Health inspection·February 14, 2024

F 0557 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interviews with direct care staff indicated that the facility had a problem with staffing and answering call lights in a timely manner: 1. During an interview on 1/29/24 at 12:38 PM, CNA (Certified Nursing Assistant) 4 stated the facility was short at least three CNA at times at the other facility. 2. During an interview on 02/02/2024 at 11:14 AM, RN 9 stated sometimes they were short of CNA and LVN (Licensed Vocational Nurse) sometimes short 1 sometimes short 2 staff. 3. During an interview on 02/02/2024 at 11:50 AM, RN 5 stated the facility was usually short of direct care staff 2-3 days a week. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555235 If continuation sheet Page 2 of 29 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 555235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ahmc Seton Medical Center 1900 Sullivan Avenue Daly City, CA 94015 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure a shower area was clean after use and two window screens were missing. Failure to clean a shower after use,and properly maintained window screens did not ensure residents were provided with a clean, comfortable, homelike environment. Lack of a window screen has the potential for flying pest to come into a resident's indoor living space. Findings: During initial tour with the Director of Nursing(DON) on 1/29/24 at 3:07 PM, the shower room across room [ROOM NUMBER] was found used and not cleaned: 1. Strands of hair on the tile floor. 2. A commode container full of empty plastic personal hygiene product bottles (lotions and shampoo containers). 3. A safety razor on the floor. 4. An opened body wash bottle labelled 211A on the grab bar. 5. Used plastic gloves in the recessed soap dish. During a concurrent interview with the DON, she stated staff should not leave the shower in this manner and staff should clean the shower after use. During initial tour with RN 6 on 1/29/24 at 10:38 AM, room [ROOM NUMBER] and 424 bed B has no window screens. During a concurrent interview, RN 6 said she would get maintenance to fix that. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555235 If continuation sheet Page 3 of 29 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 555235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ahmc Seton Medical Center 1900 Sullivan Avenue Daly City, CA 94015 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 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on interview and record review, the facility failed to inform residents about the facility's grievance process. Seven out of seven sampled residents were not aware of the grievance process (Residents 5, 19, 24, 32, 55, 57, and 72). For Resident 408, the facility failed to complete the resolution review of the grievance process. Failure to inform or follow the grievance process, did not ensure concerns from the residents or their responsible parties were addressed in an appropriate and timely manner. Findings: During the resident council meeting with residents on 01/30/2024 at 2:04 PM, Residents 5, 19, 24, 32, 55, 57, and 72 were asked about the facility's grievance process. All seven residents stated they were not aware the facility had such a process. During initial rounds on 01/30/2024 at 10:08 AM, Resident 408 stated she had eight boxes of personal items missing during her transfer to this facility. She stated the facility claimed her friend had all her missing belongings. She claimed that the facility had been lying about the whereabouts of her belongings. During an interview on 02/05/2024 at 12:04 PM, Resident 408's friend stated she only had limited possession of Resident 408's belongings. She stated she does not have eight boxes of Resident 408's belongings. She stated she has told the facility she does not have these missing items. During an interview on 02/06/2024 at 3:17 PM, the Director of Nursing (DON) stated they were aware of Resident 408's missing belongings and filed a Theft & Loss Report. Review of the report with the DON indicated under Actions(s) Taken & Resolution: (include proof or resolution) .Friend . is in possession of her belongings . The DON was asked to provide proof that she followed up with Resident 408's friend and/or Resident 408 to see if the belongings were with the friend and/or Resident 408 was happy with the resolution. The DON was unable to provide the information requested. Review of the facility's policy titled Grievance Procedure, revised on 10/23, indicated .The resident will be informed of the resolution to determine that he/she is satisfied with the actions taken. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555235 If continuation sheet Page 4 of 29 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 555235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ahmc Seton Medical Center 1900 Sullivan Avenue Daly City, CA 94015 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an interview on 02/06/2024 at 10:05 AM, Resident 6 stated he has been a dialysis patient for a long time. Residents Affected - Some Review of Resident 6's MDS assessment dated [DATE], indicated he was not on hemodialysis. However, review of Resident 6's care plan indicated he has a dialysis care plan initiated on 03/08/2023. During an interview on 02/06/2024 at 4:19 PM, the MDS nurse stated the November 2023 MDS assessment for Resident 6 regarding dialysis was inaccurately coded and she will upload a corrected MDS later. 3. Record review of Resident 13's MDS dated [DATE], indicated she had three pressure injuries and had a catheter to manage urinary incontinence. During an interview on 02/01/24 at 2:16 PM, the MDS nurse stated Resident 13's pressure injuries were coded incorrectly in her MDS assessment. There was only one pressure injury not three. The RAI manual clearly states to code skin lesions as pressure injury when both pressure and moisture are present. The MDS nurse was unable to answer why staff were identifying the sacra wound as a moisture related skin damage and not a pressure injury. Based on observation, interview, and record review, the facility failed to ensure assessments for three of 24 sampled residents (Residents 4, 6, and 13) were accurate when; 1. The Minimum Data Set (MDS - an assessment tool) for Resident 4's dental assessment was inaccurate. 2. The MDS indicated Resident 6's hemodialysis treatment was inaccurate. 3. The MDS indicated Resident 13 had three pressure ulcers when there was only one. Failure to complete accurate assessments could potentially harm the residents by not providing needed care and services to maintain their highest level of functioning. Findings: 1. Resident 4 was admitted on [DATE] with diagnosis including hypertension (high blood pressure) and mild cognitive impairment. During an observation on 1/30/24 at 12:11 PM, Resident 4's upper denture was placed in a denture cup on top of an overbed table. Resident 4 then removed her lower denture during mealtime. During a concurrent interview, Resident 4 stated, I cannot close my mouth and chew when I use it (dentures). During an interview on 2/7/24 at 10:51 AM, the Social Worker (SW) said, Resident 4 was admitted already with dentures. Review of Resident 4's MDS dated [DATE], indicated under oral/dental status, no natural teeth or tooth fragment(s) was not checked. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555235 If continuation sheet Page 5 of 29 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 555235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ahmc Seton Medical Center 1900 Sullivan Avenue Daly City, CA 94015 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Level of Harm - Minimal harm or potential for actual harm During an interview on 2/8/24 at 2:02 PM with the Director of Nursing (DON), the DON said, the facility has a history of MDS discrepancies. They do reaudit of MDS (where subacute floor audits the SNF and vice versa) but stopped the past six months due to relocation. