Health inspection·June 1, 2023

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few roles and responsibilities in the prevention and reporting of resident abuse . II. Policy . F. The facility Administrator will be responsible for . d. Ensuring that the Interdisciplinary Team meets to review and revise the plan of care with appropriate interventions for residents who are victims or perpetrators of abuse to prevent further occurrences . Review of the facility's Policy and Procedures (P&P), titled, Comprehensive Care Plans, undated, the P&P indicated, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs . The comprehensive care plan will describe, at a minimum the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being .Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made . 2.During a review of the facility's initial abuse allegation report titled, Report of Suspected Dependent Adult/Elder Abuse, dated 5/7/23, provided to the state survey agency, the report did not include the following: reporting party's name, signature, occupation, agency/name of business, relation to victim/how abuse is known, address and telephone; incident date and time of incident; reported type of abuse; reporter's observation of any known time frame; other person believed to have knowledge of abuse such as family, significant others, neighbors, medical providers, agencies involved, etc. and dates of written report mailed or faxed to agencies such as Ombudsman and State Licensing Agency. During a concurrent interview and record review with Registered Nurse (RN) 1, on 5/10/23 at 2 PM, the initial abuse allegation report titled, Report of Suspected Dependent Adult/Elder Abuse, dated 5/7/23 was reviewed. RN 1 confirmed she filled out the initial report. RN 1 acknowledged the findings and stated she did not completely fill out the report. RN 1 said, I probably missed some of the important details. RN 1 stated she was supposed to write the date and time of the alleged abuse incident on the report. RN 1 said, I need to fill out the form as accurate and complete as possible. RN 1 stated she was trained by the facility's Director of Staff Development (DSD) on abuse policy and procedures. Review of the facility's Policy and Procedures (P&P), titled, Abuse Prevention & Reporting, revision dated 1/13, the P&P indicated, . Policy . C. All staff will be oriented at time of hire and in-serviced at least annually regarding the topic of Abuse Prevention and Reporting. This training will include a review and discussion of . What, when, and to whom to report suspected, reported, or observed abuse . Employees will receive a copy of the facility's Mandated Reporter template . F. The facility Administrator will be responsible for: Ensuring that a thorough investigation of all suspected, reported, or observed abuse is completed in a timely manner and documented appropriately . Timely and accurate reporting to the appropriate agencies of any/all abuse incidents according to state and federal regulations . 3.During a concurrent interview and record review with the Director of Social Services (DSS), on 5/31/23 at 5:20 PM, the report titled, Exhibit 359 Follow-Up Investigation Report, related to the abuse allegation incident that involved Resident A and Resident B on 5/7/23 was reviewed. DSS confirmed she wrote the follow up investigation report. The report indicated, Within five (5) business days of the incident, the facility must provide in its report sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified. It (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555657 If continuation sheet Page 2 of 14 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 555657 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002 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 0607 Level of Harm - Minimal harm or potential for actual harm is important that the facility provide as much information as possible, to the best of its knowledge at the time of submission of the report. The facility should include any updates to information provided in the initial report and the following additional information, which should include, but are not limited to the following: 1. Additional/Updated Information Related to the Reported Incident, 2. Steps taken to investigate the allegation, 3. Conclusion, 4. Corrective Action(s) Taken 5. Facility Investigator and 6. Submitted by. Residents Affected - Few Further review of the report titled, Exhibit 359 Follow up Investigation Report, written by the DSS, the report did not indicate a detailed summary of all steps taken to investigate the allegation such as the summary of interviews with the alleged victim and any visual cues from the resident of psychosocial distress and harm, summary of interviews with witnesses and what the individual observed or knowledge of the alleged incident or injury, summary information from the investigation related to the incident from the resident's clinical record such as relevant portions of the RAI, the resident's care plan, nurses' notes, social services note, physician or other practitioner reports or reports from other disciplines that are related to the incident, summary information of other documents obtained, such as hospital/medical progress notes/orders and law enforcement reports as applicable, detailed summary of all corrective actions taken, the name of the facility individual/s who had the primary responsibility for conducting the investigation, name of the administrator or designee who submitted the report, and time the report was submitted to the state survey agency. DSS acknowledged the report