by state or local laws, within five (5) working days of the reported allegation. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 35 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure accurate assessment was completed for one of 3 sampled residents (Resident 1) when Resident 1's physical behavioral symptom of abusing others sexually was not coded on the Minimum Data Set (MDS, a resident assessment tool) as of the Assessment Reference Date (ARD, specific endpoint for the look-back periods in the MDS assessment process). Residents Affected - Few This failure had the potential to result in delayed identification and implementation of interventions for Resident 1's sexually inappropriate behavior; and the potential to place residents in the facility at risk for sexual abuse by Resident 1. Findings: Review of Resident 1's admission record indicated, was admitted to facility on 8/30/22 with diagnoses including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), dementia (a group of symptoms affecting memory, thinking and social abilities), history of alcohol abuse, mild cognitive impairment (trouble remembering, learning new things, concentrating, or making decisions), and cognitive communication deficit (difficulty thinking and communicating). Further review, indicated, Resident 1 was his own responsible party (decision maker). Review of Resident 1's annual Minimum Data Set (MDS, a resident assessment tool) assessment dated [DATE], indicated, Resident 1's cognition (thought process) was moderately impaired. The MDS indicated, Resident 1 did not exhibit any mood symptoms and physical behavioral symptoms directed towards others such as scratching, grabbing, and abusing others sexually. Review of Resident 1's Change in Condition dated 9/1/23, indicated, At around 1410 (2:10 PM) on 08/31/2023 .the male resident on [room number] was witnessed by CNA inside [room number] with another female resident [room number], the alleged victim. The alleged abuser was sitting on the wheelchair, pants was down while the alleged victim is touching the alleged abuser's penis. Both residents were separated, and the alleged victim was escorted back to her own room for safety while the alleged abuser stayed inside the room . An SOC-341 (known as Report of Suspected Dependent Adult/Elder Abuse) was completed and filed . CDPH and Ombudsman were also notified of the incident . During an interview on 9/14/23 at 3:40 PM, CNA 2 stated that on 8/31/23, she was walking by Resident 1's room towards the nursing station and noticed the door was open and saw Resident 2 standing in front of Resident 1 who was sitting on his wheelchair. CNA 2 stated, [Resident 1] pull-ups (disposable brief) were down. [Resident 2] was touching his penis. CNA 2 further stated, she called Resident Care Coordinator (RCC) and was told to separate the two residents and bring Resident 2 back to her room. Review of Resident 1's care plan for The resident was involved in alleged sexual abuse, initiated on 9/3/23, three days after the incident, indicated, the alleged abuser was sitting on the wheelchair, pants were down while the alleged victim is touching the alleged abuser's penis . During an interview on 9/19/23 at 10:00 AM, MDS Coordinator (MDSC) 1 stated, Resident 1's physical behavioral symptoms of sexually abusing others on 8/31/23 was not coded under Section E: Behavior (this section identifies behavioral symptoms in the last seven days that may cause distress to the resident, or may be distressing or disruptive to facility residents, staff members or the care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 36 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Level of Harm - Minimal harm or potential for actual harm environment) of his annual MDS that was completed on 9/1/23. MDSC 1 explained Resident 1's annual MDS had an ARD of 9/1/23, meaning any behaviors exhibited by the resident in the last 14 days from ARD date needs to be coded in Section E: Behavior to reflect current behavior. MDSC 1 stated, Resident 1's sexual behavior towards others should have been coded to reflect his current behavior status. Further interview with MDSC 1 indicated, a social worker is assigned to complete Section E: Behavior of the MDS. Residents Affected - Few During an interview on 9/19/23 at 10:39 AM, Social Worker (SW) 2 stated, she completed Resident 1's Section E: Behavior of the MDS on 9/1/23. SW 2 acknowledged she did not code Resident 1's sexually inappropriate behavior towards Resident 2 on 8/31/23 because the incident did not happen in a public area and stated, I did not trigger because incident happened inside the room. Review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2019, indicated, .E0200: Behavioral Symptom - Presence & Frequency - Note presence of symptoms and their frequency . A. Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) . New onset of behavioral symptoms warrants prompt evaluation, assurance of resident safety, relief of distressing symptoms, and compassionate response to the resident . Steps for Assessment: 1. Review the medical record for the 7-day look-back period. 2. Interview staff, across all shifts and disciplines, as well as others who had close interactions with the resident during the 7-day look-back period, including family or friends who visit frequently or have frequent contact with the resident. 3. Observe the resident in a variety of situations during the 7-day look-back period . Coding Tips . Code based on whether the symptoms occurred and not based on an interpretation of the behavior's meaning, cause, or the assessor's judgment that the behavior can be explained or should be tolerated . Review of the facility's policy and procedure titled, RAI (Resident Assessment Instrument) Process, revised on 10/4/16, indicated, .The Facility will utilize the RAI (Resident Assessment Instrument) process as the basis for the accurate assessment of each resident's functional capacity and health status, as outlined in the CMS RAI MDS 3.0 Manual . Review of the facility's policy and procedure titled, Social Service Assessment, revised on 12/1/13, indicated, .Policy I . A. The Social Service Assessment will address the resident's physical and psychosocial needs that should be considered in developing the resident's plan of care . Procedure . II. The Director of Social Services or designee will complete sections .E (behavior) .of the RAI Assessment based on federal timeframes . IV. Information obtained should be reflected in the coding of the MDS. A. When a Care Area is triggered, there should be documentation to reflect that the Facility has further assessed the Care Areas trigger prior to developing a Care Plan . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 37 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a person-centered care plan (CP, a road map for patient care) for two of two sampled residents (Resident 7 and Resident 9) when: a. Resident 7 did not have a CP to address osteopenia (bone loss). This failure puts Resident 7 at risk to not receive necessary care and services to manage the possible complication from osteopenia. b. There was no care plan developed to address alleged incident of missing medication and medication not being given timely for Resident 9. This failure had the potential to delay the identification and implementation of appropriate corrective actions for a possible misappropriation of property. Findings: a. A review of the face sheet indicated Resident 7 was admitted with diagnoses including dementia (a decline in memory or other thinking skills), diabetes mellitus (abnormally high sugar level in the blood), and hypertension (abnormally high blood pressure). A review of the Minimum Data Set (MDS) dated [DATE], Brief interview of Mental Status (BIMS, a brief memory test to help determine cognitive functioning) indicated severe cognitive impairment. Under functional status Resident 7 was totally dependent and required one-person physical assistance with activities of daily living including mobility, transfer, eating and toileting. A review of care plan addressing ADL's initiated 3/7/23, indicated, Resident (Resident 7) needs assistance with ADL's. At risk for declining self-performance of ADL's related to (r/t) weakness, depression (severe feeling of hopelessness and loneliness), aging, impaired cognitive function, communication, mood and behavior problem due to dementia .Goal: ADL and safely needs will be anticipated and met by staff daily . refer rehab consult as needed. Turn and reposition as ordered. Provide assistance with ADL's care as needed . During an interview on 10/5/23, at 3:49 PM, LVN 4 stated, Resident (Resident 7) barely speak, does not understand her condition and is totally dependent to staff with all her ADL needs. A review of the x-ray results dated 4/3/23, indicated, .acute oblique fracture in the supracondylar region (when the thigh bone was broken at the knee) . A review of change in condition follow up note dated 4/4/23, indicated, .Resident was sent to the ER (emergency room) . A review of the ER notes dated 4/3/23, indicated, .Resident was sent in from the nursing home due to concern of a right side femur fracture . ER notes further indicated x-ray results revealed Resident 7 has osteopenia. There was no evidence of documentation a comprehensive care plan was developed and interventions were implemented to address osteopenia for Resident 7. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 38 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few b. Resident 9 was admitted on [DATE], with diagnoses including Multiple sclerosis (Disabling disease of the brain and spinal cord), Diabetes mellitus, Heart Failure (heart can't pump blood well enough to meet body's need). During a review of Resident 9's Clinical record on 10/11/23 at 9:10 AM, the Interim Director of Nursing (ADON) 1 acknowledged that the clinical record did not contain evidence of documentation of a care plan to address the missing medication. ADON 1 stated, There should be a customized care plan to address the incident, there is no care plan on incident of missing medication. During an interview on 10/11/23 at 3:47 PM, Licensed Vocational Nurse (LVN) 11 stated I did not write a care plan regarding the incident of missing medication. A review of facility Policy and Procedure titled Comprehensive Person-centered Care planning undated, indicated, .It is the policy of this facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of the residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being . Additional changes or updates to the resident's comprehensive CP will be made based on the assessed needs of the resident .The comprehensive CP will be periodically reviewed and revised by Interdisciplinary Team after each assessment which means after each MDS assessment as required . In addition, the comprehensive CP will also be reviewed and revised at the following times: i. Onset of new problems; ii. Change of condition; iii. In preparation for discharge; iv. To address changes in behavior and care, and v. Other times as appropriate or necessary . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 39 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide necessary care and services to two of two sampled residents (Resident 10 and Resident 9) according to standards of practice when: Residents Affected - Few a. There was no evidence of documentation of progress or decline during the stay in the facility for Resident 10. b. There was no evidence of documentation of pain assessment and management for Resident 10. c. There was no evidence of documentation prescribed medication was administered as ordered by the physician for Resident 10 and Resident 9. The facility failure has the potential for the residents to not receive necessary care and services and experience adverse effects due to untreated medical conditions. Findings: a. A review of the admission Summary for Resident 10 dated 10/24/22, indicated, . Diagnosis of closed left hip intertrochanteric (bones of the thigh) fracture status post (s/p) fall; s/p post open reduction and internal fixation (ORIF, a surgical procedure) of the fractured (broken bone) left hip, biliary cirrhosis (swelling of the bile ducts [small tubes inside the