Health inspection·July 3, 2025

F 0554 Allow residents to self-administer drugs if determined clinically appropriate. 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 appropriately administer medications when one of 35 sampled residents (Resident 33) was self-administering prescribed oral medications without being appropriately assessed and approved for self-administration. This failure had the potential to place Resident 33 at risk for adverse health reactions like aspiration (choking, the accidental inhalation of food, liquid, or other material into the lungs) from improperly administered medication.Review of Resident 33's admission Record, indicated Resident 33 was readmitted to the facility on [DATE] with diagnoses including thrombosis (a blood clot, usually in the leg, which can cause swelling, pain, and redness), hypertension (high blood pressure) and dysphagia (difficulty swallowing).Review of Resident 33's Minimum Data Set (MDS -a federally mandated resident assessment tool), dated 5/21/25, indicated Resident 33 had a Brief Interview for Mental Status (BIMS, MDS tool that measures resident cognition) score of 15 which reflects intact cognitive function.During an observation on 6/24/25 at 9:05 AM, Resident 33 had an unlabeled transparent medicine cup containing six pills and one capsule placed on the overbed table, with no facility staff or nurses nearby to supervise or observe oral medication administration.During a concurrent observation and interview on 6/24/25 at 9:10 AM, Resident 33 was observed coughing. When Resident 33 was asked about the specific medications found in the overbed table, Resident 33 stated, There are seven here. A couple of them are for high blood pressure and vitamin B12, and expressed uncertainty about the remaining oral medications.During a concurrent observation and interview on 6/24/25 at 9:14 AM in Resident 33's room, License Vocational Nurse (LVN) 1 acknowledged an unlabeled transparent medicine cup containing seven oral medications. The medications were identified as follows: tamsulosin (used to treat signs and symptoms of benign prostatic hyperplasia [BPH, men's urinary problem]), benazepril (used to treat high blood pressure), metoprolol (used to treat high blood pressure and chest pain), and Eliquis (a blood thinner used to treat and prevent blood clots and stroke). LVN 1 expressed uncertainty about the remaining oral medications. When asked about the expectations during medication administration, LVN 1 stated, the expectation is to ensure the resident takes all his medications before leaving the room. During a concurrent interview and record review on 7/2/25 at 9:39 AM with the Assistant Director of Nursing (ADON) 1, Resident 33's electronic health record was reviewed. The record indicated the facility had not conducted an assessment to determine whether Resident 33 was capable and appropriate to self-administer oral medications. There was no physician's order authorizing Resident 33 to self-administer oral medications, and neither a care plan nor interdisciplinary team (IDT) notes indicated Resident 33 can safely self-administer oral medications, despite being observed doing so. When asked about the expectations for licensed nurse during medication administration, the ADON 1 stated, the licensed nurse should watch the resident take all the medication, and should not leave it at bedside before leaving the room.Review of the facility's policy and procedure (P&P), titled, Medication - Self Administration, revised January 1, Residents Affected - Few Page 1 of 26 555034 555034 07/03/2025 San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403

F 0554 2012, indicated, .The Facility will allow a resident to self-administer medications when determined capable to do so by the IDT and the resident's Attending Physician . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 555034 Page 2 of 26 555034 07/03/2025 San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of six sampled residents (Resident 53) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) when the order for Lorazepam (medication used to treat anxiety) PRN (as needed) did not have a stop date.This deficient practice had the potential for Resident 53 to receive unnecessary psychotropic medication, be exposed to adverse health consequences from the medication, which could negatively impact the resident's mental, physical, and psychosocial well-being.Resident 53 was admitted on [DATE] with diagnoses that included cerebral infarction (also known as ischemic stroke, a medical condition where a part of the brain is damaged due to a lack of blood supply), hemiplegia (paralysis on one side of the body) and hemiparesis (condition characterized by weakness on one side of the body). Resident 53 was in hospice care.Review of Resident 53's Order Review History Report for the month of June 2025 indicated, .Lorazepam Oral Tablet 0.5 mg (milligram) Give 1 tablet via G-tube (gastrostomy tube - tube inserted through the belly that brings nutrition, fluids, and medications directly to the stomach when oral intake is insufficient) every 6 hours as needed for restlessness and anxiety.Order Start Date 5/55/25. The order did not have an end date.Review of Resident 53's Medication Administration Record for June 2025 indicated, .Lorazepam Oral Tablet 0.5 mg. was administered on 6/7/25 at 4:46 PM.Review of Resident 53's Consultant Pharmacist's Medication Regimen Review (MRR) dated 6/28/25 indicated, .Patient is currently on PRN (as needed) Lorazepam since 5/15/25.the use of PRN psychotropics should be limited to 14 days in all but rare cases where therapeutic benefit outweighs risk. If patient must continue on the PRN psychotropic medication, the prescriber must clearly document rationale and indicate the duration of time the patient is to be on this PRN medication.During a concurrent interview and record review on 7/2/25 at 10:09 AM, with Licensed Vocational Nurse (LVN) 4, Resident 53's physician orders were reviewed. LVN 4 said Resident 53 had an order for Lorazepam 0.5 mg 1 tablet via G-tube every 6 hours as needed for restlessness and anxiety with a start date of 5/15/25 and indefinite as end date.During a concurrent interview and record review on 7/3/25 at 10:09 AM, with the Consultant Pharmacist (CP), Resident 53's physician orders were reviewed. For psychotropic medications, CP said PRN medications are recommended for 14 days and should be renewed after. CP stated, They haven't changed the order yet. They have to renew the date, not indefinite.During a concurrent interview and record review on 7/3/25 at 1:29 PM, with the Director of Nursing (DON), Resident 53's physician orders were reviewed. The DON acknowledged that there was no end date on Resident 53's order for PRN Lorazepam, and stated, For psychotropic medications ordered PRN, it's good for 14 days, and renewed after physician review. It's more than 14 days.Review of facility policy titled Behavior/Psychoactive Medication Management dated 5/22/25, indicated, .5. Any Psychoactive Medication ordered on an as necessary (prn) basis, must be ordered not to exceed 14 days. If the physician feels the medication needs to be continued, he/she must document the reason(s) for the continued usage and write the order for the medication; not to exceed a 90-day time frame. 555034 Page 3 of 26 555034 07/03/2025 San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the annual Minimum Data Set (MDS, a federally mandated resident assessment tool) assessment was completed within the required period of 14 calendar days from the Assessment Reference Date (ARD, specific endpoint for the look-back periods in the MDS assessment process) for one of 35 sampled residents (Resident 165).Failure to complete a comprehensive resident assessment within the required timeframe could result in delayed identification of needs and significant issues that may affect the physical, mental, and psychosocial well-being of Resident 165.Review of Resident 165's admission record indicated, was admitted to the facility on [DATE]. Review of Resident 165's annual MDS assessment with an ARD of 5/14/25, indicated, the assessment was signed as complete by the Registered Nurse (RN) Assessment Coordinator on 6/2/25, 19 days after the ARD. During a concurrent record review and interview on 7/3/25 at 4:07 PM, the MDS Coordinator (MDSC) reviewed Resident 165's annual MDS assessment with an ARD of 5/14/25 and confirmed the assessment was completed late. The MDSC stated, Resident 165's annual MDS assessment should have been completed and signed on 5/28/25. According to the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.19.1, dated October 2024, indicated, .The OBRA (Omnibus Budget Reconciliation Act of 1987) regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents . The Annual assessment is a comprehensive assessment for a resident that must be completed on an annual basis (at least every 366 days) unless an SCSA (Significant Change in Status Assessment) or an SCPA (Significant Correction to Prior Comprehensive) has been completed since the most recent comprehensive assessment was completed. 14 days after the ARD (ARD + 14 calendar days) . 555034 Page 4 of 26 555034 07/03/2025 San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403