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555235 If continuation sheet Page 6 of 29 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 555235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ahmc Seton Medical Center 1900 Sullivan Avenue Daly City, CA 94015 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. During a concurrent record review and interview on 02/06/2024 at 2:57 PM with Licensed Vocational Nurse (LVN) 1, extreme fear monitoring was identified as a target behavior for use of Seroquel (an anti-psychotic medication). Review of Resident 407's behavioral care plan indicated there was no documentation regarding extreme fear. LVN 1 stated the extreme fear Resident 407 was experiencing was this feeling that someone are going to come and get her. LVN 1 confirmed that extreme fear should have been care planned in Resident 407's care plan. 7. Review of Resident 6's dialysis care plan, initiated on 03/08/2023, indicated staff documented his dialysis access site as his left arm. While other documents such as physician orders and nursing notes indicated his dialysis site was on his right arm. During an interview 02/02/2024 at 2:11 PM, RN 9 was asked to confirm which arm Resident 6's dialysis access site was on. Confirmation fax from the dialysis center indicated Resident 6's dialysis access site was on his right arm. Based on observation, interview and record review, the facility failed to develop a comprehensive care plan (CP) for each resident that included measurable objectives and specific interventions for seven of 24 sampled residents (Residents 4, 7, 70, 78, 38, 407, and 6) when: 1. No individualized person-centered CP was developed for Resident 4's pain due to unfit dentures. 2. No individualized person-centered CP was developed for Resident 7's use of Lovenox (a blood-thinning drug used to prevent formation of blood clots). 3. No individualized person-centered CP was developed for Resident 70's use of Zolpidem (a medication primarily used for the treatment of sleeping problems). 4. CP did not reflect the use of gloves, tab and bed alarms for Resident 78. 5. CP did not reflect management of planned weight loss for Resident 38. 6. CP for Resident 407 did not address the specific target behavior (extreme fear) for the use of Seroquel (an antipsychotic medication). 7. Dialysis CP did not reflect the accurate dialysis access for Resident 6. (Dialysis is a procedure to remove waste products and excess fluid from the blood when the kidneys stop working properly). These failures had the potential for not meeting the residents' nursing needs and goals to attain their highest practicable well-being. Findings: 1. During an observation on 1/30/24 at 12:11 PM, Resident 4's upper denture was placed in a denture cup on top of an overbed table. Resident 4 then removed her lower denture during mealtime. During a concurrent interview, Resident 4 stated, I cannot close my mouth and chew when I use it. I got sore (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555235 If continuation sheet Page 7 of 29 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 555235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ahmc Seton Medical Center 1900 Sullivan Avenue Daly City, CA 94015 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 gums. Resident 4 said that she reported to the nurse about her sore gums. Level of Harm - Minimal harm or potential for actual harm During an observation and concurrent interview on 2/6/24 at 10:22 AM with Registered Nurse (RN)1, Resident 4 tried to wear her dentures and was unable to close her mouth. Resident 4 stated, I can't bite. RN1 stated, We will refer to the dental provider. Residents Affected - Some During an interview on 2/6/24 at 10:36 AM, the Certified Nursing Assistant (CNA)1 said, Resident 4 is unable to eat with her dentures, complains that her gums hurt when she wears her dentures during mealtime. CNA1 further said that this was reported to the RN in charge. During a concurrent interview and record review on 2/7/24 at 2:20 PM with RN2, Resident 4's care plans were reviewed. RN2 acknowledged that there was no CP for the new onset of pain due to unfit dentures. 2. Resident 7 was admitted on [DATE] with diagnoses including paraplegia (paralysis of the legs and lower body). Review of Resident 7's Physician Order Report dated 1/1/24 to 1/31/24 indicated, Resident 7 had an order of Lovenox with a start date of 11/8/23. During a concurrent interview and record review on 2/6/24 at 2:39 PM with RN2, Resident 7's care plans were reviewed. RN2 confirmed that the CP for Resident 7's use of Lovenox had a start date of 2/6/24. RN2 acknowledged that there was no care plan for Resident 7's use of blood thinner before 2/6/24, and stated, I don't see it. 3. Resident 70 was admitted on [DATE] with diagnoses including insomnia (persistent problem falling and staying asleep) and dementia (loss of thinking, reasoning and remembering skills). Review of Resident 70's Physician's Order Report dated 2/1/24 to 2/29/24 indicated, Resident 70 had an order for Zolpidem (drug that can treat insomnia) with a start date of 9/27/23. During a concurrent interview and record review on 2/7/24 at 2:38 PM with RN2, Resident 70's care plans were reviewed. RN2 confirmed that there was no care plan developed for Resident 70's use of Zolpidem when ordered on 9/27/23. RN2 stated, Care plan was started on 1/1/24. 4. Resident 78 was admitted on [DATE] with diagnoses including diabetes (a long-term condition in which the body has trouble controlling blood sugar and using it for energy) and cognitive communication deficit (difficulty with thinking and how one uses language). During an initial tour observation on 1/29/24 at 11:47 AM, Resident 78 was wearing a pair of gloves on both hands while holding a cymbal. During another observation on 2/5/24 at 9:15 AM, Resident 78 was asleep in her wheelchair, wearing a pair of gloves on both hands while holding a cymbal. During a concurrent interview and record review on 2/7/24 at 12:33 PM with RN2, Resident 78's CP for skin breakdown was reviewed. RN2 said Resident 78 uses gloves in the morning and mittens at night so as not to scratch self as per family's request. RN2 acknowledged that the CP for skin breakdown did not reflect the use of gloves. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555235 If continuation sheet Page 8 of 29 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 555235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ahmc Seton Medical Center 1900 Sullivan Avenue Daly City, CA 94015 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident 78's Physician Order Report dated 2/1/24 to 2/29/24 indicated, Resident 78 had orders for tab alarm with a start date of 6/29/23 and bed alarm with a start date of 7/10/23. During a concurrent interview and record review on 2/7/24 at 1:47 PM with RN4, Resident 78's CP for fall was reviewed. RN4 confirmed that Resident 78 uses tab and bed alarms. RN4 acknowledged that Resident 78's CP for fall did not indicate the use of tab and bed alarms. 5. Resident 38 was admitted on [DATE] with diagnoses including quadriplegia (paralysis of all four limbs) and obesity (overweight). During a concurrent interview and record review on 2/8/24 at 10:01 AM with the Registered Dietitian (RD), Resident 38's Nutrition Assessment and Follow Up was reviewed. The document indicated, Resident 38's weight has gradually been trending down and long-term gradual weight loss remains desired. RD acknowledged that there was no mention in the CP for Resident 38's planned weight loss. RD stated, No care plan unless it is a significant weight loss. During an interview on 2/6/24 at 2:39 PM, RN3 said, CP should be patient centered, includes current medication and diagnosis, so staff know what to do. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555235 If continuation sheet Page 9 of 29 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 555235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ahmc Seton Medical Center 1900 Sullivan Avenue Daly City, CA 94015 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 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to prevent the development of an avoidable pressure ulcer (PU) for one of 14 sampled residents (Resident 22) when interventions were not implemented to avoid skin breakdown for Resident 22. Residents Affected - Few This deficient practice resulted in the development of Stage 2 PU for Resident 22. Definition/Stages for Pressure Ulcer/Pressure Injury (also called a bed sore, is an injury to skin and underlying tissue resulting from prolonged pressure on the skin. Stage I: Intact skin with a localized area of non-blanchable redness (non-blanchable: redness persists and does not fade or turn white after removal of fingertip pressure). Stage II: Partial-thickness loss of skin with exposed upper skin layer. The wound bed is pink. May also present as an intact or ruptured blister. Fat tissue and deeper tissues (muscle, tendons, bone) are not visible. Findings: Resident 22 was admitted on [DATE] with diagnoses including hemiplegia (complete paralysis on one side of the body) and hemiparesis (partial weakness on one side of the body) and diabetes (abnormally high sugar level in the blood). The facility assessed Resident 22 as high risk for developing pressure ulcers. Review of Resident 22's Minimum Data Set (MDS - an assessment tool) dated 7/6/23 indicated, Resident 22 needed extensive assistance with bed mobility, was always incontinent with bladder and bowel functions, and had impairment on one side of both upper and lower extremities. Resident 22 had no pressure injuries on admission. During an initial tour observation on 01/29/24 at 3:04 PM, Resident 22 was lying in bed with pillow under his head, watching on his laptop. There was no device to offload pressure from his coccyx (tailbone). During a concurrent interview and record review on 2/2/24 at 11:31 AM with RN 2, Resident 22's Wound Management Detail Report (WMDR) dated 8/9/23 was reviewed. The WMDR indicated, Resident 22 was observed on 8/4/23 to have a PU on the coccyx with a measurement of 1 centimeter by 1 centimeter (1 cm x 1 cm). RN 2 said, the Stage 2 PU was discovered on 8/2/23 and was facility acquired. Review of Resident 22's WMDR dated 8/11/23 indicated, Resident 22 had a Stage 2 injury on his coccyx with a measurement of 2.5 cm x 1 cm, with irregular wound edges and declining wound healing status. The facility was waiting for the delivery of the low air low mattress (LAL - mattress designed to prevent and treat pressure wounds). Review of Resident 22's WMDR dated 9/1/23 indicated, Resident 22 was observed on 8/31/23 to have a Stage 2 injury on his coccyx measuring 3 cm x 1.4 cm x 0.2 cm, irregular wound edges with slight maceration (softening and breaking down of skin resulting from prolonged exposure to moisture) and declining wound healing status. The facility was waiting for the delivery of the LAL mattress. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555235 If continuation sheet Page 10 of 29 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 555235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ahmc Seton Medical Center 1900 Sullivan Avenue Daly City, CA 94015 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 Review of Resident 22's Physician Order Report dated 8/1/23 through 8/31/23 indicated, Resident 22 had an order for LAL mattress related to (r/t) pressure ulcer and to prevent further skin breakdown every shift with a start date of 6/29/23. Review of Resident 22's Treatment Administration Record (TAR) dated 7/1/23 through 7/31/23, 8/1/23 through 8/31/23, and 9/1/23 through 9/12/23 indicated, order for LAL mattress was not administered pending delivery of the mattress. Review of Resident 22's Interdisciplinary Team (IDT) Note dated 8/18/23 indicated, Resident 22 had a Stage 2 PU on coccyx with new measurement of 2 cm x 3 cm and excoriation on bilateral buttocks with redness throughout the area observed. The facility was waiting for LAL mattress to get installed. During a concurrent interview and record review on 2/5/24 at 10:12 AM, with RN 3, Resident 22's Progress Notes (PN) was reviewed. The PN dated 6/29/23 through 7/30/23 did not indicate RN was notified of a change in Resident 22's skin condition. The PN dated 8/2/23 indicated, CNA (Certified Nursing Assistant) reported wound on resident's coccyx area, a Stage 2 PU and an excoriated bilateral buttock. RN 3 said, Stage 1 pressure injury was not identified, and stated, I don't see any report if there's redness, excoriation before it turned to Stage 2. RN 3 added, If it was identified at an early stage, we could have prevented it going to Stage 2. During a concurrent wound care observation and interview on 2/5/24 at 11:18 AM, with the Treatment Nurse (TN), the TN explained that she will do wound treatment on the resident's coccyx. Resident 22 was lying in bed with a pillow under his head, watching on his laptop. There was no device implemented to offload pressure from his coccyx. TN said, Resident 22's coccyx had an open wound with scant amount of pink drainage. During a concurrent observation and interview on 2/13/24 at 11:22 AM, with CNA 2, Resident 22 was in bed, lying on his back with a pillow under his head. There was no device implemented to offload pressure from his coccyx. CNA 2 said Resident 22 has a wound on his back and stated, We usually put a pillow when he's on his side or when on his back. CNA 2 acknowledged that there was no pillow placed under his back. Review of Resident 22's Care Plan (CP) edited on 12/22/23, indicated the following: .Problem: Risk for Skin Breakdown secondary to (s/t) Pressure Injury r/t diagnosis (DX), disease process . Goal: Patient will remain free from skin breakdown or any pressure injury x 90 days .target date: 4/3/24. Approach: Assess the overall condition of the skin every shift. Report to MD if new skin issue; Patient on special mattress (LAL); Remind the CNA to report to Team Leader (TL)/RN if there's any skin issues noted especially during activities of daily living (ADL) care .created 8/4/23 . Review of Resident 22's CP created on 2/2/24, indicated the following: .Problem: Resident's skin has actual impairment: Stage 2 Pressure Ulcer on coccyx .Problem start date: 8/2/23 . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555235 If continuation sheet Page 11 of 29 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 555235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ahmc Seton Medical Center 1900 Sullivan Avenue Daly City, CA 94015 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 Goal: Will have no complications through the review date .target date: 4/2/24. Level of Harm - Actual harm Approach: Monitor for increase in size and any changes in wound appearance; Wound Care follow up; Off-load affected area. Reposition every 2 hours or as needed; Administer treatment as ordered . Residents Affected - Few Review of facility policy titled Skin Care, Pressure Injury, and Wound Management last revised on 1/22 indicated, .II. Skin Inspection .B. Monitoring:1. The CNA checks the patient's/resident's skin during skin and routine care and turning schedules and reports any new skin issues to licensed nurses .III. Interventions .B. Care and Interventions: 1. The care and intervention for skin breakdown/wounds is intended to prevent wound advancement and/or additional skin breakdown .3. Wound Care Nurse .b. Nursing driven treatments may include .use of therapeutic support surfaces, and offloading measures . The Journal of Legal Nurse Consulting, Volume 23 Spring 2012 indicated, Pressure ulcers occur over bony prominences like the heels, sacrum, ischial tuberosities (sitting bones) or the greater trochanters (hip bones). Pressure, coupled with other comorbid states (medical conditions that are simultaneously present in a patient) such as diabetes, can further complicate treatment and increase risk. Pressure can be lessened by implementing an appropriate pressure-redistribution support surface to both the seated and recumbent (lying) surfaces that the patient's body contacts at the first sign of risk. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555235 If continuation sheet Page 12 of 29 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 555235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ahmc Seton Medical Center 1900 Sullivan Avenue Daly City, CA 94015 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of Resident 14's record titled Minimum Data Set assessment (MDS: a standardized resident assessment tool), dated 01/16/2024, indicated she was admitted to the facility on [DATE]. She was admitted to the facility with multiple diagnoses including: heart problem, high blood pressure, bladder problem, stroke, paralysis on one side of her body, breathing problems, and chronic pain. Her MDS indicated she was dependent on staff for toileting hygiene, transfers, and lower body dressing. During a concurrent interview and record review on 02/07/2024 at 05:27 PM with the DON. The DON stated ROM was ordered for Resident 14 every shift. Review of Resident 14's electronic charting indicated there were documentation omission for 02/01/2024 no day shift, 02/02/2024 no day shift, 02/08/2024 no night shift or day shift, 01/10/2024 no pm shift, 01/11/2024 no day shift. The DON stated there would be additional documentation if there were refusals or if the resident was unavailable or if staff were unable to perform ROM. The DON stated standard of practice was if it is not documented, it was not done. Review of facility policy titled Range of Motion Exercises last revised on 6/22 indicated, .Range of motion (ROM) exercises are performed to maintain and improve muscle strength and tone; prevent contractures; maintain circulatory integrity of the limbs; enhance the utilization of a body part in physical activity and prevent complications and disability .2. Nursing staff will be responsible for implementing the physician's order for ROM .Documentation: 1. CNAs will record actions and report any abnormal observations to licensed nurse . Based on interview and record review, the facility failed to provide preventive treatment and services to maintain and improve range of motion (ROM) for four of 14 sampled residents (Residents 12, 22, 38, and 14) when the physician's order for ROM exercises was not implemented. This deficient practice had the potential to limit the residents' ROM or possible development/worsening of a contracture. According to a Medical Dictionary, retrieved from http://medical dictionary.thefreedictionary.com/range+of+motion+exercise, on 2/16/24, indicated, . Range of motion is one aspect of exercise important for increasing or maintaining joint function . Passive range of motion is movement applied to a joint solely by another person or persons or a passive motion machine. When passive range of motion is applied, the joint of an individual receiving exercise is completely relaxed while the outside force moves the body part, such as a leg or arm, throughout the available range. Injury, surgery, or immobilization of a joint may affect the normal joint range of motion . The Medical Dictionary defines contractures as, the shortening of muscles and joints which limit and interfere with daily functioning. Findings: 1. Resident 12 was admitted on [DATE] with diagnoses including dementia ((loss of thinking, reasoning and remembering skills), cerebral infarction (also known as stroke-damage to the brain from interruption of its blood supply), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness or the inability to move on one side of the body). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555235 If continuation sheet Page 13 of 29 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 555235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ahmc Seton Medical Center 1900 Sullivan Avenue Daly City, CA 94015 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 1/30/24 at 12:49 PM, Resident was lying in bed, wearing heel lift boots, both lower extremities contracted. Review of Resident 12's Minimum Data Set (MDS - an assessment tool), dated 11/16/23, indicated, Resident 12 was moderately impaired with his cognitive skills, and ROM on one side of the upper and lower extremities was impaired and required assistance with activities of daily living. Review of Resident 12's Physical Therapy Evaluation dated 11/14/23 indicated, Resident 12's rehabilitation diagnosis was decline in function, with a problem in functional ROM and a treatment plan of therapeutic exercises. Review of Resident 12's Physician Order Report dated 2/1/24 to 2/29/24, indicated, Resident 12 had an order with a start date of 10/17/23, to do passive range of motion (PROM) during activities of daily living (ADL), minimum of 3 repetitions (reps) and maximum of 10 reps in estimated time of 5 to 15 minutes every shift, to both upper and lower extremities. Review of Resident 12's Restorative Nursing Report (RNR) with date range of 10/26/23 through 11/30/23, indicated as follows: On 10/26/23 to 11/8/23, No Restorative Nursing Data Recorded. On 11/9/23 to 11/30/23, staff did not record data every shift and time in minutes were left blank, except on 11/17 and 11/19/23. 2. Resident 22 was admitted on [DATE] with diagnoses including stroke, hemiplegia and hemiparesis. During an observation on 2/2/24 at 10:44 AM, Resident 22 was in bed watching on his laptop, left arm with contracture. Resident was able to move his right arm. Review of Resident 22's MDS dated 7/6/23, indicated, Resident 22 was severely impaired with his cognitive skills, and ROM on one side of the upper and lower extremities was impaired and required assistance with activities of daily living. Review of Resident 22's Physician Order Report dated 8/1/23 to 8/31/23 indicated, Resident 22 had an order with a start date of 7/7/23, to do PROM to left upper extremity (LUE) and active assisted ROM to right upper extremity during ADLs, minimum of 3 reps and maximum of 10 reps in estimated time of 5 to 15 minutes every shift and/or as tolerated. Review of Resident 12's RNR with date range of 7/1/23/ through 7/31/23, indicated, for PROM, staff did not record data every shift and time in minutes were left blank, except on the following dates: 7/12, 7/13, 7/20, 7/22 to 7/27, 7/29, and 7/31/23 (11 days). Review of Resident 12's RNR with date range of 8/1/23/ through 8/31/23, indicated, for PROM, staff did not record data every shift and time in minutes were left blank, except on the following dates: 8/5, 8/14, 8/16 to 8/18, and 8/29/23 (6 days). Review of Resident 12's RNR with date range of 9/1/23/ through 9/30/23, indicated, for PROM, staff did not record data every shift and time in minutes were left blank, except on the following dates: 9/7, 9/8, and 9/21/23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555235 If continuation sheet Page 14 of 29 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 555235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ahmc Seton Medical Center 1900 Sullivan Avenue Daly City, CA 94015 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident 12's RNR with date range of 10/1/23/ through 10/31/23, indicated, for PROM, staff did not record data every shift and time in minutes were left blank, except on the following dates: 10/6, 10/13, 10/16, 10/18, 10/20, 10/24 to 10/27, and 10/30/23 (11 days). Review of Resident 12's RNR with date range of 12/1/23 through 12/31/23, indicated, for PROM, staff did not record data every shift and time in minutes were left blank, except on the following dates: 12/6, 12/12, 12/16, and 12/28/23. Review of Resident 12's RNR with date range of 1/1/24 through 1/31/24, indicated, for PROM, staff did not record data every shift and time in minutes were left blank, except on the following dates: 1/3, 1/23, and 1/27/24. 