did not include sufficient information as indicated in the follow up investigation form or report she used. DSS said, I will be more clear. I was not nearly thorough and descriptive enough. DSS stated the assistant to the previous Director of Social Services taught her how to use the follow up investigation form or report submitted to the state survey agency. Review of the facility's Policy and Procedures (P&P), titled, Abuse Prevention & Reporting, revision dated 1/13, the P&P indicated, . Policy . C. All staff will be oriented at time of hire and in-serviced at least annually regarding the topic of Abuse Prevention and Reporting. This training will include a review and discussion of . What, when, and to whom to report suspected, reported, or observed abuse . F. The facility Administrator will be responsible for: Ensuring that a thorough investigation of all suspected, reported, or observed abuse is completed in a timely manner and documented appropriately . Timely and accurate reporting to the appropriate agencies of any/all abuse incidents according to state and federal regulations . 4.During a concurrent interview and record review with the ADM on 6/1/23 at 11:24 AM, the facility's policy and procedure (P&P), titled, Abuse Prevention & Reporting, revision dated 1/13 was reviewed. ADM confirmed the facility's current Abuse P&P was last revised on 1/2013. ADM stated there was no revision made on the policy after 1/2013. ADM stated the facility's abuse policy did not indicate it was reviewed by the Quality Assurance Staff and the Director of Nursing in 2022. When asked how often the facility review and updates the abuse policy, ADM said, we don't have a scripted review date. Review of the facility's Policy and Procedures (P&P), titled, Abuse Prevention & Reporting, revision dated 1/13, the P&P indicated, . Policy . E. The facility's Quality Assurance Committee will review . Abuse Prevention and Reporting policies and procedures will be reviewed at least annually and updated as warranted to better safeguard residents . 5.During a concurrent interview and record review with the Administrator (ADM) on 6/1/23 at 11:38 AM, the facility's policy and procedure, titled, Abuse Prevention & Reporting, revision dated 1/13 was reviewed. When asked to describe the facility's procedure for investigating patient abuse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555657 If continuation sheet Page 3 of 14 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 555657 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few allegation incidents, ADM explained that concerned parties involved in the incident were interviewed to determine if there was any injury, including the need to relocate or guard people. ADM stated responsible parties had to be identified and notified of the incident and staff members involved or might have knowledge of the incident had to be interviewed. ADM also stated phone call notifications and submission of written and follow up incident reports to appropriate agencies within the required timeframes had to be made. When asked who was responsible for the investigation of abuse allegation incidents at the facility, ADM said, it depends on which department is involved and what kind of abuse occurred. ADM stated if the incident involved residents, the DON [Director of Nursing] is heavily involved, sometimes we involve our social worker. ADM further stated, we do a 5-day follow up [report of the investigation] and send that to CDPH (California Department of Public Health, state survey agency). When asked if the facility had a written policy and procedure for investigating abuse allegations, ADM said, I don't see it written, I don't see it in this policy [referring to facility's current policy and procedure on abuse]. ADM stated she thought the facility's current abuse policy and procedure had to be revised and said, it's time to do a major tweak. Review of the facility's Policy and Procedures (P&P), titled, Abuse Prevention & Reporting, revision dated 1/13, the P&P indicated, . Policy . E. The facility's Quality Assurance Committee will review . Abuse Prevention and Reporting policies and procedures will be reviewed at least annually and updated as warranted to better safeguard residents . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555657 If continuation sheet Page 4 of 14 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 555657 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002 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 0609 Level of Harm - Minimal harm or potential for actual harm Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based on interview and record review, the facility failed to ensure an allegation of abuse incident that occurred on 5/7/23 was reported within required timeframes to the State Survey Agency when: Residents Affected - Few 1.There was no documented evidence the abuse allegation incident that involved Resident A and Resident B on 5/7/23 was reported within 2 hours after the allegation was made. 2.There was no documented evidence the results of the abuse allegation investigation that involved Resident A and Resident B on 5/7/23 was reported within 5 working days of the incident. These failures could result in avoidable delays that help provide protections for the health, welfare, and rights of residents in the facility. Findings: 1.During an interview with the Director of Nursing (DON), on 5/30/23 at 2:15 PM, DON stated the nurse who reported the initial abuse incident that occurred on 5/7/23, between Resident A and Resident B, to the State Survey Agency cannot give me [DON] the date and time. DON was unable to provide documented evidence of the date and time the State Survey Agency was notified of the abuse allegation incident on 5/7/23. DON stated the fax machine that the nurse used to send the initial abuse report to the State Survey Agency had a date and time issue that was not fixed. 