F 0637 Assess the resident when there is a significant change in condition 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 complete a Significant Change in Status Assessment (SCSA - a comprehensive assessment for a resident that must be completed when the IDT has determined that a resident meets the significant change guidelines for either major improvement or decline) for one of one sampled resident (Resident 53) when Resident 53 was admitted for hospice services.This failure could potentially delay the provision of appropriate treatment and services for Resident 53.Resident 53 was admitted on [DATE] with diagnoses that included cerebral infarction (also known as ischemic stroke, a medical condition where a part of the brain is damaged due to a lack of blood supply), hemiplegia (paralysis on one side of the body), and hemiparesis (condition characterized by weakness on one side of the body).During a concurrent interview and record review on 7/2/25 at 9:48 AM, with the MDS Coordinator (MDSC), Resident 53's Minimum Data Set (MDS - a resident assessment tool) with Assessment Reference Date (ARD - specific endpoint for the look-back periods in the MDS assessment process) of 1/10/25 was reviewed. MDSC confirmed that Resident 53 was admitted for hospice care on 12/23/24. According to the MDSC, a significant change assessment in the MDS was required to be completed 14 days after Resident 53 was admitted to hospice care. MDSC stated, It's late because it's not within the 14 days. We didn't know patient was on hospice.Review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated October 2024, indicated, .The OBRA (Omnibus Budget Reconciliation Act of 1987) regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents . An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election.This is to ensure a coordinated plan of care between the hospice and nursing is in place. Residents Affected - Few 555034 Page 5 of 26 555034 07/03/2025 San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure safe medication administration for one of five residents (Resident 182) when Licensed Vocational Nurse (LVN) 1 did not observe Resident 182 take his medication after leaving one prescription medication on the overbed table with the presence of an ambulatory roommate. The deficient practice resulted in a medication error for Resident 182; and may result in medication error and/or adverse health reactions when taken by the roommate. During medication pass observation on 7/2/25 at 9:20 AM, LVN 1 prepared fifteen (15) medications for Resident 182 including ClearLax Polyethylene Glycol 3350 Powder for Solution (used to treat occasional constipation). LVN 1 filled the measuring cap (purple bottle cap/cover) up to the rim which was above the 17 grams (g) mark (or line) and poured it in a cup with seven (7) ounces of water. During concurrent interview, LVN 1 was not aware of the 17 g mark/line inside the cap and stated that 17 g of the ClearLax was measured up to the rim of the cap. Review of Resident 182's Order Review History Report for 6/1/25 to 6/30/25 indicated, an order to administer Polyethylene Glycol Powder Give 17 gram by mouth one time a day for constipation mix with 4-8 oz (ounces) of water. Review of the product label and manufacturer's directions for ClearLax Polyethylene Glycol 3350 Powder for Solution Osmotic Laxative, indicated, Directions ?do not take more than directed unless advised by your doctor ? the bottle top is a measuring cap marked to contain 17 grams of powder when filled to the indicated line (white section in cap). fill to top of white section in cap which is marked to indicate the correct dose (17 g). During the administration of medication, Resident 182 took a few sips of the ClearLax then placed the cup on the overbed table in front of him. On 7/2/25 at 9:54 AM, LVN 1 administered the last medication and left Resident 182 with the ClearLax mixture on the overbed table. Resident 182's roommate was observed walking inside the room. During an observation on 7/2/25 at 10:04 AM, Resident 182 left the room to go to therapy with the ClearLax mixture left on the overbed table with the roommate present in the room. During a follow-up interview on 7/2/25 at 10:05 AM, LVN 1 acknowledged she left the ClearLax in Resident 182's overbed table and stated, she needs to observe the resident take the medications. During concurrent observation, LVN 1 took the ClearLax mixture from the overbed table and discarded it. During an interview on 7/2/25 at 2:58 PM, the Director of Nursing (DON) stated the nurse should check and observe if all medications were taken by the resident. The DON also stated the nurse was not supposed to leave the medication at the bedside. Residents Affected - Few 555034 Page 6 of 26 555034 07/03/2025 San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe environment free from potentially serious accident hazards for all residents when its policies and procedures were not implemented for the following practices:1. The facility failed to ensure hot water in 6 of 8 residents' bathroom sinks were at a comfortable and safe temperature level.This deficient practice placed the residents (Residents 165, 187, and 259) at increased risk for scalding.An Immediate Jeopardy (IJ, a situation in which the provider's non-compliance with one or more requirements of participation has caused or is likely to cause serious injury, harm, impairment, or death to a resident) was declared at the [NAME] campus on 6/23/25 at 5:27 PM in the presence of the Administrator, Director of Nursing (DON), Regional Quality Management Consultants (RQMC), Assistant Chief Clinical Officer (ACCO), and [NAME] President of Operations (VPO) for the following deficient practice:Hot water temperatures were found to be between 121.6 F to 136.7 F in 6 of 8 sample rooms as evidenced by:a. room [ROOM NUMBER] = 132.2 Fb. room [ROOM NUMBER] = 136.0 Fc. room [ROOM NUMBER] = 136.7 Fd. room [ROOM NUMBER] = 121.6 Fe. room [ROOM NUMBER] = 131.9 Ff. room [ROOM NUMBER] = 130.5 F.On 6/24/25 at 10:38 AM, the facility submitted an unacceptable IJ Removal Plan (action to correct the deficient practices).On 6/24/25 at 2:36 PM, the facility submitted an unacceptable IJ Removal Plan #2.On 6/24/25 at 4:23 PM, the facility submitted an acceptable IJ Removal Plan #3.On 6/25/25 at 2:43 PM, the IJ was removed after the survey team validated onsite the IJ Removal Plan was implemented through observation, interview, and record review.2a. The facility failed to ensure safe smoking practices were followed when Resident 208 ignited her lighter inside the room while roommate (Resident 195) was actively receiving continuous supplemental oxygen.2b. The facility failed to implement their smoking policy and procedures (P&P) when it allowed five (5) of 14 residents (Resident 208, Resident 2, Resident 138, Resident 139, and Resident 81) who smoked in the facility to keep in possession of their own lighters and cigarettes inside the resident care area.These deficient practices posed an increased risk for combustion and/or fire, serious injury and/or death to residents, staff, and visitors.On 6/26/25 at 5:10 PM, an IJ was declared at the [NAME] campus in the presence of the Administrator, DON, RQMC, ACCO, and VPO for the following deficient practices:a. Without being prompted, Resident 208 ignited her lighter in the room while roommate (Resident 195) was actively receiving continuous oxygen at 2L(liters)/minute via nasal cannula. In addition, Resident 208 was in possession of three lighters and one opened pack of cigarettes.b. Resident and Staff interviews indicated, Resident 2, Resident 138, Resident 139, and Resident 81 were in possession of their own lighters and cigarettes.c. The facility failed to implement its smoking policy when it allowed Residents to keep in possession of their own lighters and cigarettes.On 6/27/25 at 11:13 AM, the facility submitted an unacceptable IJ Removal Plan.On 6/27/25 at 2:04 PM, the facility submitted an acceptable IJ Removal Plan #2.On 6/27/25 at 4:10 PM, the IJ was removed after the survey team reviewed and verified onsite the implementation of the IJ Removal Plan through observation, interview, and record review.3. The facility failed to ensure that one out of two sampled residents (Resident 898) receive adequate supervision to prevent elopement. This deficient practice resulted in Resident 898 eloping on 6/17/25 and putting Resident 898 at risk for serious injury or death.4. The facility failed to consistently implement effective interventions to prevent Resident 234 from elopement. This deficient practice resulted in Resident 234 eloping on 06/15/2025 and putting Resident 234 at risk for serious injury or death. Findings: 1. During an initial tour observation on 6/23/25 at 11:43 AM, in Residents' 195 and 208's room, while hand was held under running water in the bathroom sink faucet with hot and cold handles, the hot water was 555034 Page 7 of 26 555034 07/03/2025 San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403

F 0689 hot to touch. The bathroom was shared with Residents 1 and 214. Level of Harm - Immediate jeopardy to resident health or safety During an initial tour observation on 6/23/25 at 11:57 AM, in Residents' 165 and 187's room, while hand was held under running water in the bathroom sink faucet with hot and cold handles, the hot water was hot to touch. Residents Affected - Some During an initial tour observation on 6/23/25 at 1:05 PM, in Residents' 271 and 188's room, while hand was held under running water in the bathroom sink faucet with hot and cold handles, the hot water was hot to touch. The bathroom was shared with Resident 151. Resident 165 was admitted on [DATE] with diagnoses that included schizoaffective disorder (a mental health condition characterized by a combination of symptoms like hallucinations and delusions and mood disorder symptoms like depression or mania), cataract (a medical condition in which the lens of the eye becomes progressively opaque resulting in blurred vision), and glaucoma (a condition on increased pressure within the eyeball, causing gradual loss of sight). Resident 165's Minimum Data Set (MDS - an assessment tool), dated 5/14/25 indicated, vision and cognition were severely impaired. Resident 165's care plan for activities of daily living (ADL) indicated, .Date Initiated: 3/30/22 .Toilet Use: The resident is able to: ambulate to the bathroom (BR) on her own familiar to the location of the BR in her room and back . Resident 187 was admitted on [DATE] with diagnoses that included dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), peripheral vascular disease (PVD - a slow and progressive circulation disorder affecting blood vessels in the arms and legs), and cognitive communication deficit (difficulties in communication arising from impairments in cognitive processes, rather than primary language or speech problems). Resident 187's MDS dated [DATE] indicated, cognition was moderately impaired, and resident can walk independently. Resident 187's ADL care plan indicated, .Toilet Use: The resident is able to transfer self