3. Resident 38 was admitted on [DATE] with diagnoses including quadriplegia (condition in which both arms and legs are paralyzed and lose normal motor function), and cerebral infarction (also known as stroke). During an observation on 01/29/24 10:43 AM, Resident 38 was in bed, with contractures on both arms, had towel roll on left hand. Review of Resident 38's MDS dated 1115/23, indicated, Resident 38 was severely impaired with her cognitive skills, and ROM on both sides of the upper and lower extremities was impaired and was dependent with activities of daily living. Review of Resident 38's ADL Care Plan edited on 2/8/24, indicated the following: Problem: Limited ROM/Physical Mobility related to (r/t) quadriplegia problem start date: 11/8/23 . Goal: 1. Will participate in ADLs and prescribed therapies .3. Will be free from complications of immobility . Approach: Approach Start Date: 11/8/23 . Nursing to perform ROM exercises to all extremities during ADLs .minimum of 3 reps and maximum of 10 reps in estimated 5-15 mins and/or as tolerated to increase venous returns, prevent stiffness, maintain muscle strength, and avoid contracture deformation .CNA to document number of ROM (minutes and reps) provided in ADL flowsheet . Review of Resident 38's RNR with date range of 11/1/23 through 11/30/23, indicated, on 11/9/23 through 11/30/23, staff did not record data every shift and time in minutes were left blank, except on the following dates: 11/10, 11/21, and 11/29/23 (3 days). Review of Resident 38's RNR with date range of 12/1/23 through 12/31/23, indicated, on 12/1/23 through 12/31/23, staff did not record data every shift and time in minutes were left blank, except on the following dates: 12/2-12/4, 12/8, 12/14, 12/16-12/17, 12/19, 12/22, 12/27, 12/19, and 12/31/23 (12 days). Review of Resident 38's RNR with date range of 1/1/24 through 1/31/24, indicated, staff did not record data every shift and time in minutes were left blank on the following dates: 1/1, 1/2, 1/4, 1/6, 1/7, 1/9, 1/16, 1/18, 1/20, 1/26, 1/28, 1/29, and 1/31/24 (13 days). During an interview on 02/02/24 09:46 AM, Registered Nurse (RN) 3, stated, If blank or dash, it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555235 If continuation sheet Page 15 of 29 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 555235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ahmc Seton Medical Center 1900 Sullivan Avenue Daly City, CA 94015 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 0688 means ROM was not performed or not documented. Level of Harm - Minimal harm or potential for actual harm During an interview on 02/06/24 02:31 PM, Certified Nurse Assistant (CNA) 1 said, ROM exercise is done five minutes in the morning every day during ADLs or turning and repositioning. CNA 1 stated, If we don't do ROM exercises, resident can develop contracture. Residents Affected - Some During an interview on 02/08/24 10:17 AM, the Director of Nursing (DON) said, the facility has no RNA program, that all CNAs are responsible for ROM exercises. If ROM exercises are not provided to the resident, DON stated, Resident can develop a contracture and a change in condition (ADL decline). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555235 If continuation sheet Page 16 of 29 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 555235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ahmc Seton Medical Center 1900 Sullivan Avenue Daly City, CA 94015 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 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 pharmacy consultant's recommendation for the use of psychotropic medication was acted upon for one of eight sampled residents (Resident 86). This failure had the potential for Resident 86 to receive unnecessary psychotropic medications, be exposed to adverse health consequences from the medications, which could negatively impact the residents' mental, physical, and psychosocial well-being. Findings: Resident 86 was admitted on [DATE] with diagnoses including mood disorder (described by marked disruptions in emotions), major depressive disorder (medical illness that negatively affects how you feel, the way you think and how you act). Review of Resident 86's Physician Order Report dated 12/1/23 through 12/31/23 indicated, .Start date 11/27/23 Risperdal (Risperidone) 1 mg 1 tab oral at bedtime .for mood disorder . Review of Resident 86's Pharmacy Services: Initial Medication Regimen Review (MRR) dated 11/26/23 indicated, .D (diagnosis): Mood Disorder (need to be more specific): Risperidone 0.5 mg .Irregularities: Mood Disorder is not an appropriate diagnosis for antipsychotic use .as it may be viewed as a chemical restraint especially when used in the post-acute care (long term care, skilled nursing facilities) . Review of Resident 86's Pharmacy Services: MRR dated 12/13/23 indicated, .D: Mood Disorder (need to be more specific): Risperidone 0.5 mg .Irregularities: Mood Disorder is not an appropriate diagnosis for antipsychotic use .as it may be viewed as a chemical restraint especially when used in the post-acute care (long term care, skilled nursing facilities) . During an interview on 2/5/24 at 3:14 PM with Pharmacist 1, Pharmacist 1 said, MRR is done monthly, and all medications are reviewed. Identified irregularities are communicated to the RN and the physician. Pharmacist 1 acknowledged that identified irregularities for Resident 86 were uncorrected by the physician. During an interview on 2/8/24 at 10:17 AM with the Director of Nursing (DON), the DON said, identified irregularities in the MRR is communicated to the physician verbally by the nursing staff and documented in the progress notes if the physician agrees or disagrees. When queried about the pharmacist's identified irregularities for Resident 86's use of antipsychotic medication not acted upon by the physician, the DON stated, Possible missed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555235 If continuation sheet Page 17 of 29 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 555235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ahmc Seton Medical Center 1900 Sullivan Avenue Daly City, CA 94015 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 0758 Level of Harm - Actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure three of eight sampled residents (Residents 409, 70, and 86) were free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) when the facility did not ensure: 1.Resident 409 a. was free from side effects due to the use of Haldol. Haldol is an anti-psychotic drug used to treat symptoms of psychosis. Symptoms of psychosis includes hallucinations (perceiving sights, sounds, smells, tastes, or touches that are not real), delusions (false beliefs), and dementia (loss of the ability to think, remember, learn, make decisions, and solve problems). b. Aggressive behaviors were managed via non-medication means such as modifying smoking rules. c. Haldol dosage was not lowered for 96 days when side effects were first identified. 