2.During an interview with the Director of Social Services (DSS), on 5/31/23 at 4:30 PM, DSS stated she was responsible to report the results of the abuse allegation investigation to the State Survey Agency on 5/12/23. DSS stated she faxed the follow up investigation report to CDPH (California Department of Public Health, State Survey Agency) on 5/17/23. DSS stated she faxed the follow up investigation report late. DSS was unable to provide documented evidence of the date and time the State Survey Agency was provided with the report on results of abuse allegation investigation. Review of the facility's Policy and Procedures (P&P), titled, Abuse Prevention & Reporting, revision dated 1/13, the P&P indicated, . Policy . C. All staff will be oriented at time of hire and in-serviced at least annually regarding the topic of Abuse Prevention and Reporting. This training will include a review and discussion of . What, when, and to whom to report suspected, reported, or observed abuse . Employees will receive a copy of the facility's Mandated Reporter template . F. The facility Administrator will be responsible for: Ensuring that a thorough investigation of all suspected, reported, or observed abuse is completed in a timely manner and documented appropriately . Timely and accurate reporting to the appropriate agencies of any/all abuse incidents according to state and federal regulations . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555657 If continuation sheet Page 5 of 14 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 555657 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on interview and record review, the facility failed to ensure a resident (Resident A) with a known history of inappropriate sexual behaviors was consistently supervised and monitored by staff according to his care plan. This failure resulted in Resident A to be found unsupervised inside the room of another resident (Resident B) on 5/7/23. This failure did not ensure Resident B and other residents at the facility were protected from a potential and/or actual sexual abuse by Resident A. This failure resulted in a potential violation of Resident B's rights to privacy and dignity. Findings: During a review of Resident A's admission Record (AR), the record indicated, Resident A's diagnoses included Dementia (loss of mental functions) and Depression (mood disorder). During a review of the Minimum Data Set (MDS, an assessment tool), dated 3/24/23, Resident A's assessment for Functional Status (Section G), indicated, supervision and one-person physical assist when walking in corridor on unit and moving between locations in his room and adjacent corridor on same floor. The MDS also indicated Resident A used a walker for mobility. During a review of Resident A's History & Physical (H&P), dated 12/8/22, the H&P indicated, He [Resident A] had inappropriate sexual behavior towards staff and patients and was evaluated by psychiatry. The H&P also indicated, He [Resident A] was placed in a private room and was discouraged from leaving his room unattended. During an interview on 5/10/23, at 9:52 AM, with the Director of Nursing (DON), DON confirmed a reported allegation of abuse on 5/7/23 when Resident A was found by a Certified Nursing Assistant (CNA) 1 standing inside Resident B's room facing the sink. DON confirmed the alleged abuse report provided to the state survey agency, indicated that Resident B told the CNA 1 that Resident A touched her everywhere and wants him [Resident A] out of the room. DON stated Resident B's conservator (a person appointed by a judge to act or make decisions for the person who needs help) was notified of the incident. During an interview on 5/10/23, at 10:10 AM, with the DON, DON stated staff conducted visual checks or visual monitoring of Resident A every 30 minutes. When asked how Resident A ended up in Resident B's room unsupervised on 5/7/23, DON stated Resident A was able to walk on his own with a walker. DON stated at the time the alleged abuse incident occurred, CNA 1 was in another resident's room. DON stated Resident A should not be inside Resident B's room. During a concurrent interview and record review on 5/10/23, at 4:39 PM with the DON, Resident A's Visual Monitoring (VM) records from 7/1/22 through 5/10/23 were reviewed. The DON stated she had oversight Resident A's visual monitoring to ensure that there was staff available and that records were completed. DON stated it was important that Resident A did not go out of his room without staff supervision to protect residents in the facility given Resident A's inappropriate behavior history. DON (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555657 If continuation sheet Page 6 of 14 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 555657 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002 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 0689 Level of Harm - Minimal harm or potential for actual harm confirmed and acknowledged there was no visual monitoring by staff on Resident A and that Resident A's VM records had no information on the staff member who monitored the resident, any resident behaviors noted by the staff, and the resident's location or whereabouts for the following dates and times. July 2022 Residents Affected - Some