to the BR .Revised on: 8/29/24 . Resident 259 was admitted on [DATE] with diagnoses that included cognitive communication deficit, Alzheimer's disease (a progressive brain disorder that gradually destroys memory and thinking skills, ultimately impacting the ability to carry out even simple tasks), and type 2 diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy). Resident 259's MDS dated [DATE] indicated, impaired vision, moderate cognitive impairment, can walk independently, and independent with ADLs. During an observation on 6/23/25 at 3:40 PM, with the MS, the hot water in the residents' bathroom sink faucet was turned on and ran for 10-15 seconds, then MS tested the hot water using the facility's thermometer. The hot water temperature for each of the following residents' rooms were room [ROOM NUMBER] = 132.2 °F, room [ROOM NUMBER] = 136.0 °F, room [ROOM NUMBER] = 136.7 °F, room [ROOM NUMBER] = 121.6 °F, room [ROOM NUMBER] = 131.9 °F, and room [ROOM NUMBER] = 130.5 °F. During an interview on 6/23/25 at 4:00 PM, the MS said that random bathroom water temperature check was done each day. MS stated, Anything over 120 °F is too hot. Review of facility's undated policy titled Water Temperatures indicated, .The Facility ensures water is maintained at temperatures suitable to meet residents' needs. Tap water in the Facility is maintained within a temperature range to prevent scalding of residents. Procedure: I. Water heaters that 555034 Page 8 of 26 555034 07/03/2025 San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some service resident rooms, bathrooms, common areas, and tub/shower areas are set to temperatures of no more than 120 °F (49 °C) . 2a. The list of smokers provided by the facility dated 6/23/25 indicated, there were 14 residents who smoke in the facility (Resident 208, 2, 138, 139, 81, 116, 57, 140, 5, 241, 263, 285, 58, and 182). During an observation on 6/26/25 at 10:27 AM, a “No Smoking Oxygen In Use sign was posted by the door of Resident 208 and Resident 195’s room. Resident 208’s roommate (Resident 195) was observed lying in bed receiving oxygen at two (2) liters per minute via a nasal cannula (NC, thin flexible tube with small prongs inserted into the nostrils). During an interview on 6/26/25 at 10:28 AM, Resident 208 stated the facility allowed her to smoke in the designated smoking area with staff supervision during smoking hours. When asked where she keeps her smoking materials, Resident 208 stated, “15 cigarettes are in the locked box in the utility room. [Staff Name] from Activities keeps them. But I keep [five] 5 cigarettes with me.” Resident 208 added, “I have a collector’s item lighter that I keep.” During concurrent observation and interview on 6/26/25 at 10:32 AM, in Resident 208’s room, without being prompted, Resident 208 opened the left bedside drawer and took out two (2) objects. Resident 208 showed a brown, pen shaped object with a skull design on one end and a silver, square shaped object with engraved letters on one side. Resident 208 identified the two objects as lighters and stated that she keeps these “two collector’s item lighters” in her possession. After showing the two lighters, Resident 208 suddenly removed the skull shaped part and without being prompted, ignited the lighter which sparked and produced a small yellow/orange flame. Furthermore, Resident 208’s roommate (Resident 195) was on the other bed actively receiving oxygen at 2 liters per minute via a nasal cannula. Review of Resident 195’s “Order Review History Report” for 6/1/25 to 6/30/25, indicated an order to administer “Oxygen 2L/min (liters per minute) via NC continuous to keep O2 Sat (oxygen saturation, amount of oxygen that’s circulating the blood) at/above 92 % (percent, a unit of proportion) for low oxygen every shift related to chronic respiratory failure (occurs when the lungs can't adequately oxygenate the blood or remove carbon dioxide, leading to long-term breathing difficulties) with hypoxia (low levels of oxygen in your body tissues). During a follow up interview on 6/26/25 at 10:42 AM, Resident 208 stated that she was informed of the “rules for smoking” six months ago. During an observation on 6/26/25 at 10:46 AM, in resident’s room, Resident 208 showed the brown and silver colored (collector’s item) lighters and without being prompted, Resident 208 ignited again the pen shaped lighter which immediately sparked. Further observation and interview on 6/26/25 at 10:48 AM, in Resident 208’s room, Resident 208 stated that she keeps some cigarettes and a disposable lighter in her possession because staff are not available at times to provide their smoking materials. During concurrent observation, Resident 208 took something out from the side of her wheelchair next to her bed and showed an opened cigarette pack. Resident 208 then opened the cigarette pack and showed the contents which included a few cigarettes sticks and a pink disposable lighter that had the last four letters of Resident 208’s name. 555034 Page 9 of 26 555034 07/03/2025 San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Review of Resident 208’s admission record indicated, was admitted on [DATE] with diagnoses including nicotine dependence (an addiction to tobacco products caused by the drug nicotine), mild cognitive impairment (a condition in which people have more memory or thinking problems than other people their age), fracture of unspecified part of neck of right femur (refers to a broken bone in the neck of the right thigh bone, where the exact location of the fracture within the neck is not specified), presence of left artificial hip joint (indicates a hip replacement surgery where the damaged or diseased parts of the left hip joint have been replaced with artificial components, typically made of metal, ceramic, and/or plastic), and muscle weakness. Review of Resident 208's Minimum Data Set (MDS, a federally mandated resident assessment tool) assessment, dated 5/26/25, indicated no cognitive impairment. Under the Active Diagnoses section of the MDS assessment indicated, Resident 208’s active diagnoses included nicotine dependence, psychotic disorder (a group of serious mental illnesses characterized by psychosis, a condition where a person has difficulty distinguishing between what is real and what is not), and mild cognitive impairment. Review of Resident 208’s “Smoking and Safety” assessment dated [DATE], indicated, “Resident is not consistent with following smoking times. Spoke with resident again and reiterated rules and regulations of smoking protocol.” Resident 208’s “Smoking and Safety” assessment did not indicate Resident 208 was safe to have smoking materials in her possession. Furthermore, the assessment did not address the “Smoking Care Planning” section. Review of Resident 208’s smoking care plan revised on 12/2/24 indicated, individualized plan for safe use and storage of smoking materials was not addressed. Further review of Resident 208’s clinical record indicated, Resident 208 acknowledged and signed a copy of the facility’s “Smoking Policy” on 3/5/25. Review of the facility’s policy and procedures titled “Oxygen Therapy”, revised 11/2017, indicated, “Oxygen is administered under safe and sanitary conditions to meet resident needs … II. A. No smoking signs will be prominently displayed wherever oxygen is being stored or administered. B. Smoking is not allowed near where the oxygen is being stored or administered …” 2b. During an observation on 6/26/25 at 11:40 AM, in Resident 548 and Resident 2’s room, CNA 4 was attending to Resident 548 who was sitting on the bed receiving oxygen at 2 L/min via a nasal cannula. Resident 548’s roommate (Resident 2) was not in bed. During further observation, Resident 2 had an oxygen concentrator attached to an oxygen tubing next to her bed. During an interview on 6/26/25 at 11:41 AM, CNA 4 stated Resident 2 was out for an appointment and confirmed that Resident 2 uses the oxygen concentrator next to her bed whenever she’s in bed/room. CNA 4 also confirmed Resident 2 was an active smoker in the facility. CNA 4 stated that Resident 2 usually goes out to smoke with supervision and always keeps her smoking materials in her pocket. Review of Resident 548’s Order Review History Report for 6/1/25 to 6/30/25, indicated an order to administer Oxygen at 2L/min via nasal cannula to keep O2 Sat at/above 92% continuous for COPD (Chronic Obstructive Pulmonary Disease, a group of lung diseases that block airflow and make it difficult to breathe) / CHF (Congestive Heart Failure, a chronic condition in which the heart doesn't pump blood as well as it should). 555034 Page 10 of 26 555034 07/03/2025 San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Review of Resident 2’s admission record indicated, was admitted on [DATE] with diagnoses including asthma (a chronic respiratory disease that affects the airways in the lungs, causing them to become inflamed and narrowed, making it difficult to breath), heart failure, and seizure disorder (abnormal electrical activity in your brain). Review of Resident 2’s Order Review History Report for 6/1/25 to 6/30/25, indicated an order to administer Oxygen at 2L/min via nasal cannula for mild SOB (shortness of breath) as needed. During concurrent observation and interview on 6/26/25 at 11:43 AM, Resident 81 was lying in bed, alert and oriented. Resident 81 stated he smokes in front of the building and keeps his cigarettes and lighter with him in the room. Resident 81 further stated, “I don’t give it to the nurse. I want it with me. It’s easier.” During an observation on 6/26/25 at 11:44 AM, Resident 138 was sitting in his wheelchair outside his room watching on a computer tablet. Resident 138 agreed for interview and went inside his room. During concurrent observation and interview at 11:45 AM, in the resident’s room, Resident 138’s bedside (top) drawer was unlocked and slightly opened. Resident 138 stated he keeps the lighter and cigarettes in his possession and was saying, “here, there”, while pointing to his pocket and to the unlocked bedside (top) drawer. Resident 138 refused to open and check the bedside drawer. During an interview on 6/26/25 at 11:47 AM, Certified Nursing Assistant (CNA) 3 stated, Resident 138 had a lighter and cigarettes kept in his pocket and bedside drawer. CNA 3 also stated that residents’ smoking materials were stored in the Activities Department. CNA 3 further stated that residents should not keep smoking materials in the room for safety reasons. During an interview on 6/26/25 at 11:48 AM, CNA 5 stated, residents should not keep cigarettes or lighters in their rooms and that she would report to the nurse immediately when she finds them in a resident’s room. During an interview on 6/26/25 at 11:54 AM, Resident 139 stated she smokes and vapes occasionally, and that she keeps her cigarettes and lighter in her fanny pack at all times. Resident 139 also stated, she is aware of the facility’s smoking policy which includes safe storage of smoking materials. Review of the facility’s undated “Smoking Policy” acknowledgement form indicated, “… 8. All residents that smoke will have their smoking materials (lighter, cigarettes, e-cigs [electronic cigarettes], etc.) kept in a safe place at Nursing Stations . 