Health inspection·January 30, 2024

F 0684 - Apprearance: SL. (slightly) Cloudy (RR: clear) Level of Harm - Minimal harm or potential for actual harm - [NAME] Blood Cell (help the body fight infection and other diseases): 11-20 (RR: between 0 [zero] to 5 [five]) Residents Affected - Few - [NAME] Blood Cell clump (typically observed when there is inflammation or bacterial infections of the kidneys and urinary tract): Present (RR: none seen) - Bacteria: Few (RR: none seen) - Squamous Epithelial: Few (RR: None Seen) The DON stated, It (urinalysis result) is not normal. Review with the DON, of Resident 1's progress notes, dated 1/23/19 with no time documented, indicated, Nsg (nursing) PM (referring to work hours from 3 PM to 11:30 PM) . U/A (urinalysis) faxed to MD (medical doctor)/ on MD's chart . Further review of Resident 1's progress notes, dated 1/24/19 at 3PM indicated, UA results faxed to MD. No new orders received . The DON also reviewed Resident 1's progress notes dated 1/25/19 to 1/26/19 and verified that there was no documentation that the physician was notified of the UA results by telephone. The DON stated, There needs to be a follow up. There was no telephone order for antibiotics from the provider (physician) despite having the results faxed multiple times. They (staff) should have called the doctor. 2. Review of facility document, titled, Physician's Telephone Orders (PTO), dated 12/12/18 for Resident 1, indicated Transfer to w/c (wheelchair) daily qd (daily) 1x (time)/ (per) day 7 (seven) x (times) wk (week) by 2 (two) x (HHA [home health aide]) . Further review of Resident's PTO, dated 12/20/18, indicated, D/C (discontinue) manual HHA x 2 (two) order. Start Hoyer Lift (a mechanical lift device) 7x/wk as an optimal and safe procedure. Review of Resident 1's minimum data set (MDS - an assessment tool), dated 12/19/18 indicated Resident 1 was totally dependent on staff and required two or more persons physical assist to transfer to or from wheelchair. The MDS also indicated Resident 1 used a wheelchair for mobility. During a concurrent review of Resident 1's clinical records and interview on 1/30/24 at 10:52 AM, the DON reviewed Resident 1's care plan (CP), titled Resident needs assistance with .Transfer . dated 12/12/18. The CP indicated Approach .Transfer to w/c daily 1x/day 7x/wk by 2 assist (assistance) with HHA as per family request. The DON reviewed Resident 1's ADL (Activities of Daily Living) Flow Sheets for the months of December 2018 and January 2019. The ADL Flow Sheets included Transfers as one of the activities for Resident 1. The DON stated that transfers mean, transfer to and from the wheelchair. The ADL Flow Sheets, dated 12/12/18 to 12/14/18, 12/17/18, 12/29/18, 1/1/19, 1/5/19 to 1/1/10/19, 1/12/19 to 1/15/19, and 1/17/19 to 1/26/19 were marked with X on the check boxes for Transfers. The DON stated, 'X' indicates the CNA (certified nursing assistant) providing care did not write their initials which should support they got her up. The DON verified that there was no documentation of Resident 1's refusal to transfer on the ADL Flow Sheets. The DON also reviewed Resident 1's progress notes, dated 12/12/18 to 1/26/19 and stated, There's no documentation of resident refusal. If she refused, they (staff) should have documented it. Review of facility policy titled, Laboratory Services, revised on1/1/12, indicated, Procedure .II. Reporting Laboratory Results .C. The Licensed Nurse promptly notifies the Attending Physician of the laboratory test findings and reports the results according to the following guidelines .ii. Results (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 2 of 3 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 01/30/2024 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 0684 Level of Harm - Minimal harm or potential for actual harm abnormal - Telephone/page Attending Physician and fax to Attending Physician with date and time noted on results .D. The nurse documents the time when laboratory results were reported along with the Attending Physician's response in the resident's medical record . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 3 of 3