There were no visual monitoring records on file for Resident A from: 7/1/22 through 7/6/22 (6 days) 7/15/22 through 7/16/22 (2 days) 7/19/22 (1 day) August 2022 There were no visual monitoring records on file for Resident A from: 8/4/22 to 8/13/22 (10 days) 8/27/22 - no visual monitoring from 7:30 AM up to 3 PM 8/30/22 - no visual monitoring from 7:30 AM up to 3 PM September 2022 9/2/22 - no visual monitoring from 10 AM up to 3 PM 9/7/22 - no visual monitoring from 4 PM up to 11 PM October 2022 10/13/22 - no visual monitoring from 7:30 AM up to 3 PM December 2022 There were no visual monitoring records on file for Resident A from: 12/24/22 to 12/31/22 (8 days) 12/13/22 - no visual monitoring from 9:30 PM up to 11 PM March 2023 3/12/23 - no visual monitoring from 4 PM up to 11 PM 3/13/23 - no visual monitoring from 3:30 PM up to 11:30 PM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555657 If continuation sheet Page 7 of 14 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 555657 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002 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 0689 3/14/23 - no visual monitoring from 12 AM up to 7 AM Level of Harm - Minimal harm or potential for actual harm April 2023 4/28/23 - no visual monitoring from 4 PM up to 11:30 PM Residents Affected - Some 4/29/23 - no visual monitoring from 12 AM up to 6:30 AM 4/29/23 - no visual monitoring from 7:30 PM up to 11 PM May 2023 5/1/23 - no visual monitoring from 7:30 AM up to 3 PM 5/2/23 - no visual monitoring from 7:30 AM up to 11 PM 5/3/23 - no visual monitoring from 7:30 AM up to 11 PM 5/4/23 - no visual monitoring from 7:30 AM up to 3 PM 5/4/23 - no visual monitoring from 4 PM up to 11 PM 5/5/23 - no visual monitoring from 4 PM up to 11 PM 5/7/23 - no visual monitoring from 11 PM up to 11:30 PM 5/8/23 - no visual monitoring from 12 AM up to 7 AM 5/9/23 - no visual monitoring from 12 AM up to 6:30 AM During an interview on 5/10/23, at 1:35 PM, with the Registered Nurse (RN) 1 assigned to Resident A on 5/7/23, the date of Resident B's reported abuse allegation incident, RN 1 stated she did not know that Resident A was able to walk of his room unsupervised by staff at the time. RN 1 stated she was aware a staff had to be present when Resident A left his room based on his care plan. During an interview on 5/16/23, at 3:58 PM, with the CNA 1, who was assigned to Resident A on 5/7/23, the date of Resident B's reported abuse allegation incident, CNA 1 stated she and RN 1 were responsible to monitor and check Resident A's whereabouts to ensure the resident did not leave his room unsupervised given his history of inappropriate behavior towards other residents. CNA 1 stated she found Resident A inside Resident B's room at the time of the alleged incident on 5/7/23. When asked why Resident 1 was able to leave his room without staff supervision, CNA 1 said, At the time, we are busy and we are short handed and when you're busy you cannot watch a patient closely. CNA 1 stated she was helping a resident in another room when the alleged incident happened. CNA 1 stated, she was unable to monitor Resident A at the time of the alleged incident because they were short-handed. During a review of Resident A's behavioral care plan (BCP), dated 3/1/23, the BCP indicated an intervention initiated on 7/1/22 that included, On visual monitoring, to know the whereabout [sic] of the resident. Further, Resident A's care plan (CP), dated 3/1/23, indicated, Resident has episodes .inappropriately touching staff and other residents on genitals or breasts. The CP included an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555657 If continuation sheet Page 8 of 14 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 555657 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002 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 0689 intervention that was initiated on 9/8/22 that indicated, Staff to accompany him when he leaves the room. Level of Harm - Minimal harm or potential for actual harm During a concurrent interview and record review of Resident A's care plans on 5/10/23, at 5:16 PM with the DON, DON stated Resident A's care plan interventions on visual monitoring and supervision by staff when Resident A left his room were not followed and implemented by staff. Residents Affected - Some Review of the facility's Policy and Procedures (P&P), titled, Comprehensive Care Plans, undated, the P&P indicated, Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs . The comprehensive care plan will describe, at a minimum the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable, physical, mental, and psychosocial well-being .Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made . Review of the facility's Policy and Procedures (P&P), titled, Visual Monitoring, dated 11/18/21, the P&P indicated, The facility may develop arrangements for Visual Monitoring for the staff or outside resources to provide dedicated individual to provide monitoring of the resident every 30 minutes for a specific period of time. Definition: Visual Monitoring is the term used by the Facility when assigning staff members or individual person to observe the resident's whereabouts and activities being done during the specific time. Policy Explanation: 1. Charge nurses may consult with the Director of Nursing or Administrator regarding the concern need for any resident to require Visual monitoring. 2. The director of Nursing or Administrator (or their designees) will assess the situation and confirm the need for visual monitoring. 