10. No resident is allowed to keep any smoking materials in their room . 14. Residents whether it is traditional tobacco cigarettes, pipes, cigars, or electronic (e-cigarettes) cigarettes are governed by this policy.” 3. During an interview on 07/02/2025 at 1:13 PM, with the Administrator, stated Resident 898 was found approximately 3 to 4 hours after Resident 898 was found missing from the facility on 06/17/2025 at 5:15 PM. Code Purple alarm was activated at the facility when Resident 898 was discovered to be missing, which involved an announcement of Code Purple through the overhead paging system (a system that allows a person to speak into a microphone and have their voice broadcast through speakers located throughout the facility). The facility defines Code Purple to mean a resident left the facility 555034 Page 11 of 26 555034 07/03/2025 San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some without the expectation for leaving the facility or supervision.During an interview on 07/02/2025 at 1:31 PM with the Director of Staff Development (DSD), Resident 898 had exit seeking behavior in the past.During an interview on 07/02/2025 at 2:18 PM with the Director of Nursing (DON), Resident 898 had a wander guard (a special bracelet worn by residents at risk for wandering and elopement, that alerts facility staff when resident leaves a safe area defined by the facility) in place prior to the elopement. During concurrent observation and interview on 07/02/2025 at 10:09 AM with Resident 898, Resident 898 was unable to remember the elopement. Resident 898 was also unable to correctly state the day of the week or current city. Resident 898 had difficulty stating names of siblings. Resident 898 was wearing both an identification wrist band on the right wrist and a wander guard wrist band on the left wrist. During a review of Progress Note entitled Communication with Physician and dated 06/17/2025 at 18:26 for Resident 898, the situation described was, Resident eloped from the facility. The background described is, Resident has a history of elopement and wandering. A recommendation that was made was, Send resident to [emergency room] ER if or when he returns to the facility to be evaluated.During an interview on 07/03/25 at 10:54 AM with the DON, Resident 898 was admitted to the facility on [DATE] for dementia and worsening mental status. Resident 898 was evaluated for elopement risk on 06/02/2025 and was determined to be at risk for elopement with a score of 6 out of 10. Resident 898 was evaluated again for elopement risk on 06/17/2025 and was determined to be at risk for elopement with a score of 6 out of 10, with no change in the elopement risk score. The higher the elopement risk score the higher the risk for elopement. The DON stated the facility has cameras in the hallway, but the facility was unable to identify Resident 898 on any of the camera recordings on the day of the elopement 06/17/2025. During a record review of Elopement Evaluations dated 06/02/2025 and 06/17/2025 did not reveal a specific total score for each evaluation. Both documents note, Score value of 1 or higher indicates Risk of Elopement. Elopement Evaluation for 06/02/2025 at 21:26 has 6 marked questions as yes answers from a total of 10 questions. Elopement Evaluation for 06/17/2025 at 17:40 has 3 marked questions yes answers from a total of 10 questions. The questions answered yes for the Elopement Evaluation for 06/02/2025 include the following: Does the Resident have a history of elopement or an attempted elopement while at home; Does the resident have a history of elopement or attempted leaving the facility without informing staff; Has the Resident verbally expressed the desire to go home, packed belongings to go home or stayed near an exit door; Does the Resident wander?; Is the wandering behavior a pattern, goal-directed (i.e. specific destination in mind, going home etc.; and, Is the Resident's wandering behavior likely to affect the safety or well-being of self/others. The questions answered yes for the Elopement Evaluation for 06/17/2025 include the following: Does the resident have a history of elopement or attempted leaving the facility without informing staff; Does the Resident wander?; and, Is the wandering behavior a pattern, goal-directed (i.e. specific destination in mind, going home etc.). During a record review of the Medication Administration Record (MAR) for June 2025 shows 3 separate orders for, Check placement of wander guard . with different stop and start dates. The order to Check placement of wander guard every shift is it in place, Yes or No? with start date of 06/10/2025 to 06/12/2025 is marked as completed for 2 days in June, 06/10/2025 and 06/11/2025. The order to, Check placement of wander guard on left wrist every shift is it in place, Yes or No? with start date of 06/14/2025 and no stop date is marked as completed for Day, Evening, and Night shifts from 06/15/2025 to 06/30/2025, and marked as completed for Evening and Night shift for 06/14/2025. The order to, Check placement of wander guard every shift for wanderer is it in place, Yes or No? with start date 06/02/2025 and end date of 06/10/2025 is marked completed for Day, Evening, and Night shifts for 06/03/2025 to 06/09/2025 and marked completed for Night 555034 Page 12 of 26 555034 07/03/2025 San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some shift only for 06/02/2025. During an interview on 07/03/25 at 1:38 PM with ADON 2, Resident 898's reason for admission to the facility was because Resident 898's caregiver was in the hospital. Resident 898 was found wandering around the vicinity of the caregiver's hospital and identified by police. Resident 898 was evaluated by Hospital 1 and later transferred to the facility for care, while Resident 898's caregiver was hospitalized and unable to care for Resident 898. During a record review of Discharge Summary from CPMC Mission [NAME] Campus dated 06/02/2025, Resident 898's principal problem is AMS (altered mental status) with active problems including, wandering behavior due to dementia, schizophrenia. During a record review of Physical History and Physical (H&P) dated 06/02/2025, the main reason Resident 898 had been admitted to Hospital 1 for 8 days, from 05/25/25 to 06/02/25, was because of AMS and family is unable to care for Resident 898.During a record review of Progress Note dated 06/17/2025 at 10:56 PM, Resident 898 was returned to the facility by [NAME] Police Department and there was no mention of injuries or where Resident 898 had been found. Pickup of Resident 898 was requested by Royal Ambulance. Resident 898 was picked up from the facility at 10:50 PM and taken to a Hospital 2 for evaluation. During a record review of Care Plan Report with no date, notes one of Resident 898's care plan focuses is an elopement risk/wanderer r/t [related to] Impaired safety awareness, cognitive impairment, history of elopement initiated on 06/03/2025 by ADON 2.During a record review of facility procedure entitled P-AP17 Wandering and Elopement and with revision date 01/31/2023, defines elopement as a behavior that may lead to the resident leaving the facility unsupervised and/or without permission. The procedure notes that if Facility Staff observes a resident leaving the premises unaccompanied or without having followed proper procedures, he/she may: a. Try to prevent the departure in a courteous manner. b. Get help from other Facility Staff in the immediate vicinity, if necessary. c. If the resident exits the facility despite efforts to stop the resident, a staff member will accompany or follow the resident to ensure the resident's safety until assistance arrives. 4. Review of Resident 234's records, titled RESIDENT INFORMATION, printed on 07/01/2025, indicated she had multiple diagnoses including: alcohol abuse (an impaired ability to stop/control alcohol use despite adverse consequences), .alcohol -induced persisting amnestic disorder (severe memory loss associated with chronic alcohol abuse), abnormal walking pattern, anxiety disorder (a mental disorder associated with excessive worry, fear, or nervousness that interferes with daily life), delusional disorder (a mental disorder when one cannot tell what is real from what is imaginary), and history of falls. During an interview on 07/01/2025 at 11:40 AM, CNA 1 stated she has cared for Resident 234 for 2-3 years. CNA 1 stated Resident 234 was very .forgetful, she is always trying to find her husband, constantly asking staff how to get a hold of her husband. She doesn't remember her husband passed away two years ago. CNA 1 stated Resident 234 has a history of trying to get out (elope). To keep her from elopement, CNA 1 stated she tries to distract (Resident 234) to activity (and Resident 234) wears a wanderguard. Wanderguard: a bracelet type device that activates an audible alarm when a resident is approaching an exit. Review of Resident 234's record titled Elopement, dated 07/10/2024, indicated Resident 234 eloped from the facility At .(1:15 PM, nurses were) alerted by staff that .(Resident 234) was seen exiting the facility .staff did a search of the facility and unable to locate her.