Health inspection·February 15, 2024

F 0686 Level of Harm - Actual harm Deep Tissue Injury (DTI): Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying soft tissue. This injury results from intense and/or prolonged pressure at the bone-muscle connection. The wound may evolve rapidly to reveal the actual extent of tissue injury. Residents Affected - Few Reverse staging: The practice of applying a lower stage classification from the pressure injury staging system to describe a wound's appearance as it heals. This practice is discouraged as a healing pressure injury does not fully replace the damaged underlying tissues such as muscle and fat tissues. cm: centimeter (1 centimeter equals approximately 0.394 inches) Findings: Review of Resident 1's record titled Minimum Data Set assessment (MDS: a standardized resident assessment tool), dated 01/05/2024, indicated she was admitted to the facility on [DATE] with multiple diagnoses including: generalized muscle weakness, high blood pressure, difficulty swallowing food or liquids, and urine retention. His MDS indicated he had memory problems and was severely impaired in daily decision making. His MDS indicated he needed extensive assistance with bed mobility and was totally dependent on staff for dressing, eating, toileting and personal hygiene. Review of Resident 1's record titled Skin Only Evaluation, dated 12/28/22, indicated he was admitted with these pressure injuries: 1. Left hip, Stage II, size = 2.5 cm by 2 cm 2. Right hip, Stage I, size = 8 cm by 5 cm 3. Left heel, stage I, irregular size. 4. Right heel, stage I, irregular size Review of Resident 1's record titled Skin Only Evaluation, dated 01/02/2023, indicated reverse staging of Resident 1's left hip pressure injury from stage II to stage I. Review of the same document indicated Resident 1 developed a new pressure injury: a DTI (Deep Tissue Injury) to his left lateral foot. The same document also indicated that Resident 1 had discoloration to his right hip (size = 9 cm by 7 cm) and discoloration to his right mid back (size = 8 cm by 7cm). During a concurrent interview and record review on 01/19/2024 at 2:15 PM, LVN 1 (Licensed Vocational Nurse) stated he had been working as a LVN for three years. LVN 1 stated staff are not allowed to reverse stage pressure injuries. Record review with LVN 1 indicated he was the nurse who assessed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 2 of 5 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 02/15/2024 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 0686 Level of Harm - Actual harm Residents Affected - Few and signed off on 1/2/23 that Resident 1's left hip pressure injury was now a stage I (left hip was previously assessed as a stage II on 12/28/22). LVN 1 offered no explanation regarding why he reverse staged Resident 1's left hip injury from a stage II to a stage I. Review of Resident 1's medical record titled Progress Notes, dated 01/03/2023, indicated he was transferred to a hospital emergency room for evaluation because Resident 1's responsible party was concerned about his increase muscle weakness and his decline in mobility since admission. Review of Resident 1's hospital records titled Careplan Notes, encounter date 01/03/2023, indicated upon admission he had these pressure injuries: 1. Right hip, unstageable pressure injury, size = 6 cm by 7 cm 2. Right back, unstageable pressure injury, size = 7 cm by 8cm 3. Right elbow, unstageable pressure injury, size = 1cm by 1 cm During an interview on 01/19/2024 at 2:15 PM, LVN 1 was shown the assessment discrepancies between his assessments dated 01/02/2023 and the hospital admission skin assessments dated 01/03/2023. Facility assessment 01/02/2023 1. right hip, Discoloration, size = 9 cm by 7 cm 2. right mid back, Discoloration, size =8cm by 7 cm 3. right elbow (no data) Hospital admission assessment, 01/03/2023 1. right hip, unstageable pressure injury, size = 8 cm by 7cm 2. Right back, unstageable pressure injury, size = 7 cm by 8cm 3. Right elbow, unstageable pressure injury, size = 1 cm by 1 cm During an interview on 01/22/2024 at 3:35 PM, Nursing Supervisor (NS) 1 was asked about (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 3 of 5 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 02/15/2024 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 0686 Level of Harm - Actual harm Residents Affected - Few turning/repositioning dependent residents. NS1 stated Definitely some of these residents are not turned every two hours. NS 1 stated she know these residents were not being turned because I watch the CNA (Certified Nursing Assistant). We don't have regular staff. Most of them are agency. So, it's very hard to supervise them. NS1 stated the facility does not have a turning/reposition system in place nor does the facility have a way for supervisors to audit to verify if dependent residents were turned/repositioned according to their needs. During an interview with the Administrator and the Director of Nursing (DON) on 01/23/2024 at 1:50 PM, the DON stated the facility does not document repositioning/turning of residents. The DON stated her expectation of staff was for staff to follow standard practice and she stated standard practice was to turn/reposition dependent residents every two hours. On 02/15/2024, the facility was asked to provide a list of Certified Nursing Assistants (CNA)who cared for Resident 1. The following interviews were with the CNAs who cared for Resident 1. During an interview on 02/16/2024 at 9:23 AM, CNA 1 was asked about her workload from December 2022 to January 2024. CNA 1 stated they were Short staff all the time that's why a lot of people left.There were a lot of .(residents) to take care of. The .(resident) ratio to staff was just ridiculous. You would have people on the schedule and people won't show up. 80% of the time you come in and they were short. They would tell you you got this whole hallway of 25 .(residents). A list of showers and take care of .(residents) and feed .(residents). It was hard to do all they want you to do. With the workload, it was hard to reposition dependent .(residents) on top of that you would have to find help to reposition some of these .(residents). During an interview on 02/16/2024 at 9:49 AM, CNA 2 was asked about her workload from December 2022 to January 2024. CNA 2 stated Staffing is always bad. 80% 95% of the time the staffing is bad. Sometimes we have 14 .(residents) to take care of in the morning.We can't give the right care. CNA 2 was asked to specify what she meant by the right care and CNA 2 stated ADL. CNA 2 was asked if this included turning and repositioning dependent residents and CNA 1 stated Yes sir. During an interview on 02/19/2024 at 8:25 AM, CNA 3 was asked if the unit was short staff from December 2022 to January 2023. CNA stated Yes. we only have 4 CNA on day shift. That's about 15-16 .(residents) per CNA in the morning. We should only have 7-8 (residents) in the morning. CNA 3 was asked if she was able to reposition dependent residents during her shift. CNA 3 stated We cannot, not with the workload we have. The facility was asked to provide facility policies regarding: 1. Turning and repositioning of dependent resident. Specifically, if there was a system in place for turning/repositioning, regarding how these activities are documented, and how direct care givers are supervised/audited to ensure compliance. 2. Staging of pressure injuries. Specifically, differentiating between stage I versus discoloration versus deep tissue injury, differentiating between stage I and stage II. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 4 of 5 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 02/15/2024 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 0686 Level of Harm - Actual harm The facility answered via email on 02/16/2024 that they do not have item 1 (turning and repositioning of dependent residents). Review of item 2 sent by the facility failed to address how staff were expected to differentiate between pressure injuries and other skin issues. Item 2 sent by the facility consisted of : Residents Affected - Few 1. A policy titled SK04 Skin Integrity Management, revised on 10/26/2023 2. A policy titled SK01 Pressure Injury Prevention, revised on 03/30/2023. 3. A policy titled Skin and Wound Management, revised on 01/01/2012 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555034 If continuation sheet Page 5 of 5