2. Resident 70 a. there was no clinical indication for the use of Citalopram (an antidepressant drug). b. order for Ativan (also known as lorazepam, a medication used to treat anxiety [a condition characterized by extreme fear and worry that interferes with daily activities]) PRN (as needed) did not have a stop date. 3. Resident 86 a. there was no clinical indication for the use of Risperdal (an antipsychotic medication). b. order for Ativan PRN did not have a stop date. These failures led to Resident 409 developing side effects from the use of Haldol and being put on Ingrezza. Ingrezza is a medication to counteract the side effects of Haldol. For Residents 70 and 86 these failures had the potential for them to receive unnecessary psychotropic medications, be exposed to adverse health consequences from the medications, which could negatively impact the residents' mental, physical, and psychosocial well-being (having to do with the mental, emotional, and social aspects of a resident's life). Findings: 1. Review of Resident 409's record titled Minimum Data Set assessment (MDS - a standardized resident assessment tool), dated 01/11/2024, indicated he had multiple admissions and discharges to the facility. The last admission was dated 12/27/2023. He was admitted to the facility with multiple diagnoses including anxiety disorder, vascular dementia with behavioral disturbances (blood vessel related loss of intellectual ability manifested by verbal or physical aggression, agitation and/or wandering). According to his MDS, he scored 6 out of 10 on his Brief Interview for Mental Status assessment (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555235 If continuation sheet Page 18 of 29 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 555235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ahmc Seton Medical Center 1900 Sullivan Avenue Daly City, CA 94015 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 0758 Level of Harm - Actual harm Residents Affected - Few (BIMS - assessment tool used to determine mental status and memory). A BIMS score of 6 indicated, Resident 409 had severe problems with reasoning and memory. His MDS indicated he had no physical behavior directed towards others (hitting, kicking, pushing, grabbing), no verbal behavior directed towards others (threatening others, screaming or cursing at others) and no other behaviors not directed toward others. Review of Resident 409's record titled Physician Orders, dated 1/1/2023, indicated, he has been on Haldol 5 mg (milligram) twice a day since 1/1/2023, to treat a major neurocognitive disorder with behavioral disturbances continues screaming; yelling. Major neurocognitive disorder is a decreased mental function due to a medical disease other than a mental illness. Review of Resident 409's record titled Medication Regimen Review (MRR), dated 10/18/2021, indicated, .NUMEROUS REPORTS OF AGRESSION, SCREAMING AND YELLING-TYPICALLY IN SETTING OF WANTING TO SMOKE. Review of Resident 409's record titled Consult Note - Psychiatry, dated 10/30/2021, indicated, .Psychiatry re-consulted after episode of agitation, via telephone today, when .(resident) was refusing to respond to limits set and escalated, refusing .(to) allow lighter to be taken away and refusing to listen to RN (Registered Nurse). During an interview on 2/14/2024 at 7:48 AM, RN 3 stated Resident 409's aggressive behaviors seem to be centered around smoking. During an interview on 2/14/2024 at 8:01 AM, Certified Nursing Assistant (CNA) 3 stated Resident 409 can be .anxious when you are like not on time with what he wants. He doesn't really want to wait. to be change or for his medications. when he pushes the call light, he wants it immediately. CNA 3 was asked if Resident 409's aggressive behaviors were centered around not getting his cigarettes on time, running out of cigarettes, and an inability to keep his own lighter, CNA 3 stated, Yes. During an interview on 2/14/2024 at 9:50 AM, the Director of Infection Prevention (DIP) stated, We were cited previously for not having a structured smoking program in place to make sure residents were safe. So, we put one in place and this is the consequence of that. Some residents can get agitated, when there's a change. The above record reviews and staff interviews were shared with the DIP. The DIP agreed that issues around smoking appear to be a trigger for Resident 409's aggressive behaviors. The DIP was asked if the facility was medicating Resident 409 for a facility imposed smoking restrictions such as: scheduled smoking times, restrictions to cigarettes, and giving up his lighter, the DIP did not verbally answer and just shrugged his shoulders. Review of Resident 409's record titled PHARMACY SERVICES MRR CHART REVIEW, dated 03/23/2023, indicated, Resident 409 had side effects associated with Haldol. Staff charted Resident 409 was on .(Haldol) 5MG . (twice a day).RESIDENT OBSERVED WITH JAW GRINDING AND CLENCHING, SIALORRHEA. (excessive saliva production and drooling) HALDOL IS KNOWN TO CAUSE SIALORRHEA, DYSPHAGIA, AND SWALLOWING ISSUES. Review of Resident 409's record titled Prescription Order, dated 6/27/2023, indicated he was not started on Ingrezza, a medication to treat Haldol's side effects, until 6/27/2023. During an interview on 2/14/2024 at 9:49 AM, Pharmacist 1 stated that there was a delay in starting Ingrezza as this was a specialty medication that required a third party approval. Pharmacist 1 was asked if decreasing Haldol dosage while waiting for the Ingrezza to be approved was a viable clinical option, Pharmacist 1 said Yes, the team would recommend that. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555235 If continuation sheet Page 19 of 29 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 555235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ahmc Seton Medical Center 1900 Sullivan Avenue Daly City, CA 94015 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 0758 Level of Harm - Actual harm Residents Affected - Few Review of Resident 409's records titled History and Physical, dated 1/23/2023, and Initial Medication Regimen Review, dated 1/11/2024, indicated Resident 409's Haldol has not been lowered. Resident 409 has been on Haldol 5 mg twice a day for this entire time. 2. Resident 70 was admitted on [DATE] with diagnoses including dementia, delusional disorders and anxiety disorder. Review of Resident 70's Physician Order Report dated from 2/1/24 through 2/29/24 indicated, .Start Date 11/30/23 .Citalopram 10 mg (milligram) 1 tab (tablet) oral once a day . Review of Resident 70's Medication Administration Record for December 2023 indicated, .Citalopram 10 mg 1 tab oral once a day . was administered on 12/1/23 through 12/31/23 at 8 AM. Review of Resident 70's Medication Administration Record for January 2024 indicated, .Citalopram 10 mg 1 tab oral once a day . was administered on 12/1/23 through 12/31/23 at 8 AM. Review of Resident 70's Medication Administration Record for January 2024 indicated, .Citalopram 10 mg 1 tab oral once a day . was administered on 1/1/24 through 1/31/24 at 8 AM. Review of Resident 70's admission MDS dated 7/18/23 and quarterly MDS dated 1/11/24 indicated, Resident 70 was admitted with diagnoses including dementia and anxiety disorder. Diagnosis of depression was not coded on the MDS. During a concurrent interview and record review on 2/7/24 at 2:16 PM with Registered Nurse (RN)3, Resident 70's History and Physical was reviewed. RN3 stated, I cannot find any diagnosis of depression. Review of Resident 70's Physician Order Report dated from 2/1/24 through 2/29/24 indicated, .Start date: 7/13/23 .End date: open-ended .lorazepam 0.5 mg every 4 hours PRN . During an interview on 2/5/24 at 3:14 PM with Pharmacist 1, Pharmacist 1 said, MRR is done monthly, and all medications are reviewed. Identified irregularities are communicated to the RN and the physician. For psychotropic medications, Pharmacist 1 said, PRN medications are recommended for 14 days and should be renewed after. 