[NAME] .(police department was) . contacted and a missing persons report filed. The document indicated Resident 234 was found 2 hours and 35 minutes later approximately 1 mile away from the facility. During a concurrent interview and record review on 06/26/2025 at 10:18 AM with LVN 1, review of the facility's daily log communication between shifts on the facility's computer (not titled), indicated Resident 234 Eloped on 06/15 at around 7:30 pm, went out on the street. LVN 1 was asked to search Resident 234's record for any documentation regarding this elopement. LVN 1 was unable 555034 Page 13 of 26 555034 07/03/2025 San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some to find any documentation in Resident 234's medical records regarding this elopement. During an interview on 07/02/2025 at 10:09 AM, CNA 2 stated Resident 234 was a high elopement risk because she .wanders around the facility she very active . We really need to keep an eye on her. she always says I need to go home. Things like that. We always keep an eye on her. CNA 2 stated on 06/15/2025, she does not . remember the exact time around break time so I was at the break room eating .(when)one of my co-workers called me that she saw .(Resident 234) outside so I ran out of the break room .ran out of the building .and we saw.(Resident 234) across . the road . On 07/01/2025 at 3:20 PM, the Registered Nurse Supervisor (RNS1) and the Director of Nursing (DON) were interviewed regarding Resident 234's elopement on 06/15/2025. The RNS 1 and the DON searched Resident 234's records and confirmed there was no documentation regarding the elopement. The DON stated her expectations were staff would initiate a change of condition charting, notify the responsible party, physician, ombudsman and CDPH (California Department of Public Health). The DON stated she expected staff to conduct an investigation to identify potential weakness in the facility's so the facility could put interventions in place to prevent Resident 234 from elopement. Review of the facility's policy titled Wandering and Elopement, Revised on 01/31/2023, indicate .Elopement - A behavior that may lead to the resident leaving the facility unsupervised and/or without permission. When the resident who eloped returns to the Facility, the Licensed Nurse should: i. Assess the resident for possible injuries, changes of condition and vital signs. ii. Notify the Attending Physician of the return of the resident and the result of the exam; and iii. Notify the resident's responsible party of the return of the resident and the result of the exam. iv. Upon return the Licensed Nurse will implement immediate interventions to prevent further elopement of the resident and update the plan of care. b. The Interdisciplinary Team as part of the investigation will conduct a post elopement meeting to determine if alternate prevention measures can be put in place (activities, rehab, etc.) and if necessary, determine if the resident can safely remain in the facility. c. If the resident cannot be safely kept in the facility the Interdisciplinary team will discuss with the physician and responsible party/surrogate decision maker, the transfer of the resident to a safe environment. 555034 Page 14 of 26 555034 07/03/2025 San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure care and services were provided to one of three sampled residents (Resident 14) who had an indwelling urinary catheter, by failing to consistently monitor for catheter kinks.This deficient practice had the potential for Resident 14 to develop urinary tract infection.Definition of Terms:The MedicineNet Medical Dictionary define indwelling Foley catheter as a flexible plastic tube (a catheter) inserted into the bladder that remains ( dwells) there to provide continuous urinary drainageUrinary Tract Infection (UTI) - an infection in any part of the urinary system -the kidneys, ureters, bladder, and urethraCatheter-Associated Urinary Tract Infection (CAUTI) occurs when germs enter the urinary tract through a urinary catheter and cause infectionDuring an observation on 6/23/25 at 10:13 AM, Resident 14 was in bed, with a Foley catheter attached to a collecting bag. Light yellowish urine was noted on the tubing, not draining to the collecting bag.During a follow-up observation on 6/30/25 at 2:55 PM, Resident 14 was in bed, with a Foley catheter attached to a collecting bag. Light yellowish urine was noted on the tubing, not draining to the collecting bag.During a follow-up observation on 7/1/25 at 11:30 AM, Resident 14 was in bed, with a Foley catheter attached to a collecting bag. Light yellowish urine was noted on the tubing, not draining to the collecting bag.During a concurrent observation and interview on 7/2/25 at 1:41 PM, with Licensed Vocational Nurse (LVN) 3, LVN 3 acknowledged that on the tubing connected to the Foley catheter, light yellowish urine was not draining to the collecting bag. LVN 3 checked Resident 14's Foley catheter, and stated, It's kinked. LVN 3 further stated, Bladder could be distended and rupture, and could result to UTI because bacteria is not eliminated, as possible risks associated with catheter kinking.During an interview on 7/2/25 at 2:15 PM, with Certified Nursing Assistant (CNA) 6, as part of Resident 14's urinary catheter care, CNA 6 empties the collecting bag and regularly checks the catheter for kinks and leaks, at start of shift, before/after lunch, and before end of shift. For urine in tubing not flowing to the collecting bag, CNA 6 stated, It is important to report (to Licensed Nurse) because it is dangerous. Urine might flow back and may cause infection.Resident 14 was admitted on [DATE] with diagnoses that included obstructive uropathy (a disorder of the urinary tract that occurs due to obstructed urinary flow), benign prostatic hyperplasia (BPH - a condition in which the prostate gland, located below the bladder in men, enlarges and can interfere with urination), UTI, and infection and inflammatory reaction due to indwelling urethral catheter (tube that lets urine leave your body).Review of Resident 14's Minimum Data Set (MDS - an assessment tool) dated 6/20/25 indicated, Resident 14 had moderately impaired cognition, was dependent on toileting hygiene, with indwelling catheter, and bowel incontinence.Review of Resident 14's electronic health record indicated, Resident 14 was hospitalized from [DATE] to 6/13/25 with diagnosis of septic shock (a widespread infection causing organ failure and dangerously low blood pressure) secondary to CAUTI.Review of facility policy titled Indwelling Catheter revised on 9/1/14, indicated, .Procedure.II. Drainage. B. The catheter and collecting tube will be kept free from kinking.According to the Centers for Disease Control and Prevention (CDC), The most important risk factor for developing a CAUTI is prolonged use of a urinary catheter.Patients should not twist or kink the catheter tubing. Proper techniques for urinary catheter maintenance.Maintain unobstructed urine flow. Keep the catheter and collecting tube free from kinking. [https://www.cdc.gov/infection-control/hcp/cauti/summary-of-recommendations.html] accessed 7/16/25. 555034 Page 15 of 26 555034 07/03/2025 San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403

F 0756 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the consultant pharmacist's (CP) recommendation for the use of psychotropic medication was acted upon for one of six sampled residents (Resident 53).This failure had the potential for Resident 53 to receive unnecessary psychotropic medication, be exposed to adverse health consequences from the medication, which could negatively impact the resident's mental, physical, and psychosocial well-being.Resident 53 was admitted on [DATE] with diagnoses that included cerebral infarction (also known as ischemic stroke, a medical condition where a part of the brain is damaged due to a lack of blood supply), hemiplegia (paralysis on one side of the body) and hemiparesis (condition characterized by weakness on one side of the body). Resident 53 was in hospice care.Review of Resident 53's Order Review History Report for the month of June 2025 indicated, .Lorazepam (medication used to treat anxiety) Oral Tablet 0.5 mg (milligram) Give 1 tablet via G-tube (gastrostomy tube - tube inserted through the belly that brings nutrition, fluids, and medications directly to the stomach when oral intake is insufficient) every 6 hours as needed for restlessness and anxiety.Order Start Date 5/15/25.Review of Resident 53's Consultant Pharmacist's Medication Regimen Review (MRR) dated 6/28/25 indicated, .Patient is currently on PRN (as needed) Lorazepam since 5/15/25.the use of PRN psychotropics should be limited to 14 days in all but rare cases where therapeutic benefit outweighs risk. If patient must continue on the PRN psychotropic medication, the prescriber must clearly document rationale and indicate the duration of time the patient is to be on this PRN medication.During a concurrent interview and record review on 7/2/25 at 10:09 AM, with Licensed Vocational Nurse (LVN) 4, Resident 53's physician orders were reviewed. LVN 4 said Resident 53 had an order for Lorazepam 0.5 mg 1 tablet via G-tube every 6 hours as needed for restlessness and anxiety with a start date of 5/15/25 and an end date of indefinite.During an interview on 7/3/25 at 10:09 AM, the CP said, MRR is done monthly, and all medications are reviewed. Identified irregularities are communicated to the nurse and the physician. CP acknowledged that there was no response from the physician, for recommendation in Resident 53's MRR on 6/28/25.During an interview on 7/3/25 at 1:29 PM, with the Director of Nursing (DON), the DON said, identified irregularities in the MRR are communicated by the nursing staff to the physician for review. The DON stated, For psychotropic medications ordered PRN, it's good for 14 days, and renewed after physician review. 