Health inspection·May 8, 2025

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide a written notice of bed hold (holding or reserving a resident ' s bed while the resident is absent from the facility for therapeutic leave or hospitalization) to four of four sampled residents (Resident 1, 2, 3, and 4) or their responsible party (RP) at the time of transfer to acute care hospital. This failure could result in residents and/or their RP not being fully informed of their right to request a bed hold and to return to the facility after hospitalization, potentially leading to inappropriate discharge. Findings: 1. Resident 1 was initially admitted on [DATE] and was readmitted on [DATE], with diagnoses that include encephalopathy (a general term that describes brain disease, damage, or malfunction usually related to inflammation within the body) and urinary tract infection (an infection in any part of the urinary system). During a concurrent interview and record review on 5/8/25 at 3:37 PM, the Assistant Director of Nursing (ADON) reviewed the facility document, titled Admit/Discharge Report (ADR), dated 12/1/24 to 1/31/25. The ADR indicated Resident 1 was hospitalized on [DATE] and returned to the facility on 1/30/25. During an interview on 5/8/25 at 4:36 PM, Resident 1's RP was sent to the emergency room on 1/8/25. Resident 1's RP stated, They (facility) never gave a 7 (seven) - day hold notice (bed hold notice). She was not given anything. Neither was I. During a concurrent interview and review of Resident 1 ' s electronic health record (EHR) on 5/14/25 at 10:04 AM, Registered Nurse (RN) 1 was unable to find evidence that a written notice of bed hold was given to Resident 1 or their RP. 2. Resident 2 was initially admitted on [DATE] and re-admitted on [DATE], with diagnoses that include left femoral neck fracture (a break in the upper part of the thigh bone that connects the rounded ball of the hip joint to the long shaft of the thigh bone). During a concurrent interview and record review on 5/8/25 at 11:12 AM, the ADON reviewed the ADR. The ADR indicated Resident 2 was transferred to the hospital on 1/5/25 and was discharged to another facility on 1/13/25. Page 1 of 2 555235 555235 05/08/2025 Ahmc Seton Medical Center 1900 Sullivan Avenue Daly City, CA 94015

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 5/8/25 at 2:34 PM, Resident 2 ' s RP was asked if the facility gave a written notice of bed hold during Resident 2 ' s hospitalization on 1/5/25. Resident 2 ' s RP stated, No. I don ' t remember seeing a bed hold notice .they (facility) did not give us a copy. Resident 2's RP further stated, I didn ' t know she (Resident 2) can come back (to the facility) after going to the hospital even after it ' s past 7 days. During a concurrent interview and record review on 5/14/25 at 9:50 AM, RN 1 reviewed Resident 2 ' s EHR. RN 1 was unable to find documentation that a written notice of bed hold was given to Resident 2 ' s RP. RN 1 stated, No, when asked if Resident 2 ' s RP was given a written notice of bed hold. 3. Resident 3 was initially admitted on [DATE] and re-admitted on [DATE], with diagnoses that include congestive heart failure (a condition where the heart can't pump enough blood to meet the body's needs) and hypertensive heart disease with heart failure (damage to the heart muscle due to long-term high blood pressure leading to heart failure). During a concurrent interview and record review on 5/8/25 at 10:25 AM, the ADON reviewed Resident 3 ' s EHR. The ADON stated Resident 3 was hospitalized on [DATE] and returned to the facility on 5/6/25. The ADON was unable to find evidence that a written notice of bed hold was given to Resident 3 ' s RP. When asked how bed hold notification is given to the resident or their RP, the ADON stated, Usually verbal because they ' re (RP) not here during transfer to acute care (hospital). The ADON added, We fax it (bed hold notice) to the billing office. It ' s available if they (resident or RP) want a copy. 4. Resident 4 was initially admitted on [DATE] and re-admitted on [DATE], with diagnoses that include acute bronchitis (a short-term inflammation of the bronchi, the tubes that carry air to your lungs). During a concurrent interview and record review on 5/8/25 at 10:56 AM, the ADON reviewed the ADR. The ADR indicated Resident 4 was transferred to the hospital on 1/29/25 and returned to the facility on 1/30/25. During a concurrent interview and record review on 5/14/25 at 9:26 AM, RN 1 stated Resident 2 ' s family members were notified of the transfer to the hospital via phone. When asked if a written notice of bed hold was given to Resident 2 ' s RP, RN 1 stated, No. Review of the facility policy, titled Bed Hold, revised on 8/2020 and 3/2025, indicated Policy: Residents who require transfer to an acute facility for hospitalization, have the right to request a bed hold. The facility will provide information to the residents/responsible party regarding bed hold during the admission process. When a resident is transferred for acute hospitalization, written notice of his/her right to request a bed hold will be given to the resident/responsible party. Within 24 hours of receipt of the notice, the resident/responsible party shall notify the facility of the request for a bed hold. 555235 Page 2 of 2