Health inspection·February 10, 2023

F 0600 3. Level of Harm - Minimal harm or potential for actual harm Oxycodone (an opioid pain medication used to treat moderate to severe pain. This opioid medication is controlled by the FDA=Food and Drug Administration to minimize risk for addiction) every eight hours as needed for moderate to severe pain. Residents Affected - Few Review of Resident 20's medical records titled ED to Hosp-Admission, dated 12/9/2022, indicated Resident 20 was admitted for worsening of her pancreatitis. Within the same document, staff assessments indicated she was experiencing uncontrolled sharp severe stomach pain. During an interview on 2/7/23 at 10:00 AM, Resident 20 stated I have to wait a long time for my pain medication. It's usually agency nurse. They don't know me and they make me wait. It's very painful. I have this pancreatitis. One time with this agency nurse I waited at least 20 minutes. The regular staff they know. They know to bring my pain medicine right away when I call. So painful, I get mad at them when they don't come with my pain medicine. Last time they sent me to . hospital for my stomach pain. I get scared if they don't come (with my pain medication). I don't want to go to hospital again. Resident 28 Review of Resident 28's record titled admission RECORD, printed on 2/9/2023, indicated she was admitted with multiple diagnosis including: Quadriplegia (unable to have full control of arms and legs), spinal cord injury, spinal bone fracture, cramps and spasms, depression and assistance with personal care. Review of Resident 28's record titled MDS, dated 1/23/2023, indicated her BIMS score was 12 out of 15. A score of 12 indicated moderate impairment in memory and reasoning. According to her MDS, she required extensive assistance of two staff for bed mobility, transfers, dressing, and personal hygiene. According to her MDS she was totally dependent on the assistance of two staff for bowel incontinence. She has a suprapubic catheter (a tube draining the bladder). She displayed no episodes of hallucination, no delusion, and no rejection of care. Review of Resident 28's care plans, printed on 2/9/2023, indicated her pain medications included: Tramadol (Tramadol is an opioid pain medication used to treat moderate to severe pain. This opioid medication is controlled by the FDA=Food and Drug Administration to minimize risk for addiction), and gabapentin (a medication for nerve pain and muscle spasms). Resident 28's care plan also indicated .The resident needs to change position every 2-3 hours. Alternate periods of rest .with activity out of bed in order to prevent respiratory complications, . During an interview on 2/9/23 at 3:45 PM, CNA 4 (Certified Nursing Assistant) stated, Resident 28 complains about her call light not being answered. During a concurrent observation and interview on 2/9/23 at 3:50 PM in Resident 28's room, Resident 28 was observed with a special call light, a round, flat rubber laying on her left abdomen just below her chest. Observation indicated Resident 28 was able to move her left arm/hand. During the interview, Resident 28 stated, .They don't have (enough) help at night! Only two CNAs for 40 patients . Review of a communication between Resident 28 and this Department (on a document called Intake Information), dated 2/3/2023, indicated .Today Monday January the 30th there was no nursing staff making (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555276 If continuation sheet Page 2 of 7 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 555276 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Bruno Skilled Nursing 890 El Camino Real San Bruno, CA 94066 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few medication passes or focusing on patient medical needs for my wing of this facility. I am to have a round of morning medication's including anti-contracture medication and muscle relaxers between 8 and 9 AM. At 10:30 AM I began having muscle contractions and contractures that I could not control and they were very painful. During a second interview on 2/10/23 at 3:05 PM, Resident 28 stated, .the medication, if my pain pill is late my muscle does a lot of contraction and muscle spasm.Everything will be fine if they fully staff the night and evening shift. Resident 32 Review of Resident 32's record titled MDS, dated 12/28/2022, indicated his BIMS score was 15 out of 15. A score of 15 indicated no impairment in memory and reasoning. According to his MDS, he required: extensive assistance of two staff for bed mobility; extensive assistance of two staff for personal hygiene; extensive assistance of one staff for transfers; extensive assistance of one staff to use the toilet. According to his MDS he was always incontinent of bowel and bladder (has no control over his urine and stool); he displayed no episodes of hallucination (seeing, hearing, or