555034 Page 16 of 26 555034 07/03/2025 San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were met for food storage in the kitchen when:1. Diced peaches sat in a partially opened container in the refrigerator.2. A large cut of beef was inside a sealed clear plastic package with no expiration date in the freezer.3. Chocolate puddings were prepared in not fully dried small wet bowls.4. There were an expired container of liquid smoked sauce and brisk coffee roasters in a small bin found in the dry storage.5. Food distribution to the residents were delivered in a timely manner.These failures had the potential to result in putting residents at risk for foodborne illness (a disease caused by consuming contaminated food or drink).1. During a concurrent observation and interview on 6/30/25 at 2:24 PM with Dietary Manager (DM) 1 in the kitchen, diced peaches sat in a partially opened container in a refrigerator. DM 1 stated, I don't know when asked why the lid of the container was open. DM 1 stated, It should be closed when asked what to do with the lid of the container. During a concurrent observation and interview on 6/30/25 at 2:45 PM with Registered Dietitian (RD) 1, RD 1 stated, Limited contamination issue when asked about the risk of the diced peaches in the partially opened container in the refrigerator while watching the pictures of them. RD 1 stated, The lid should be closed when asked about the lid of the container. During a concurrent interview and record review on 6/30/25 at 4:08 PM with RD 1, the facility's policy and procedure (P&P) titled, Food Storage and Handling revised on 2/29/24 was reviewed. The P&P indicated, . 13. Dry Storage Area . g. Place opened products in storage containers with tight fitting lids . RD 1 stated, they are following this practice for all food storage including refrigerators in the kitchen when asked. RD 1 stated, the lid of the container did not fit well, and that's why the lid was open. RD 1 stated, she would replace the container with the new container. During an Interview on 7/03/25 at 11:08 AM with Infection Preventionist (IP) 1, IP 1 stated, It should be sealed when asked about the risk of the diced peaches in the partially opened container in the refrigerator. IP 1 stated, Potential exposure to outside elements like pest and dust when asked. IP 1 stated, the diced peaches in the partially opened container could create food born illness when asked. 2. During a concurrent observation and interview on 6/30/25 at 2:26 PM with DM 1 in the kitchen, a large cut of beef was inside a sealed clear plastic package with no expiration date in the freezer. DM 1 stated, I don't know when asked when the expiration date of the beef would be. DM 1 stated, We received it today, but he stated There should be some stamp when asked about the expiration date of the beef. During a concurrent observation and interview on 6/30/25 at 2:48 PM with RD 1, RD 1 stated, It needs to be dated. We don't know how long it was there (in the freezer) when asked about the large cut of beef inside the sealed clear plastic package with no expiration date in the freezer while watching the pictures of it. During an Interview on 7/03/25 at 11:09 AM with IP 1, IP 1 stated, Potential for food born illnesses when asked about the risk of the large cut of beef inside the sealed clear plastic package with no expiration date in the freezer. 555034 Page 17 of 26 555034 07/03/2025 San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of the facility's P&P titled, Food Storage and Handling revised on 2/29/24 indicated, . All items will be correctly labeled and dated . b. Raw meat, poultry, and seafood should be labeled, dated . 3. During observation on 6/23/2025 at 11:45AM found a stack of partially dried small bowls in a stacking tray. During observation on 6/23/2025 at 11:46AM found a tray of wet small bowls containing chocolate pudding prepared for lunch at the tray line tableDuring an interview on 6/23/2025 at 11:51AM with Regional RD, stated we shouldn't be serving food with wet dinnerwares.4. During observation on 6/23/2025 at 9:35AM, in Dry storage found an expired container of liquid smoked sauce, date received 5/17/2024, prep date 1/23/2025. During observation on 6/23/2025 at 9:35AM, in Dry storage, a large quantity of packets of brisk coffee roasters with no expiry date or best before dates in a bin, found at the bottom shelf. 5. During observation on 7/3/25 at 9:20 AM in the kitchen, two metal dish drying racks are at the entrance and one in front of the handwashing sink. Cooks are busy with food preparation. The floor was wet with yellow cones. Observed staff wearing hair nets and face masks. Staff who just entered the kitchen washed their hands at the sink near the entrance before proceeding inside the kitchen. During an interview with the Regional Registered Dietitian (RD 1) consultant who stated: Our kitchen manager is [name]. The menu for the day is: Fish with dill sauce; seasoned fries; herbs; corn and tomato; wheat roll; and the dessert is ice cream. - The tray line starts from 11:30 AM to 11:45 AM. Mealtimes are Breakfast is 7 to 9 AM; Lunch is 12 to 2 PM; and Dinner is 5-7 PM. During a concurrent observation and interview at the tray line, food temperature checks with the RD 1 indicated only the hamburger patty (an alternative menu) was below the temperature heat range of 140°F and above. It was 126°F. The RD 1 called for the Regional Dietary Manager (RDM) who took the metal container of the hamburger patty for reheating. The hamburger patty came back at 12:10 PM with temperature of (surveyor's thermometer) 146.5°F while RD 1's thermometer read 160°F.During observation at the tray line observed [NAME] 1 was serving, assisted by a Kitchen Aide (KA 2). On the tray service line were three kitchen aides: KA 1; KA 3; and KA 4; the RDC in the center line, and RD 1 at the end of the line who checks the plates for accuracy before it was placed in the meal cart. The meal cart carrier is KA 5. During a concurrent observation and interview at the tray line on 7/3/25 around 1:30 PM the kitchen staff on tray line was still plating. The RD 1 was yelling, “we are late!” There are a total of eleven (11) meal carts for the whole facility. The last meal cart left the kitchen at 2:40 PM. RD 1 stated, I'm very sad, we are late today. Yesterday we were early. There were two call-ins today. During a review of the facility's policy and procedures (P&P) titled: Meal Service Times, Operational Manual – Dietary Services, date revised July 01, 2014. Purpose: To provide the dietary department with guidelines for meal service. Policy: Meals are served at a regular scheduled hour…. Procedure: … II. The Dietary Manager works with the Director of Nursing Services and other staff to determine routine mealtimes for daily service. A. Changes in mealtimes will be coordinated between the Dietary Manager and the Director of Nursing Services. III. The Dietary Manager is responsible for monitoring meal service time daily to ensure the facility meets posted mealtimes…. V. Mealtimes are typically at 7:00 am, 12:00 pm, and 5:00 pm. 555034 Page 18 of 26 555034 07/03/2025 San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403

F 0850 Hire a qualified full-time social worker in a facility with more than 120 beds. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to employ a qualified social worker on a full-time basis that met the qualifications specified in the regulation for 267 of 267 residents residing in the facility. This failure had the potential to result in residents not receiving sufficient and appropriate coordination of medically related social services to meet their needs.Review of the facility's license to operate, it was indicated the facility had a bed capacity of 281, with an effective date of 2/1/25 and expiring date of 1/31/26.Review of the facility's census at the start of the survey, it was indicated 267 residents were admitted , with an additional two (2) residents on bedhold status. During an offsite preparation interview on 6/18/25 at 1:59 PM, Ombudsman 1 stated the facility has no full time Social Worker (SW), just temporary, resulting to no or delay discharge planning.During an interview on 6/23/25 at 11:10 AM, Resident 40 stated having difficulty hearing and was waiting for hearing aid. When asked if Resident 40 had spoken with the SW regarding the concern, Resident 40 stated, I haven't talked to one. It has been a long time.During an interview on 6/23/25 at 11:27 AM, Resident 204 complained of hand pain, stated, having carpal tunnel (condition where the nerve in the wrist gets pinched causing pain and tingling), and expressed the need for a brace. Resident 204 added, Certified Nursing Assistant (CNA) and License Nurse were informed about the concern. When asked if Resident 204 had spoken with the SW regarding the concern, Resident 204 stated wanting to speak with the SW and further stated, I have not met the Social Worker.During an interview on 7/3/25 at 1:25 PM, SW 1 stated she was designated as the Assistant Social Services Director of the facility but does not have a bachelor's degree in social work or human services field. Additionally, SW 1 stated she's only been working with the facility for three (3) months.During an interview on 7/3/25 at 1:44 PM, the Regional Discharge Liaison (RDL) confirmed and stated the three (3) Social Workers including SW 1 had no background in bachelor's degree in social work or human services field. The RDL also stated she's a regional consultant and oversees the discharge planning of the facility.Furthermore, the facility was unable to provide pertinent information regarding employing a qualified social worker on a full-time basis. The facility was unable to provide credentials for the three social workers, including SW 1 who was identified as the Assistant Social Services Director.During an interview on 7/3/25 at 4:04 PM with the [NAME] President of Operations (VPO), the Administrator (ADMIN), and the Director of Nursing (DON), the VPO acknowledged and stated, the facility does not have a full time Social Worker. Residents Affected - Many 555034 Page 19 of 26 555034 07/03/2025 San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. 