liver]), diabetes (abnormally high sugar level in the blood), heart failure (when the heart muscle does not pump as strong as it should), hyponatremia (abnormally low salt [sodium] content in the blood), dementia (decline in memory or other thinking skills), anxiety ( a mental illness), anemia (abnormally low count of the red blood cells), osteoarthritis (OSA, pain and swelling of the bones and joints), gastroesophageal reflux (GERD, when the stomach contents goes up to the esophagus [a long tube where the food passes from the throat down to the stomach]). A review of the Transfer Form for Resident 10 dated 10/25/22, at 11:35 AM, indicated, .Reason for transfer: sanguineous (leakage of fresh blood) drainage to left hip surgical site . During an interview on 9/14/23, at 3:42 PM, Social Worker (SW) 1 stated, I don't know that patient (Resident 10). During an interview and record review for Resident 10 on 9/19/23, at 9:53 AM, Assistant Director of Nursing (ADON) 1 stated, I only see the admission assessments and nothing else. The nurses' notes should include residents' condition during their shift. The nurses should document concerns, like pain, how was the surgical site, any signs of infection, reactions to medications. There are no nurses' notes. I don't see any nurses' notes. ADON 1 further acknowledged there were no evidence of documentation to address provision of care to the left hip surgical incision for Resident 10 and stated, There is no treatment administration record. During an interview and record review on 9/26/23, at 1:24 PM, Licensed Vocational Nurse (LVN) 6 stated, There's no nurse's notes (NN). I remember the [family member] saying that [Resident 10] was weaker. She was sent to emergency room (ER). The NN shows how a resident was doing during their shift. To communicate with other nurses. For new admission, NN is done every shift for the first three days. LVN 6 further acknowledged that there was no treatment administration record to address care for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 40 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 the left hip surgical incision. Level of Harm - Minimal harm or potential for actual harm A review of the job description for a Registered Nurse (RN) and LVN indicated, .Records care information accurately, timely, and concisely. Completes all required documentation including resident observations, interventions, and patient response(s) in the medical record in accordance with policy .Prepares, administers medications as ordered by the physicians and within the legal scope of nursing . Completes all medical treatments as indicated and as ordered by the physician . Residents Affected - Few A review of the Policy and Procedure, titled, Progress notes dated 1/1/12, indicated, Purpose: To provide an interdisciplinary record of each resident's progress. Each discipline will be responsible for documenting the resident's progress. All disciplines in the facility will document progress in the appropriate section of the resident's medical record according to professional standards and regulations. Progress notes will reflect the resident's current status, progress, or lack of progress, change in condition, adjustment to the facility, and other relevant information.Progress notes are to be documented in a timely manner. A review of the Policy and Procedure titled, Completion & Correction dated 1/1/12, indicated, .Entries will be recorded promptly as the events or observations occurs. Entries will be complete, legible, descriptive, and accurate. Any person (s) making observations or rendering direct services to the resident will document in the record . Information's concerning pertinent observations, psychosocial and physical manifestations, incidents, unusual occurrences, and abnormal behavior will be documented as soon as possible . b. A review of the Clinical admission Evaluation for Resident 10 dated 10/24/22, at 1400 (2 PM) indicated, .Indicators of pain: vocal complaints of pain. Detailed pain description (location, characteristics, etcetera [etc.]): pain in left hip surgical site. Most recent pain level: 5 .Frequency: multiple times a day . During an interview on 9/14/23, at 3:34 PM, ADON 1 stated, I do not know this patient. The nurse that admitted the resident (Resident 10) quit last year. A review of the change in condition notes dated 10/25/23, indicated, Resident 10 was transferred to the ER (Emergency Room). A review of the Order Summary Report (Physician [medical doctor] orders) for Resident 10 dated 10/24/22, indicated, . Acetaminophen tablet 500 mg (milligrams, a unit of measure), give one (1) tablet by mouth every four hours as needed for pain Gabapentin capsule, give 100 mg by mouth three times a day for nerve pain. Oxycodone HCL (used to treat severe pain) give 0.5 tablet by mouth every 6 hours as needed for pain . During an interview and record review on 9/19/23, at 9:53 AM, ADON 1 acknowledged there was no evidence of documentation that pain medication were administered to Resident 10 on 10/24/22 and 10/25/22. ADON 1 stated, Maybe she has no medications. Sometimes the medication is delivered the next day. ADON 1 reviewed the admission record and stated, She was admitted at 2 PM. But there are so many documentations on admission. It takes a while maybe that's why the medications were not ordered. During an interview on 9/19/23, at 12:40 PM, Pharmacist stated, (Our pharmacy named) stops accepting orders at 5 PM. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 41 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 9/19/23, at 1:10 PM, Director of Staff Development stated, The new admission medications orders should be sent to the pharmacy before five (5) PM to get them delivered the same day. If the orders were sent after 5 PM, it will be delivered the next day. We do not have Oxycodone Hydrochloride (Oxycodone HCL, used for moderate to severe pain) in the emergency supply. For pain medication not available in our emergency supply, the nurse should call and notify the doctor that we have tramadol available. The nurses know that. During an interview on 9/27/23, at 10:23 AM, LVN 5 stated, Sometimes the medications are delivered the next day. I have experienced my patient not having pain medications available. I called the doctor and told him we have Tramadol. Some doctors will give an order for Tramadol. That's how it's done. Other doctors will not change the order. It can be a problem. We have tylenol. A review of the Policy and Procedure titled, Pain Management dated 5/26/23, indicated .Pain assessment will be completed for each resident upon admission, quarterly, when there is a new onset of pain, exacerbation of pain, or when there is a significant change in status. The Licensed Nurse will complete a Pain Assessment for residents identified as having pain .The goal for pain management will be resident centered and determined by the resident's acceptable level of pain. Pain Management. The Licensed Nurse will administer pain medication as ordered and document medication administered on the Medication Administration Record (MAR). After medications/interventions are implemented, the licensed nurse will re-evaluate the resident's level of pain within one hour. The Licensed Nurse will assess the resident for pain and document results on the MAR each shift. If there is a new onset of pain, if the pain has changed in nature, or the pain has not been relieved with current medication, the Licensed Nurse will notify the Attending Physician .Documentation: Pain Assessments will be maintained in the resident's medical record. The licensed Nurse will document resident's pain level and response to interventions in the medical record. The licensed Nurse will update the Care Plan for pain management with any change in treatment and/or medication . c1. A review of the physician orders for Resident 10 dated 10/24/22, indicated, .Acetaminophen (used to relieve pain) tablet 500 mg. Give one (1) tablet by mouth every four (4) hours as needed for pain . Ferrous Sulfate (Iron supplement, helps in production of red blood delayed release 324 mg. Give one tablet by mouth with meals for supplement. Furosemide (water pill, helps the body get rid of extra fluids) tablet 20 milligrams (mg, a unit of measurement). Give 1 tablet by mouth two (2) times a day for CHF. Gabapentin (used to relieve pain) capsule. Give 100 mg by mouth three (3) times a day for nerve pain. Glipizide (used to lower blood sugar level) tablet 10 mg. Give 1 tablet by mouth 2 times a day for DM type 2. Lactulose solution 10 grams (GM, a unit of measurement) per 15 ml (milliliters, a unit of measure) (10 GM/15 ml). Give 45 ml by mouth three times a day for liver disease and constipation. Lipitor (used to lower the cholesterol level) tablet 40 mg. Give 40 mg by mouth one time a day. Metformin Hydrochloride (HCL) (used to lower blood sugar level) tablet 850 mg. Give 1 tablet by mouth 3 times a day for DM type 2. Metoprolol Tartrate (used to lower blood pressure) tablet 25 mg. Give 25 mg by mouth 2 times a day for hypertension (Abnormally high blood pressure) .Oxycodone Hydrochloride (HCL) (used to treat moderate to severe pain) tablet 5 mg. Give 0.5 tablet by mouth every six (6) hours as needed . Rifaximin (an antibiotic [used to kill bacteria] used to treat diarrhea) tablet 550 mg. Give one tablet by mouth 2 times a day . A review of the Medication Administration Record (MAR) for Resident 10 for the month of 10/2022, indicated medication administration schedule times as follows: .Lipitor 8 AM (0800). Furosemide 0900 ( 9 AM), 1700 (5 PM). Glipizide 9 AM, 5 PM. Metoprolol Tartrate 8AM, 5 PM. Rifaximin 8 AM, 5 PM. Ferrous sulfate 8 AM, 12 PM (1200), 7 PM. Gabapentin 9AM, 1300 (1 PM), 5 PM. Lactulose solution 9AM, 1300 (1 PM), 5 PM. Metformin HCL ( AM, 1 PM, 5 PM . Further review of the MAR dated 10/24/23, day of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 42 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 admission, indicated the medication administration schedule times were crossed out. Level of Harm - Minimal harm or potential for actual harm A review of the MAR for resident 10 dated 10/25/22, indicated the following entries, .Lipitor 9 (Other, see progress notes). Furosemide 9, 6 (hospitalized ). Glipizide 9, 6. Metoprolol, 9, 6. Blood pressure 136/78. Rifaximin 9,6. Ferrous Sulfate 2 (drug refused), 6,6. Gabapentin 9, 6, 6. Lactulose solution 9, 6, 6. Metformin HCL 9, 6, 6 . Residents Affected - Few A review of the progress notes for Resident 10 dated 10/25/22, indicated, .Lipitor .medication not available, admitted [DATE] . metformin .medication not available, admitted on [DATE], furosemide .not available, admitted [DATE], gabapentin .not available, admitted [DATE], glipizide .medication not available, admitted [DATE], lactulose solution .medication not available, admitted [DATE], rifaximin .medication not available, admitted [DATE], metoprolol tartrate . medication not available, admitted [DATE] . During an interview and record review on 9/19/23, at 9:53 AM, ADON 1 stated, Maybe she has no medications. Sometimes the medication is delivered the next day. During an interview on 10/5/23, 11:02 AM, LVN 8 stated, It happened to my residents a couple of times where the medications was not delivered. There's a time frame for ordering meds. The orders have to be sent to the pharmacy by 5 PM to get them by 9 PM the same day. I am not sure what is in the policy. c2 . Resident 9 was admitted on [DATE], with diagnoses including Multiple Sclerosis (disabling disease of the brain and spinal cord), Diabetes Mellitus (disease that affect how the body uses blood sugar), Heart Failure (heart can't pump blood well enough to meet body's need). A review of Resident 9's Physician order Dated 6/14/23, indicated Semaglutide (0.25 or 0.5MG/DOS Subcutaneous solution. Pen injector 2MG/3ML (semaglutide) Inject 0.25MG subcutaneously in the afternoon every Monday for weight management until 7/10/2023 and Semaglutide (0.25 or 0.5MG/DOS Subcutaneous solution. Pen injector 2MG/3 ML (semaglutide) Inject 0.5 MG subcutaneously in the afternoon every Monday for weight management until 7/10/2023. During an interview on 10/11/23 at 9:10 AM with the ADON 1, ADON 1 reviewed Resident 9's Medication