sensing things that are not based on reality), no delusion (believing in something that is not based on reality), and no rejection of care. Review of Resident 32's record titled admission RECORD, printed on 2/10/23, indicated he was admitted with multiple diagnosis including: Spinal stenosis to the lower part of the spine (Spinal stenosis is deformation of the spinal bones, causing pain, numbness, muscle weakness, and loss of urine or stool control). Review of Resident 32's record titled PACS-MEDICATION ADMINISTRATION RECORD, printed on 2/10/2023, indicated Resident 32 was on multiple medications to control his pain. Resident 32 was on : 1. Acetaminophen (over the counter pain medication to treat mild and moderate pain) three times a day for chronic knee pain. 2. Lidocaine 5% patch (a patch with pain medication to numb nerves in specific area of the body) every 12 hours for chronic knee pain. 3. Gabapentin twice a day. 4. Tramadol every eight hours as needed for moderate to severe pain. Using the medication administration record above, Tramadol usage analysis for the month February (2/1/2023 to 2/10/2023), indicated there were 30 opportunities for Tramadol administration. Staff administered 13 doses of Tramadol during this time period (43.3% of the time, Resident 32 was in pain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555276 If continuation sheet Page 3 of 7 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 555276 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Bruno Skilled Nursing 890 El Camino Real San Bruno, CA 94066 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 0600 and asked for Tramadol on as needed basis for pain relief). Level of Harm - Minimal harm or potential for actual harm During an interview on 2/7/23 at 12:10 PM, Resident 32 stated They answer my call light but it might be an hour before the nurse come to give me my pain medication. I be ringing my call light. I see them walking past, I hear them talking in the hallway. They have all kind of excuses when they answer my call light: I was on break, I had to help another patient . I am not getting the best of service here. Can you imagine, I'm already at maximum pain, I ask for pain medication and they make you wait and wait. The service here is lousy, makes me feel neglected when I have to wait and wait for them to come help me. Residents Affected - Few Staff interviews During an interview on 2/10/23 at 11:53 AM, CNA 1 (Certified Nursing Assistant) stated I remember working there on PM shift. For two hours, the regular staff were just arguing about assignment. And nobody was answering the call light. The call light was just ringing and ringing. During an interview on 2/10/23 12:40 PM, CNA 2 stated I work the NOC shift (night shift = 11 PM to 7 AM). They don't have enough staff. There was only two CNA for NOC shift, there wasn't enough staff to answer all the call lights. Policy review Review of the facility's policy titled Abuse and Neglect - Clinical Protocol, not dated, indicated neglect means .the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555276 If continuation sheet Page 4 of 7 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 555276 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Bruno Skilled Nursing 890 El Camino Real San Bruno, CA 94066 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 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation and interview the facility failed to provide pharmaceutical services to meet the needs of each resident when multiple expired medications were available for resident use in the medication room. Residents Affected - Few Findings: During an observation on 2/6/23 at 1:30 PM in the facility medication room, there were seven bottles of Magnesium Citrate Saline Laxative non-pasteurized oral solution that were found to have expired. The expiration date was August 2022. The expiration date, based on the manufacturer, indicated that the Magnesium Citrate should not have been available for resident use. During an observation on 2/6/23 at 1:30 PM in the facility medication room medication refrigerator it was observed there were multiple expired emergency kits. The emergency kits had multiple medications that were used when the pharmacy was closed. The following expiration dates were found on the emergency kits: COVID Kit 8/23/22 Refrigerator Kit 1/2023 Refrigerator Kit 1/2023 During an interview on 2/6/23 at 1:30 PM the Registered Pharmacist 1 stated that he was the facility pharmacist. He also stated that the emergency kits were no longer supposed to be in the medication room because all the kits were now being dispensed through the AlixaRx. The AlixaRx was an automated dispensing cabinet (ADC). The ADC was an electronic operated machine that would open drawers and medication would then be available including medication emergency kits. RPH 1 said they changed the system about six months ago. He further said that no emergency kits should be freely available in the medication room refrigerator, and he has told pharmacy multiple times to pick up the expired emergency kits. He also said he would have them removed right away. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555276 If continuation sheet Page 5 of 7 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 555276 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Bruno Skilled Nursing 890 El Camino Real San Bruno, CA 94066 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and document review the facility failed to maintain a medication error rate less than five percent when three medications errors were observed for thirty three observed opportunities which would equal a medication error rate of nine percent. Residents Affected - Few Findings: During an observation on 2/6/23 at 11:56 AM Licensed Vocational Nurse (LVN 1) administered four different medications (Allopurinol, Amlodopine, Eliquis, and Hydralazine) to Resident 101. LVN 1 flushed with 1-3 ml of water between each medication. During an interview on 2/6/23 at 2:30 PM LVN 1 stated that she flushed with 1-3 ml of water instead of the policy required 15 ml. LVN 1 also stated she did not know that 15 ml flushes were required between medications when administering through an enteral tube. During an observation on 2/7/23 at 8:05 AM LVN 2 prepared Fluticasone Nasal Spray (medication used for allergies) and then left the nasal spray unattended on the meal tray in front of Resident 20. Resident 20 pick up the Fluticasone Nasal Spray and administered the spray into her right nostril. LVN 2 came back into the room picked up the Fluticasone Nasal Spray and readministered the medication into Resident 20's right nostril. A review on 2/07/23 of Resident 20's physician's orders indicated orders for Fluticasone 1 spray in each nostril for Resident 20. LVN 2 had erroneously administered twice the dose into the right nostril. During an interview on 2/7/23 at 10:15 AM LVN 2 stated that he had forgotten not to leave the Fluticasone Nasal Spray unattended. LVN 2 also stated that he should not have left the Fluticasone Nasal Spray on the meal tray when he left the room. A review on 2/7/23 of the Fluticasone Nasal Spray manufacturer's insert under the section Instructions for Use indicated Step 1. Blow your nose to clear your nostrils .Close 1 nostril. Tilt your head forward slightly and, keeping the bottle upright . During an observation on 2/7/23 at 8:05 AM LVN 2 while administering Fluticasone Nasal Spray did not blow Resident 20's nose to clear the nostrils before administration, and did not close 1 nostril while instructing the resident to tilt their head slightly forward. During an interview on 2/7/23 at 10:15 AM LVN 2 stated that he did not know that he had to clear the nostrils and had to close one of Resident 20's nostril while administering the Fluticasone Nasal spray. LVN 2 said was not aware of the manufacturer's administration requirements. A review on 2/6/23 of the facility policy dated 12/17 entitled Specific Medication Administration Procedures Eye Drop Administration indicated Instruct resident to close eyes slowly to allow for even distribution over surface of the eye. The resident should also refrain from blinking or squeezing eyes shut .While the eye is closed, use one finger to compress the tear duct in the inner corner (inner canthus) of the eye for 1-2 minutes. This reduces systemic absorption of the medication . During an observation on 2/7/23 at 8:05 AM LVN 2 did not instruct Resident 20 to close eyes slowly after administering Timolol eye drops (medications for glaucoma) to Resident 20. LVN 2 also did not hold the tear duct in the inner corner of the eye for 1-2 minutes after the administration of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555276 If continuation sheet Page 6 of 7 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 555276 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Bruno Skilled Nursing 890 El Camino Real San Bruno, CA 94066 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 0759 Timolol. Level of Harm - Minimal harm or potential for actual harm During an interview on 2/7/23 at 10:15 AM LVN 2 stated that he was not familiar with the facility policy for eye drop administration. He also stated that he did not instruct Resident 20 to close eyes slowly after administration of the eye drops. LVN 2 said that he did not hold the tear duct in the inner corner of Resident 20's eyes. Residents Affected - Few A review on 2/6/23 of the facility policy dated revised 2018 entitled Administering Medications through an Enteral Tube indicated If administering more than one medication, flush with 15 ml .between medications . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555276 If continuation sheet Page 7 of 7