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 provide pneumococcal immunization (known as pneumococcal vaccination, refers to the process of administering vaccines to protect against pneumococcal disease, caused by the bacteria Streptococcus pneumoniae, also known as pneumococcus. These vaccines work by triggering the body's immune system to produce antibodies that fight off the bacteria, preventing or reducing the severity of these infections) for one of 5 sampled residents (Resident 650) when there was no evidence that the pneumococcal vaccine was given to Resident 650 even after a phone consent had been received from the responsible party on 2/26/25.This failure had the potential to result in putting Resident 650 at risk for acquiring (getting), transmitting (causing infections to pass on from one place or person to another), or experiencing complications from pneumococcal disease.Review of Resident 650's clinical record indicated, Resident 650 was admitted to the facility with diagnoses including acute respiratory failure (a life-threatening condition where the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide), acute cystitis (an infection of the bladder), and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). The record further indicated, #### (Resident 650's family member's name) was the responsible party.Review of Resident 650's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 2/27/25 indicated, Resident 650 was cognitively moderately impaired. Then, review of Resident 650's MDS dated [DATE] indicated, Resident 650 was cognitively severely impaired. During a concurrent Interview and record review on 7/3/25 at 10:11 AM with Preventionist (IP) 1, Resident 650's Immunization Report (IR) printed on 7/3/25 was reviewed. The IR indicated, there was no record of pneumococcal vaccine for Resident 650. IP 1 stated, No record when asked if the facility had provided the pneumococcal vaccine to Resident 650. IP 1 stated, It should be given when asked about the pneumococcal vaccine. IP 1 stated, They can get respiratory symptom when asked about the risk of not getting pneumococcal vaccine. IP 1 stated, I obtain consents for vaccines for residents and communicate with **** (pharmacy name) to schedule monthly vaccine clinics for them to send a team to help administer vaccines for our residents at our facility . when asked about IP's role regarding vaccination. IP 1 stated, I validate all appropriate vaccine consents are obtained, and vaccines are given by the pharmacy team during vaccine clinic days. IP 1 stated, Benefits of receiving vaccines can help resident build immunity against the viruses, when asked. IP 1 acknowledged, Not all residents are up to date with their vaccines when asked if Resident 650 had received the pneumococcal vaccine.During a concurrent interview and record review on 7/3/25 at 11:10 AM with IP 2, IP 2 stated, they should have contacted Resident 650's responsible party when asked about Resident 650's cognition (the process of knowing and understanding through thought, experience, and the senses) on the MDS dated [DATE] and dated 3/13/25.During a concurrent interview and record review on 7/3/25 at 12:37 PM with IP 1, Resident 650's consent titled, PNEUMOCOCCAL VACCINE INFORMED CONSENT/DECLINATION dated 2/26/25 was reviewed. The consent indicated, #### (Resident 650's responsible party and family member's name) gave verbal consent via the phone to allow the facility to give the pneumococcal vaccine to Resident 650. IP 1 verified, there was no record of Resident 650 receiving the pneumococcal vaccine even after receiving verbal consent from the responsible party by phone on 2/26/25.During a concurrent interview and record review on 7/3/25 at 12:40 PM with IP 2, Resident 650's Immunization Report (IR) printed on 7/3/25 was reviewed again. IP 2 stated, No when asked if there was a record of Resident 650 receiving the pneumococcal vaccine after receiving verbal consent from the responsible party by phone on 2/26/25. IP 2 stated, Yes when asked if the pneumococcal vaccine should have been given to Resident 650 after the verbal consent from Residents Affected - Few 555034 Page 20 of 26 555034 07/03/2025 San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403

F 0883 Level of Harm - Minimal harm or potential for actual harm the responsible party.Review of the facility's policy and procedure (P&P) titled, IPC601 Pneumococcal Vaccination dated 10/2/23 indicated, . The facility will provide all residents the opportunity to receive the pneumococcal vaccine . 4. Administer the appropriate vaccine . a. Document one of the following in the resident's medical record: i. The resident received the Pneumococcal vaccine . Residents Affected - Few 555034 Page 21 of 26 555034 07/03/2025 San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403

F 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide COVID-19 immunization (also known as COVID-19 vaccine that helps our bodies develop immunity to the virus that causes COVID-19 without us having to get the illness. Different COVID-19 vaccines may work in our bodies differently, but all provide protection against the virus that causes COVID-19) for one of 5 sampled residents (Resident 650) when there was no evidence that the COVID-19 vaccine was given to Resident 650 even after a phone consent had been received from the responsible party on 2/26/25.This failure had the potential to result in putting Resident 650 at risk for acquiring (getting), transmitting (causing infections to pass on from one place or person to another), or experiencing complications from Coronavirus disease (COVID-19, an infectious disease caused by the SARS-CoV-2 virus. Most people infected with the virus will experience mild to moderate respiratory illness and recover without requiring special treatment. However, some will become seriously ill and require medical attention).Review of Resident 650's clinical record indicated, Resident 650 was admitted to the facility with diagnoses including acute respiratory failure (a life-threatening condition where the lungs cannot provide enough oxygen to the body or remove enough carbon dioxide), acute cystitis (an infection of the bladder), and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). The record further indicated, #### (Resident 650's family member's name) was the responsible party.Review of Resident 650's Minimum Data Set (MDS, a federally mandated resident assessment tool) dated 2/27/25 indicated, Resident 650 was cognitively moderately impaired. Then, review of Resident 650's MDS dated [DATE] indicated, Resident 650 was cognitively severely impaired.During a concurrent Interview and record review on 7/3/25 at 10:11 AM with Infection Preventionist (IP) 1, Resident 650's Immunization Report (IR) printed on 7/3/25 was reviewed. The IR indicated, the last COVID-19 vaccine was given on 4/28/21, and there was no more record of COVID-19 vaccine after 4/28/21 for Resident 650. IP 1 stated, No record when asked if the facility had provided the COVID-19 vaccine to Resident 650 after 4/28/21. IP 1 stated, Nothing was documented. No records of it when asked again about the COVID-19 vaccine after 4/28/21. IP 1 stated, . It should be given when asked about COVID-19 vaccine. IP 1 stated, They can get respiratory symptom when asked about the risk of not getting COVID-19 vaccine. IP 1 stated, I obtain consents for vaccines for residents and communicate with **** (pharmacy name) to schedule monthly vaccine clinics for them to send a team to help administer vaccines for our residents at our facility . when asked about IP's role regarding vaccination. IP 1 stated, I validate all appropriate vaccine consents are obtained, and vaccines are given by the pharmacy team during vaccine clinic days. IP 1 stated, Benefits of receiving vaccines can help resident build immunity against the viruses, when asked. IP 1 acknowledged, Not all residents are up to date with their vaccines when asked if Resident 650 had received the COVID-19 vaccine.During a concurrent interview and record review on 7/3/25 at 11:10 AM with IP 2, IP 2 stated, they should have contacted Resident 650's responsible party when asked about Resident 650's cognition (the process of knowing and understanding through thought, experience, and the senses) on the MDS dated [DATE] and dated 3/13/25.During a concurrent interview and record review on 7/3/25 at 12:39 PM with IP 1, Resident 650's consent titled, RESIDENT COVID-19 VACCINE INFORMED CONSENT OR DECLINATION dated 2/26/25 was reviewed. The consent indicated, #### (Resident 650's responsible party and family member's name) gave verbal consent via the phone to allow the facility to give the COVID-19 vaccine to Resident 650. IP 1 verified, there was no record of Resident 650 receiving the COVID-19 vaccine even after receiving verbal consent from the responsible party by 555034 Page 22 of 26 555034 07/03/2025 San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403