administration record (MAR), ADON 1 acknowledged the MAR did not contain evidence that medication was given on 6/26/23 and 7/10/23 and stated I don't know why there is no documentation of the meds being given on June 26 and July 10. Maybe the nurse forgot to sign it. During an interview on 10/11/23 at 3:47 PM, LVN 11 stated Medication was due 2 PM - 3 PM. I had 12 hours shift that day from 7 AM - 7 PM. It was not given within my shift. A review of the Policy and Procedure titled Medication Administration dated 1/1/2012, indicated, .To ensure accurate administration of medications for the residents in the facility. Medication will be administered directly by a Licensed Nurse and upon the order of the physician .Medications and treatments will be administered as prescribed to ensure compliance with dose guidelines .When as needed (PRN) medication is given, it will be charted on the MAR .If the PRN is for complaint of pain, the nurse will document the pain score prior to giving the medication and after administration of the pain medication . Nursing staff will keep in mind the seven rights when administering medications .The right medication. The right amount. The right resident. The right time. The right route. Resident has the right to know what the medication does. Resident has the right to refuse the medication . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 43 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide supervision and assistance to prevent a fall to Resident 4; and prevent injuries to three residents (Resident 5, Resident 6, and Resident 7) . This facility failure resulted in Resident 4 sustaining fractures (broken) to the 4th, 5th, 6th, 7th, and 8th right ribs (part of the bony framework that protect the chest) and Resident 5, Resident 6, and Resident 7, who were totally dependent on staff with their activities of daily living (ADL, self-care activities) were found with fractures of the femur (thigh bone) of unknown cause. Findings: A. A review of the face sheet indicated, Resident 4 was admitted with diagnoses including heart failure (when the muscles of the heart does not pump as strong as it should), and asthma (a lung disease). A review of the Minimum Data Set (MDS, a standard assessment tool) dated 3/20/23, Brief interview of mental status (BIMS, a brief memory test to help determine cognitive function) score of 2 indicated severe cognitive impairment. Under functional status, Resident 4 required one-person physical assistance in performance of ADL including mobility, transfer, and toilet use. Resident 4 was frequently incontinent (inability to control) bladder function (passing urine) and bowel function . A review of the Fall Risk assessment form dated, 3/20/23, indicated, . If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. Prevention protocol should be initiated immediately and documented on the care plan. A review of the fall risk evaluation dated 3/20/23, indicated Resident 4 had a score of 11, at risk for falls. A review of the Bowel and Bladder Program Screener for Resident 4 dated 3/20/23, indicated: a. Voids appropriately without incontinent: Not always, but at least daily, score of 2. b. Incontinent of stool 1-3 times (x) a week: score of 2. c. Ability to get to the bathroom (BR) /transfer to toilet/commode/urinal, adjust clothing and wipe: Independently, but slowly: score of 2. d. Mental status: Confused, needs prompting, score of 1. e. Mentally aware of need to toilet: Usually aware of need to toilet, score of 2. f. Condition of skin on genital, perineal, buttocks: No redness, score of 3. g. Predisposing factors: Diabetes, MS, Cerebrovascular accident (CVA, stroke, blood supply to the brain is blocked ), bladder or prostate disease, frequent urinary tract infection (UTI), spinal cord injuries, cerebral palsy. Score of 2. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 44 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Score: 14. Category: Candidate for schedule toileting (timed voiding). Level of Harm - Actual harm A review of the care plan addressing Resident 4 risk for falls and injury, initiated on 11/29/22, indicated, .related to (r/t) confusion, deconditioning, gait balance problems, incontinence, poor communication/comprehension, psychoactive drug use, unaware of safety needs, uses wheelchair for locomotion on and off unit. Resident is noted to transfer self from bed and walk pushing her wheelchair, not redirectable at times, easily gets agitated .Interventions: Anticipate and meet (Resident 4) needs, she frequently goes up to the nurse ' s station for juice, sandwiches, and snacks. Educate resident about safety reminders and what to do if a fall occurs. Follow facility fall protocol. Involve family in explaining to the resident the risk and benefits of following safety protocol in their language. Provide nonskid socks when resident is walking barefoot. Physical therapy (PT) evaluates and treat as ordered or as needed (PRN). The resident needs a safe environment with even floors free from spills and/or clutter, adequate, glare free light, a working and reachable call light, the bed in low position at night, handrails on walls, personal items within reach . Residents Affected - Few During observation on 9/14/23, at 2:56 PM, Resident 4 was sitting up in a wheelchair. She was alert, calm and pleasant. Resident 4 was calling out and waving to staff. Assistant Director of Nursing (ADON) 2 responded to Resident 4 and stated, She said that she doesn't' need anything. A review of the nurses' notes dated 5/18/23, 11:31 AM indicated, Patient (Resident 4) found on floor, next to bed side commode .patient was assisted back to bed and instructed to use the call light when she needs help .moderate pain on her right ribs . A review of the nurses' notes, a late entry, dated 5/18/23, indicated, .Resident (Resident 4) had an unwitnessed fall attempting to self-toilet to commode after breakfast without assist and without using call light . A review of the post fall assessment for Resident 4 dated 5/18/23, indicated, .Date/Time of fall: 5/18/23, 9:45 AM. Fall was not witnessed. Fall occurred in resident ' s room. Resident was attempting to self-toilet at the time of fall .Contributing factors: self-toileting using bedside commode without assistance .Conclusion .Any additional needs identified: Yes. Needs identified: Re-education. Additional needs note: teaching resident to use call light whenever she needs help. A review of the Interdisciplinary Team (IDT, group of healthcare professionals working together to provide care) notes dated 5/19/23, indicated, .Resident (Resident 4) had an unwitnessed fall on 5/18/23, at 9:15 AM when she attempted to use the bedside commode and was found sitting on the floor Resident did report 5/10 pain on her right ribs area.Resident is at high risk for falls related to impaired cognition, impaired safety awareness, impaired balance. In addition to taking medication that can increased the fall risk including diuretic, antidepressant, narcotic analgesic antihypertensive .The resident will benefit from assistance to the bedside commode after breakfast. Care plan reviewed with DON, ADON, SW. A review of nurse's notes for Resident 4 dated 5/19/23, indicated, .X-ray (a procedure to take pictures of the inside of the body) result came back on 9/19/23, with Mildly displaced (when bones come out of alignment) fractures of the lateral 4th, 5th, 6th, 7th, and 8th ribs . A review of the nurses' notes for Resident 4 addressing Change in Condition, dated 5/19/23, indicated, .Plan of care for this fall is to assist with toileting before and after meals and as needed because the resident had a fall when attempting to use the bedside commode without using the call light (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 45 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 .call light within reach and educated to use the call light whenever she needs help . Level of Harm - Actual harm During an interview on 9/14/23, at 3:05 PM, Licensed Vocational Nurse (LVN) 2 stated, When she (Resident 4) wanted to go to the toilet, she will say pee (urinate, pass urine) or point to the bathroom. She is usually continent during the day, incontinent at night. She doesn't want to get up at night. We have been telling her to use the call light. She is not using the call light. She can't remember she needs to use the call light. Residents Affected - Few During an interview on 9/14/23, at 3:24 PM, LVN 1 stated, The resident (Resident 4) doesn't use the call light. She doesn't remember the instructions on how to use the call light. And most of the time was not able to follow directions. She has dementia. During an interview on 9/14/23, at 4:28 PM, Certified Nurse Assistant (CNA) 3 stated, We are always short of staff. It's hard. There's not enough help. We have to hurry so everyone is taken cared of. During an interview on 9/14/23, at 4:55 PM, Physical Therapy (PT, used to improve movement and manage pain) Director stated, We do not evaluate a resident unless there is a physician order. We can screen. PT Director further stated that PT screening (used to identify resident's needs and rehabilitation potential) was not done to Resident 4 after the fall episode. During an interview on 9/17/23, at 1:54 PM, CNA 1 stated, I help her (Resident 4)go from bed to wheelchair. She cannot stand up by herself. She does not use the call light. She knocks on the table or knocks the door when she wants to go to the toilet. CNA 1 further stated that Resident 4 tries to transfer out of bed by herself that she had to check her more frequently. During an interview on 9/19/23. at 3:05 PM, ADON 1 stated, She (Resident 4) was not on any toileting program. The care plan for risk for fall and injury was not revised and updated to include that Resident 4 required one person assistance during mobility and transfer. A review of the care plan addressing bowel and bladder function was not revised and updated to include that Resident 4 required one-person physical assistance with toilet use. B1. A review of the face sheet indicated Resident 5 was admitted with diagnoses including stroke, seizure disorder (epilepsy) and dementia (decline in memory or other thinking skills). A review of MDS dated [DATE], BIMS indicated severe cognitive impairment. Under functional status Resident 5 was totally dependent with ADL including mobility, transfer, eating, and toileting. A review of the nurses' notes dated 5/24/23, addressing Resident 5's Change in Condition indicated, . CNA reported to Licensed Nurse (LN) that the resident 's (Resident 6) right thigh looked bigger than the left one .LN noted the resident with internal rotation of the right hip and swelling to the right thigh. With slight discomfort when right thigh was touched . A review of the Physician (Medical doctor) notes dated 5/24/23, indicated, .Patient (Resident 5) reported to have a possible fracture of which an x-ray was done on 5/24/23, showing right intertrochanteric (relating to the bones of the thigh) fracture, staff reports no fall . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 46 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few During an interview and review of the clinical record for Resident 5 on 9/14/23, at 3:05 PM, ADON 1 stated, I don't see an IDT charting about the incident. She's conserved (appointment of a guardian or a protector by a judge to manage the personal or financial affairs of another person who is incapable of fully managing their own affairs due to age or physical or mental limitations). The conservator (guardian, protector) transferred her to another facility. The conservator had another resident here. Both residents were transferred to another facility after both had a fracture. The Conservator for Resident 5 was not available for an interview. B2. A review of the face sheet indicated Resident 6 was admitted with diagnoses including dementia, heart failure, and diabetes (high levels of sugar in the blood). A review of the MDS for Resident 6 dated 4/7/23, Brief Interview of Mental Status score of 6 indicated severe cognitive impairment. Under functional status Resident 6 was dependent requiring one-person physical assistance with ADL ' s including mobility, transfer, dressing, and