3. Resident 86 was admitted on [DATE] with diagnoses including mood disorder (described by marked disruptions in emotions), major depressive disorder (medical illness that negatively affects how you feel, the way you think and how you act). Review of Resident 86's Physician Order Report dated 12/1/23 through 12/31/23 indicated, .Start date 11/27/23 Risperdal (Risperidone) 1 mg 1 tab oral at bedtime .for mood disorder . Review of Resident 86's Pharmacy Services: MRR dated 11/26/23 and 12/13/23 indicated, .D (diagnosis): Mood Disorder (need to be more specific): Risperidone 0.5 mg .Irregularities: Mood Disorder is not an appropriate diagnosis for antipsychotic use .it may be viewed as a chemical restraint especially when used in the post-acute care (long term care, skilled nursing facilities) . Review of Resident 86's admission MDS dated 11/27/23 indicated, Resident 86 was admitted with diagnoses including stroke and depression. Diagnosis of psychotic disorder was not coded on the MDS. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555235 If continuation sheet Page 20 of 29 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 555235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ahmc Seton Medical Center 1900 Sullivan Avenue Daly City, CA 94015 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 0758 During an interview on 2/5/24 at 11:16 AM with RN3, RN3 stated, I don't see any diagnosis of psychosis, only depression and mood disorder. Level of Harm - Actual harm Residents Affected - Few Review of Resident 86's Physician Order Report dated 2/1/24 through 2/29/24 indicated, .Start date: 12/13/23 .End date: open ended .lorazepam 0.5 mg BID (twice a day) PRN . Review of Resident 86's Pharmacy Services: MRR dated 12/13/23 indicated, .D: Anxiety: Lorazepam 0.5 mg ordered as PRN and without frequency .Need to have specific frequency and duration of therapy . During an interview on 2/5/24 at 3:14 PM with Pharmacist 1, Pharmacist 1 acknowledged that identified irregularities for the use of Lorazepam by Resident 86 were uncorrected by the physician. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555235 If continuation sheet Page 21 of 29 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 555235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ahmc Seton Medical Center 1900 Sullivan Avenue Daly City, CA 94015 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 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. Based on observation, interviews, and record review, the facility failed to maintain a sanitary environment by neglecting to properly clean one of the four fixed kettles between serving porridge and soup for lunch. Additionally, kitchen prep surface drainage holes, encrusted with dried, unidentifiable food particles, were exposed and untreated. This failure had the potential to result in potential health risks to residents. Findings: During a kitchen observation on Tuesday, 01/30/24 at 10:28 AM, four large empty built-in cooking kettles were noticed, with only the last kettle functioning. At 10:36 AM, a stainless-steel prep table near the outside of dietary offices revealed a hole approximately 2 inches in diameter, uncovered, and encrusted with food residue. Another prep table on the opposite side of the room had a similar uncovered hole, also encrusted with unknown residue. In an interview on 01/30/2024 at 10:55 AM with S14 (Dietary cook), S14 explained the process of cleaning the kettle, stating, I rinse after cooking. If using 'creamier' items that leave residue on the sides, I will sometimes scrub if needed. During an interview with S04at 2 PM on 01/30/2024, S04 indicated dietetic staff should clean and sanitize fixed equipment between each use. Review of the facility's P & P titled Food Service Equipment Safety and Sanitation last dated 9/2033, page 2 of 3 indicated for Steam Kettles Positive locking devices shall be provided to hold steam kettles in the desired position. Kettles are cleaned and sanitized after each use to reduce the risk of cross contamination using appropriate chemical solutions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555235 If continuation sheet Page 22 of 29 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 555235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ahmc Seton Medical Center 1900 Sullivan Avenue Daly City, CA 94015 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain an accurate record for 3 of 24 sample residents (Resident 25, 396, and 397). For Residents 25 and 397, staff failed to document their fluid intake accurately. For Resident 396 an anti-psychotic target behavior was documented incorrectly. Failure to accurately document fluid intake or target behavior has the potential for the care team to act or recommend treatment based on inaccurate information. Findings: 1. Review of Resident 397's record titled Minimum Data Set(MDS- an assessment form), dated 11/10/2023, indicated he was admitted to the facility on [DATE] with multiple diagnoses including: gastric reflux (stomach acid flows back towards mouth), anxiety, asthma, diabetes (blood sugar control issues), noncompliant with medical treatment, and localized fluid retention. Review of Resident 397's matrix provided by the facility 01/31/2024 indicated he had excessive unplanned weight loss. Part of managing a resident with unplanned weight loss is accurate documentation regarding their food and fluid intakes. Interviews with direct care staff indicated they were not recording fluid intake accurately. Review of their fluid intake documentation found inaccurate entries. During an interview on 02/07/2024 at 10:01 AM CNA 3 stated we combine the whole meal including the fluid intake we don't separate those out unless they have extra fluids outside of the tray or they ask for extra fluid then we chart those. During an interview with the Registered Dietitian (RD) on 02/07/2024 at 9:59 AM, the RD stated her expectation was that staff should be charting the meal percent eaten separate from the fluid intake. For example, 50% consumed in food and 250 cc in fluid. Those two should be charted separately, not combined as stated by CNA 3. 2. Review of Resident 396's record titled MDS, dated 11/13/2023, indicated she was admitted to the facility on [DATE] with multiple diagnoses including: anxiety, depression, schizophrenia (mental illness-seeing or hearing things that are not there), and bipolar (mental illness with extreme mood swings). During a concurrent record review and interview with RN 8 on 02/07/2024 at 9:11 AM, RN 8 stated the target behavior for Resident 396 for bipolar was hallucination e.g. hearing voices, paranoia e.g. suspicious of staff, and delusion e.g. seeing things or person. RN 8 was asked to differentiate between hallucination and delusion. RN 8 agreed that the target behavior delusion seeing things or person needs to be revised/clarified. 3. Review of Resident 25's record titled MDS, dated 10/10/2023, indicated he was admitted to the facility on [DATE] with multiple diagnoses including: anemia (low blood cells), high blood pressure, kidney failure (kidney produces urine and elimates toxins) require dialysis (the process of removing excess water and toxins from the blood in people with kidney disease), and diabetes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555235 If continuation sheet Page 23 of 29 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 555235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ahmc Seton Medical Center 1900 Sullivan Avenue Daly City, CA 94015 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 0842 Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review on 02/07/2024 at 2:41 PM, RN 1 stated Resident 25 was on a 1200 ml (milliliter) fluid restriction. Some dialysis residents are placed on fluid restrictions to control swelling, high blood pressure and fluid buildup in the lungs. Review of the Resident 25's paper-based intake and output (I/O) for January 2024 found low total entries 510 ml, 580 ml, and 430 ml. RN 1 admitted that the I/O record was Resident 25 was not accurate. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555235 If continuation sheet Page 24 of 29 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 555235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ahmc Seton Medical Center 1900 Sullivan Avenue Daly City, CA 94015 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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure education regarding protective vaccine were documented and follow up and/or refusals were documented in two of four sampled resident's records (Residents 70 and 88). Residents Affected - Few Failure to document education did not ensure residents and/or their responsible parties could make an informed decisions regarding vaccines. Failure to follow up and/or document refusals did not ensure residents healthcare choices were honored. Findings: Pneumovax vaccines help our bodies develop immunity to the bacteria that causes pneumonia. During a concurrent record and interview with RN 5 on 02/02/2024 at 11:18 AM, these items were found missing: 1. Resident 88: no pneumovax vaccine was administered, no refusal for pneumovax, and no education regarding pneumovax. 2. Resident 70: no pneumovax vaccine was administered, no refusal for pneumovax, and no education regarding pneumovax. RN 5 was asked to search these records for the missing information and RN 5 was unable to find the information. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555235 If continuation sheet Page 25 of 29 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 555235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ahmc Seton Medical Center 1900 Sullivan Avenue Daly City, CA 94015 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 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. Based on interview and record review, the facility failed to ensure education regarding protective vaccine were documented and follow up and/or refusals were documented in two of four sampled resident's records (Residents 13 and 89). Failure to document education did not ensure residents and/or their responsible parties could make an informed decisions regarding vaccines. Failure to follow up and/or document refusals did not ensure residents healthcare choices were honored. Findings: COVID-19 vaccines help our bodies develop immunity to the virus that causes COVID-19. During a concurrent record review and interview with RN 5 on 02/02/2024 at 11:18 AM, these items were found missing: 1. Resident 89, no COVID-19 vaccine was administered, no refusal for COVID-19 vaccine, and no education regarding COVID - 19 vaccine. 2. Resident 13, no COVID- 19 or pneumovax vaccine were administered, no refusals for COVID -19 or pneumovax vaccines and no education regarding COVID- 19 and pneumovax. RN 5 was asked to search these records for the missing information and RN 5 was unable to find the information. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555235 If continuation sheet Page 26 of 29 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 555235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ahmc Seton Medical Center 1900 Sullivan Avenue Daly City, CA 94015 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, an emergency cart plastic lock tag did not match the lock tag documented on the log. Failure to follow procedure regarding logging lock tags did not ensure emergency devices and/or supplies would be available in the event of an medical emergency. Residents Affected - Few Findings: During initial rounds on 01/29/2024 at 12:45 PM, a crash cart's (a cart containing essential life saving devices, medications and other supplies) red plastic lock tag (placed to ensure no one has accessed or tampered with the cart) was found not to match the information on the crash cart's log book. This observation was confirmed with RN 7. RN 7 was unable to provide an explanation of why the tag does not match the one in the log book. RN 7 explained that once the cart is accessed, the whole cart is sent to central supply to be re-stocked and new red plastic lock tag installed and the tag number is entered into the log book. Review of the facility's policy titled Pharmacy: Emergency Drugs: Crash Carts / Drug Trays / Boxes, revised on 3/21, indicated .Emergency crash carts in strategic locations throughout the patient care units will be standardized for easy use by all personnel with maintenance of these carts being a joint responsibility of Pharmacy personnel, pharmacist or pharmacy technician, and Departmental personnel.The crash cart will be physically checked every 30 days by the Pharmacist or pharmacy technician to ensure that all required equipment, supplies, and drugs are readily available. New locks will be applied, pulled tight and documented. Label will be put on the crash cart to note that the cart has been visually inspected.Departmental personnel will document these routine checks and take appropriate actions should any items be missing or need replacement. The policy provided by the facility failed to address the responsibility of floor staff in documenting how the red tags are checked and documented in a logbook. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555235 If continuation sheet Page 27 of 29 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 555235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ahmc Seton Medical Center 1900 Sullivan Avenue Daly City, CA 94015 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 0920 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to provide for a community dining and activity area on the 4th floor, 5th floor, and 7th floors, resulting in residents being confined to their rooms for all meals. Findings: During an observation on 01/29/2024 at 11:45 AM, there was no common area/dining room for the residents noted on the 7th floor. During an observation on 01/30/2024 at 03:50 PM on the 9th floor, there were no added chairs/tables. The room is currently being used for singing activity. Residents from 4th, 5th, and 7th floors share use of this one room. Capacity is limited, especially with all residents brought in wheelchairs accompanied by their CNAs. During an observation on 01/30/24 at 04:35 PM, there was no common area/dining room for the residents on the 5th floor. During an interview with S04 (Director of Dietary) on 2/01/2024 at 3:25 PM, stated unaware if [NAME] has any plans for installing a dining area on each floor. During an interview with S01 (Director of Admin) on 2/01/2024 at 4:55PM, stated Coastside is still awaiting insurance estimates for future plans. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555235 If continuation sheet Page 28 of 29 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 555235 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/14/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ahmc Seton Medical Center 1900 Sullivan Avenue Daly City, CA 94015 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 0924 Put firmly secured handrails on each side of hallways. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to have a secure handrail in their corridor. Failure to maintain handrails did not ensure residents who relied on handrails for mobility and/or support would be safe from a fall. Residents Affected - Few Findings: During initial tour on 01/29/2024 at 10:29 AM, a handrail outside room [ROOM NUMBER] was found not secured properly to the wall. This observation was confirmed with RN 6. RN 6 stated she would inform maintenance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555235 If continuation sheet Page 29 of 29