F 0887 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few phone on 2/26/25.During a concurrent interview and record review on 7/3/25 at 12:40 PM with IP 2, Resident 650's Immunization Report (IR) printed on 7/3/25 was reviewed again. IP 2 stated, No when asked if there was a record of Resident 650 receiving the COVID-19 vaccine after receiving verbal consent from the responsible party by phone on 2/26/25. IP 2 stated, Yes when asked if the COVID-19 should have been given to Resident 650 after the verbal consent from the responsible party.Review of the facility's policy and procedure (P&P) titled, COVID-19 Vaccination Program Infection Control Manual revised on 3/15/22 indicated, . The facility will offer SARS-CoV-2 vaccinations . to all Residents . D. For Residents, transcribe all the information from the vaccination card into the Resident's medical record . 555034 Page 23 of 26 555034 07/03/2025 San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an effective pest control program when:1. A live cockroach was observed on the floor in the kitchen.2. A pest control company report dated 5/27/25 indicated, confirmed cockroach activity in the downstairs kitchen and documented that service was performed. The company provided recommendations, made some recommendations; however, the facility has not implemented them.3. A pest control company report dated 6/30/25 indicated that service was performed to help control an ongoing cockroach problem. This indicates that, despite previous treatment on 5/27/25 cockroaches were still present in the kitchen.4.An interview with the pest control technician revealed that there was a small to moderate number of German cockroaches found in the kitchen. The technician also advised checking the bait stations (small containers with insecticide used to attract and kill pests) regularly to track and manage the cockroach activity 5. The recommendations of the pest control company were not followed, including proper sanitation of the kitchen and other areas of the facility, and bait stations were not monitored.6. The facility did not implement frequent and thorough monitoring for pest activity in high risk areas (places where pests are more likely to appear such as kitchen, food storage areas and locations with moisture or clutter), as recommended by the pest control company.7. Licensed Vocational Nurse (LVN) 2, interview stated she saw roaches in the activity room on the 2nd floor and reported the incident to the Maintenance Director on 6/10/25.This failure had the potential to create an unsanitary environment for a universe of 281 residents. The presence of pests can contribute to the spread of infection and food borne Illnesses (food poisoning) . Findings:1.During an observation on 6/30/2025 at 9:43AM in the kitchen food preparation area, a live cockroach around one centimeter long, crawling slowly on the floor under the steam table ( a heated serving table).During an interview on 6/30/2025 at 9:43AM with Dietary Manager (DM) 1, DM 1 stated, I've only been at the facility for three weeks, but I've never seen anything like that since I started. During an Interview on 06/30/25 02:28 PM with Registered Dietitian (RD) 1, RD 1 stated, I've never seen cockroaches in the kitchen until today. During an interview on 6/30/2025 at 2:31PM with [NAME] 1, [NAME] 1 stated, I only saw flies in the kitchen but not cockroach.During an observation on 6/30/2025 at 2:42PM, in the garbage area at the back of the facility, there were a lot of flies buzzing around the trash area. It reflects the facility's failure to maintain an effective pest control program. This condition combined with the sighting of a cockroach in the kitchen creates an environment that attracts and supports pest activity.During an interview on 6/30/2025 at 3:30PM with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, I saw roaches in 2nd floor activity room on 6/10/2025. I reported the sighting verbally to Maintenance, but I haven't heard anything back from him since.2. During the interview on 7/1/2025 at 8:26AM with Environmental Supervisor (ES), ES stated, the pest control service came on 5/27/2025, to conduct an assessment. ES added, I've been trying to get the pest service back here for the past three weeks. I've been calling everyday and even escalated the issue to someone higher up to consider using a different vendor because I wasn't satisfied with the current pest control company's response and services. They keep re-scheduling or canceling whenever I make an appointment. During a review of the Pest Control Services (PCS) document dated 5/27/2025, PCS technician's comments summary noted, Cockroach activity noted in the downstairs kitchen Cockroach activity confirmed in the downstairs kitchen; treatment focused accordingly.Recommendations included:a. Maintain strict sanitation routine, especially in the downstairs kitchen where activity was found.b. Monitor bait stations regularly and report any increases in pest activity.c. Continue scheduled treatments and consider enhanced monitoring in high-risk areas like the kitchen and trash zones.3. During a review of the Pest Control Services (PCS) document Residents Affected - Some 555034 Page 24 of 26 555034 07/03/2025 San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some dated 6/30/2025, PCS technician's comments summary indicated, Comprehensive pest control services were provided at a Senior Living Facility (Skilled Nursing Facility) to address cockroach, fly and ant activity. Treatment involved targeted applications of insecticide and insect growth regulator (IGR), along with installation of glue monitors (sticky trap) and bait placements for monitoring and control.Recommendations:a. Continue monitoring glue boards (sticky traps used to catch insects like cockroach by trapping them on a sticky surface) and bait placements (pest bait stations are small containers with food mixed with pesticide to attract and kill pests) regularly for pest activity.b. Maintain sanitation in kitchen and affected units to support control.During an interview on 6/30/2025 at 2:28PM with Registered Dietitian (RD) 1 RD 1 stated, Pest control is done monthly, they were actually here today. To my knowledge the Pest Control Company were here last May 2025 to do treatment and to make rounds. They also came last week I'm not sure of the exact date , to check and assess their previous treatment. To be clear they were here for the flies. We didn't notify them about the cockroach because there was no sightings but when they came in this morning, I told them we had seen a cockroach, so they sprayed.4. During an interview on 6/30/25 at 1:50 PM through telephone, with the Pest Control Technician (PCT) 1, PCT 1 stated, there is a low to mild infestation of German roaches in the kitchen. One of our recommendation was to monitor the roach bait stations so that the Pest Control Company could be alerted if there was a change in roach activity. I installed 15 bait stations in the kitchen the last time I went there on 5/27/2025. During an interview on 7/1/2025at 11:52AM with RD 1, RD 1 stated, we don't do the monitoring, I believe the maintenance supposed to check regarding pests but I haven't seen the maintenance checking the bait stations . To my knowledge we have only nine bait stations in the kitchen.5. During an observation on 6/30/2025 at 11:20AM, in the dishwashing area, stagnant water was seen under the drying rack and table. The floor was messy with food residues found underneath and on top of the metal table.During an observation on 6/30/2025 at 2:42PM, in the garbage area at the back of the facility, there were a lot of flies buzzing around the trash area. It reflects the facility's failure to maintain an effective pest control program. This condition combined with the sighting of a cockroach in the kitchen creates an environment that attracts and supports pest activity.During observation on 6/30/2025 at 2:54PM, In the dry storage area, a dried blackish banana peel was found at the bottom of the storage rack with a white plastic lid resting on top of it.During an observation on 6/30/2025 at 3:05PM under the dish drying rack in the kitchen, observed an opened packets of peppers, non-dairy creamer, sugar, bread plastic clip, and a lid for cup.During an observation on 7/1/2025 at 11:13AM, in the dry storage area, pieces of cereal were seen on the floor behind a container beside an air vent located at the bottom of a the wall. During an interview on 7/1/2025 at 11:23 with Dietary Aide (DA) 1, DA 1 stated, At times kitchen staff shows a lack of discipline when placing trays here on the dishwashing table, often leaving the plates with leftover foods instead of disposing of it in the trash bins.During an interview on 7/1/2025 at 11:52AM with RD 1, RD 1 stated, we don't do the monitoring, I believe the maintenance supposed to check regarding pests but I haven't seen the maintenance checking the bait stations . To my knowledge we have only nine bait stations in the kitchen.Record review titled Pest Control Policy dated 1/1/2012, Pest Control Policy indicated The facility maintains an ongoing pest control program to ensure the building and grounds are kept free of insects, rodents, and other pests. I. General Practices. The maintenance department assists, when appropriate and necessary, with pest control services. III. Staff Role: A. Facility Staff will report to the Housekeeping Supervisor any sign of rodents or insects, including ants, in the facility. i. The Housekeeping Supervisor takes immediate action to remove the pests from the facility. ii. If necessary, after informing the administrator, the housekeeping 555034 Page 25 of 26 555034 07/03/2025 San Mateo Medical Center D/P Snf 222 West 39th Avenue San Mateo, CA 94403

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Supervisor will call the extermination company for assistance.During an interview on 7/1/2025 at 1:50PM with Environmental Supervisor (ES) 1, ES 1 stated, that the pest control company did not instruct facility staff to inspect or monitor the traps. ES 1 further explained that the previous administrator had left, and the responsibility for overseeing pest control was only recently assigned to me approximately a month ago. 6. During record review Pest Control Services (PCS) document dated 5/27/2025, PCS technician's comments summary indicated cockroach activity noted in the downstairs kitchen. No activity observed in bait stations .Cockroach activity confirmed in the downstairs kitchen; treatment focused accordingly. Recommendations: 1. Maintain strict sanitation routine, especially in the downstairs kitchen where activity was found. 2. Monitor bait stations regularly and report any increases in pest activity. 3. Continue scheduled treatments and consider enhanced monitoring in high-risk areas like the kitchen and trash zones.During an interview on 7/1/2025 at 1:50PM with ES 1, ES 1 stated, that the pest control company did not instruct facility staff to inspect or monitor the traps.7. During an interview on 6/30/2025 at 3:30PM with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, I saw cockroaches in the second floor activity room on 6/10/2025. I reported the sighting verbally to Maintenance, but I haven't heard anything back from him since.During an observation on 6/30/2025 at 2:56PM , Resident 75 room, there were multiple opened food items ( Hawaiian bread, opened chips on the top of the fridge) and used containers. In addition, several flies were observed in the room and line of ants going into the bedside drawer. 555034 Page 26 of 26