toilet use. A review of the nurses' notes for Resident 6 dated 5/24/23, indicated, CNA reported that the resident has bruising on her right thigh .noted scattered yellowish, greenish discoloration on the right groin, extending to the right hip to entire posterior (back) thigh .No fall incident reported during the past week Resident has cognitive impairment related to dementia, and unable to provide description on the origin of bruising . A review of the ER (Emergency Room) notes for Resident 6 dated 5/25/23, indicated, . closed fracture of the right hip . A review of the facility investigation dated 5/30/23, indicated, .Conclusion: Resident (Resident 6) has not experienced any falls or any unusual incidents in the past two weeks. (Resident 6) was found to have a spontaneous fracture which the leading cause is decreased bone mass which has a propensity to affect older female adults . The facility was not able to provide evidence of documentation that addressed Resident 6 had decreased bone mass. The Conservator for Resident 6 was not available for interview. B3. A review of the face sheet indicated Resident 7 was admitted with diagnoses including dementia, diabetes, and hypertension (abnormally high blood pressure). A review of the MDS dated [DATE], BIMS score of 7 indicated severe cognitive impairment. Under functional status Resident 7 was totally dependent and required one-person physical assistance with activities of daily living including mobility, transfer, eating and toileting. A review of care plan for Resident 7 addressing ADL's initiated 3/7/23, indicated, Resident needs assistance with ADL's. At risk for declining self-performance of ADL's related to (r/t) weakness, depression (severe feeling of hopelessness and loneliness), aging, impaired cognitive function, communication, mood and behavior problem due to dementia . Noted sometimes talking to self nonsense when awake. Goal: ADL and safely needs will be anticipated and met by staff daily . refer rehab consult as needed. Turn and reposition as ordered. Provide assistance with ADL's care as needed . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 47 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 The care plan was not revised and updated to include Resident 7 requiring one-person physical assistance with ADL's. Level of Harm - Actual harm During an observation on 10/5/23 at 3:48 PM, Resident 7 was asleep in bed in side lying position. Residents Affected - Few During an interview on 10/5/23, at 3:49 PM, LVN 4 stated, The resident (Resident 7) barely speak, does not understand her condition and is totally dependent to staff with all her ADL needs . A review of the Change in Condition (CIC) Evaluation for Resident 7 dated 3/31/23, indicated . CNA reported .new skin issue . New onset of swelling and tenderness 4/10. Pain with touch . A review of the x-ray results for Resident 7 dated 4/3/23, indicated, .acute oblique fracture in the supracondylar region (when the thigh bone was broken at the knee) . A review of change in condition follow up note for Resident 7 dated 4/4/23, indicated, . Resident was sent to the ER (emergency room) yesterday to confirm fracture results obtained from the in house X-ray .Returned this morning with orders for oxycodone (used to treat moderate to severe pain) . A review of the emergency department notes for Resident 7 dated 4/3/23, indicated .Displaced (when bones come out of alignment) right distal femoral fracture .called nurses at (facility) .States that the patient is immobile . During an interview on 9/19/23, at 1:50 PM, Director of Staff Development stated she have not provided in-service to address accident prevention for residents for the last 12 months. A review of the Policy and Procedure titled, Fall Management Program, dated 2/1/11, indicated, Purpose: To provide residents a safe environment that minimizes complications associated with falls .The IDT and or the licensed nurse will develop a care plan according to the identified risk factors will initiate, update, and root cause(s) per care area guidelines. The IDT will initiate, review, and update the resident ' s fall risk status and care plan at the following intervals: on admission, quarterly, annually, upon identification of a significant change of condition, post fall and as needed. The license nurse will evaluate the resident ' s response to the interventions on the Weekly Summary and update the resident care plan as necessary . A review of the Policy and Procedure titled Safety and Supervision of Residents dated 1/2011, indicated, .Out facility strives to make the environment as free from accident hazard as possible. Resident safety and supervision and assistance to prevent accidents are facility wide priorities .Our facility-oriented approach to safety addresses risks for group of residents. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes . When accident hazard are identified, the Safety Committee shall evaluate and analyze the causes of the hazards and develop strategies to mitigate or remove the hazards to the extent possible. Employees shall be trained and Inserviced on potential accident hazards and how to identify and report accident, and try to prevent avoidable accidents. The Safety Committee and staff shall monitor interventions to mitigate accident hazards in the facility and modify as necessary . Our resident-oriented approach to safety and accident hazards for individual residents. Staff shall use various sources to identify risks factors for residents, including the information obtained from the medical history, physical exam, observations of the resident, and the MDS. The interdisciplinary care team shall analyze information obtained from assessments and observations to identify any specific accident hazards or risks for that resident. The care team shall target (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 48 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete interventions to reduce the potential for accidents. Implementing interventions to reduce accident risks and hazards shall include the following: communicating specific interventions to all relevant staff; assigning responsibility for carrying out interventions; providing training, as necessary; ensuring that interventions are implemented; and documenting interventions. Monitoring the effectiveness of interventions shall include the following: ensuring the interventions are implemented correctly and consistently; evaluating the effectiveness of interventions; modifying or replacing interventions as needed; and evaluating the effectiveness of new or revised interventions .The facility-oriented approach and resident-oriented approaches to safety are used together to implement a system approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjust interventions accordingly. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. The type and frequency of resident supervision may vary among residents and over time for the same resident. For example, resident supervision may need to be increased when there are temporary hazard in the environment .or if there is a change in condition .risks factors and environmental hazards include: bed safety, safe lifting and movement of the residents, falls, smoking, unsafe wandering, poison control, electrical safety, water temperature . Event ID: Facility ID: 555034 If continuation sheet Page 49 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0776 Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a diagnostic procedure was provided for Resident 7 when a stat (medical term for rush) x-ray (a procedure to create images of the structure of the inside of the body, used to assess broken bones) was not completed as ordered by the physician. Residents Affected - Few The failure resulted to the delay in identification and treatment of a femur (thigh bone) fracture (broken bone) for Resident 7. Findings: A review of the MDS dated [DATE], BIMS score of 4 indicated severe cognitive impairment. Under functional status Resident 7 was totally dependent and required one-person physical assistance with activities of daily living including mobility, transfer, eating and toileting. During an interview on 10/5/23, at 3:49 PM, Licensed Vocational Nurse (LVN) 4 stated, Resident (Resident 7) barely speak, does not understand her condition and is totally dependent to staff with all her ADL needs. She needs physical help from a staff. She didn't fall when she had the fracture. We use the numerical pain scale. 1-4 for mild pain, 5-7 for moderate pain, 8 -9 for severe pain, 10 and over is excoriating pain. A review of the Change in Condition (CIC) Evaluation dated 3/31/23, indicated . CNA reported .new skin issue . New onset of swelling and tenderness 4/10. Pain with touch . A review of the progress notes dated 3/31/23, indicated, (X-ray services provider named) called at 15:30 (3:30 PM) for stat x-ray and stated would arrive in four to six hours (4-6 hrs.) . A review of progress notes dated 4/1/23, indicated, .(X-ray services provider named) contacted and stated technician is sick . A review of CIC follow up note dated 4/2/23, indicated, .(X-ray services provider named) contacted and no time table for technician to arrive . A review of the x-ray results dated 4/3/23, indicated, .acute oblique fracture in the supracondylar region (when the thigh bone was broken at the knee) . A review of change in condition ff up note dated 4/4/23, indicated, .Resident (Resident 7) was sent to the ER (emergency room) yesterday to confirm fracture results obtained from the in house X-ray .Returned this morning with orders for oxycodone (used to treat moderate to severe pain) . A review of the ER notes dated 4/3/23, indicated, .Displaced (the bones have come out of alignment) right distal femoral fracture . During an interview on 10/5/23, at 10:55 AM, LVN 8 stated, We always have a problem with X-rays. And the laboratory (labs). Sometimes the urine specimen was picked up after three days. I have reported it. Everyone knows the problem. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 50 of 51 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555034 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0776 Level of Harm - Actual harm Residents Affected - Few During an interview on 10/5/23, at 11: 15 AM, LVN 9 stated, X-rays and labs has been a problem with (X-ray and laboratory services provider named). We have reported it to the supervisors and to the DON. We are still using the same company. During an interview on 10/6/23, at 9:10 PM, LVN 3 stated, Stat means as soon as possible. Especially for suspected fracture, it should be right away. Stat x-rays never happened. They were never on time. A doctor will order an X-ray for today, its is not going to be done until the next day. Sometimes a stat order for a Friday will be done on a Monday. It's a long wait. We have been having this problem for so long now. The supervisors and the DON is aware. During an interview on 10/6/23, at 9:19 PM, LVN 10 stated, Stat order means as soon as possible. The stat order for X-ray for the resident (Resident 7) was done on 4/3/23. We have to wait until X-ray send someone. We have reported this problem. During an interview on 10/12/23, at 4:30 PM, Medical Director acknowledged that the staff had reached out to him regarding stat orders for x-rays were not completed as ordered. MD stated, Also the labs (test, ordered by a doctor to take a samples including blood, urine, other bodily fluid, to get information about your health) it takes days before it's done. The facility was not able to provide evidence of documentation the X-ray and Laboratory services were reviewed, and the staff concerns were addressed to ensure that the services are completed as ordered by the physician to meet the residents needs. A review of the Policy and Procedure titled, Laboratory Services dated 1/1/12, indicated, To ensure the provision of Laboratory services as required for the residents at the facility. The facility will provide laboratory services in an accurate and timely manner to meet the needs of residents per Attending Physician orders. Laboratory services will be provided when ordered by the Attending physician FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 51 of 51