3. Once confirmed, the charge nurse will assign CNA or non-nursing personnel to visually observe or monitor the resident every 30 minutes and it will be documented on a visual monitoring sheet with specific coding for behaviors observe and location codes at specific times. 4. The charge nurse from the resident's unit will be responsible for overseeing the process. 5. The Director of Nursing will validate that visual monitoring is being conducted, per instruction. Review of the facility's Policy and Procedures (P&P), titled, Resident Rights, dated 4/28/04, the P&P indicated, Policy - 1. The facility's governing body, administration and employees fully support the concept that each resident shall be informed of his/her rights in a language that the resident understands, and of the facility rules and regulations governing resident conduct and responsibilities . Procedure . Resident rights include: a. Federal - OBRA- Rights; b. Title 22 - Regulatory Rights; c. Statutory Rights . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555657 If continuation sheet Page 9 of 14 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 555657 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002 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 - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Based on interview and record review, the facility failed to ensure medical records related to provision of care and services to 1 resident (Resident A) were complete and accurately documented, in accordance with accepted professional standards and practices, including the facility's policy and procedures when: 1.Resident A had two non-identical One-on-One Monitoring (is the term used by the Facility when assigning a staff member or other individual to provide close observation of a resident for a specific period of time) records completed by staff on 5/11/23. 2.Resident A's One-on-One Monitoring staff assignment record on 5/8/23 for Staff 1 (S1) did not correspond with S1's timecard report and employment status. 3.There was no record of half-hour Visual Monitoring checks (is the term used by the Facility when assigning a charge nurse to the caregiver watching One-on-One monitoring of a patient) conducted by charge nurses for Resident A on 5/16/23. These failures resulted in inconsistent and unreliable documentation of Resident A's records. These failures had the potential to not ensure Resident A was monitored consistently by staff. Findings: 1.During a concurrent interview and record review with the Medical Records Staff (MRS) on 5/17/23 at 9:35 PM, Resident A's Visual Monitoring binder was reviewed. MRS explained staff assigned to do One-on-One monitoring on Resident A were instructed and trained to fill out and complete the Visual Monitoring sheets for designated times. The Visual Monitoring sheets indicated the time, staff initials, and behavior and location codes noted on Resident A. The Visual Monitoring sheets from 5/10/23 through 5/17/23 were reviewed with MRS present. MRS confirmed there were two Visual Monitoring sheets noted in the Visual Monitoring binder, and completed by staff for Resident A on 5/11/23, that were not identical. When asked, MRS stated couldn't tell which one is real. MRS acknowledged she was unable to determine the accuracy and reliability of the One-on-One Visual Monitoring record for Resident A on 5/11/23. Review of the facility's Policy and Procedures (P&P), titled, One-on-One Monitoring, dated 5/11/23, the P&P indicated, . Policy Explanation .Once confirmed, a staff member or other trained individual will be assigned to perform the one-on-one monitoring for a specific amount of time .The Director of Nursing will validate that one-on-one monitoring is conducted, per instruction . The facility will retain written documentation of one-on-one monitoring for an appropriate length of time. Review of the facility's Policy and Procedures (P&P), titled, Documentation in Medical Record, undated, the P&P indicated, . Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation . Policy Explanation and Compliance Guidelines . Principles of documentation include, but are not limited to . Documentation shall be accurate, relevant and complete . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555657 If continuation sheet Page 10 of 14 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 555657 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002 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 2.During review of Resident A's One-on-One Monitoring staff assignment record for 5/8/23, the record indicated Staff 1 (S1) was assigned to the resident from 11:30 PM to 5:30 AM the following day, 5/9/23. During a review of facility's the Employee Time Card Report, for 5/8/23, the report indicated the following: a record of S1's name, time In 11:30p [pm], and time Out 5:30a+1 [am] the next day, 5/9/23. Residents Affected - Some During an interview with S1 on 5/25/23 at 12:18 PM, S1 stated she was promoted to a supervisor position for over a year now. S1 stated her new role as supervisor was a salaried position. S1 stated since she held the salaried position, she stopped clocking in and out from the facility's timecard system. S1 stated she had not clocked in and out for timecard purposes for more than a year since they put me to salaried. When asked, S1 stated she provided One-on-One Monitoring on Resident A on 5/8/23 from 11:30 PM up to 5:30 AM on 5/9/23. Review of the facility's Policy and Procedures (P&P), titled, Documentation in Medical Record, undated, the P&P indicated, . Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation . Policy Explanation and Compliance Guidelines . Principles of documentation include, but are not limited to . Documentation shall be accurate, relevant and complete . 3.During a concurrent interview and record review with Charge Nurse (CN) 1, on 5/17/23 at 8:51 PM, Resident A's half-hour Visual Monitoring binder used by charge nurses was reviewed. With CN 1 present, the half-hour Visual Monitoring sheets from 5/11/23 through 5/17/23 were reviewed. CN 1 confirmed the finding and said, I don't see a paper for monitoring by charge nurses for 5/16/23. CN 1 stated there should have been documentation on Resident A's visual monitoring by charge nurses for 5/16/23. CN 1 acknowledged no documentation meant the monitoring was not done by the nurses. CN 1 stated he was not working that day and said, I don't know what happened that day. CN 1 stated they were short-handed on 5/16/23 and had registry nurses on the schedule. Review of the facility's Policy and Procedures (P&P), titled, Documentation in Medical Record, undated, the P&P indicated, . Policy: Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation . Policy Explanation and Compliance Guidelines . Principles of documentation include, but are not limited to . Documentation shall be accurate, relevant and complete . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555657 If continuation sheet Page 11 of 14 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 555657 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002 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 0943 Level of Harm - Minimal harm or potential for actual harm Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Based on interview and record review, the facility failed to ensure staff were effectively trained on abuse reporting and investigation when: Residents Affected - Few 1.The initial abuse allegation report did not have sufficient information on the alleged abuse incident that involved Resident A and Resident B on 5/7/23. 2.The follow up investigation report did not have sufficient information on the results of the alleged abuse incident that involved Resident A and Resident B on 5/7/23. Lack of sufficient information and/or knowledge on abuse allegation reporting and investigations by staff could result in inconsistent implementation of the facility's abuse policies and procedures. These failures could result in avoidable delays that help provide protections for the health, welfare, and rights of residents in the facility. Findings: 1.During a review of the facility's initial abuse allegation report titled, Report of Suspected Dependent Adult/Elder Abuse, dated 5/7/23, provided to the state survey agency, the report did not include the following: reporting party's name, signature, occupation, agency/name of business, relation to victim/how abuse is known, address and telephone; incident date and time of incident; reported type of abuse; reporter's observation of any known time frame; other person believed to have knowledge of abuse such as family, significant others, neighbors, medical providers, agencies involved, etc. and dates of written report mailed or faxed to agencies such as Ombudsman and State Licensing Agency. During a concurrent interview and record review with Registered Nurse (RN) 1, on 5/10/23 at 2 PM, the initial abuse allegation report titled, Report of Suspected Dependent Adult/Elder Abuse, dated 5/7/23 was reviewed. RN 1 confirmed she filled out the initial report. RN 1 acknowledged the findings and stated she did not completely fill out the report. RN 1 said, I probably missed some of the important details. RN 1 stated she was supposed to write the date and time of the alleged abuse incident on the report. RN 1 said, I need to fill out the form as accurate and complete as possible. RN 1 stated she was trained by the facility's Director of Staff Development (DSD) on abuse policy and procedures. During a concurrent interview and record review with the Director of Staff Development (DSD) on 5/25/23 at 4:30 PM, the initial abuse allegation report used by the facility titled, Report of Suspected Dependent Adult/Elder Abuse, was reviewed. DSD stated she conducted abuse training and in-services to staff at the facility quarterly. DSD stated she provided training to staff on how to fill out the initial abuse report. DSD stated staff were taught to be objective and complete the form. DSD stated staff were expected to fill out all sections of the report and to indicate not applicable if appropriate. DSD stated it was not acceptable for the staff to not provide sufficient information on the initial report. DSD stated staff were taught and expected to fill out the report completely and accurately. When asked how she evaluated the staff's knowledge and competency on abuse policies and procedures, DSD stated staff were provided opportunities to ask questions during abuse training and in-services. DSD stated she had not done reviews of the initial abuse reports completed by the staff. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555657 If continuation sheet Page 12 of 14 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 555657 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002 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 0943 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few DSD stated it was important to review the initial abuse reports to assess knowledge and competency of staff and ensure they were equipped with the right information when reporting abuse. 2.During a concurrent interview and record review with the Director of Social Services (DSS), on 5/31/23 at 5:20 PM, the report titled, Exhibit 359 Follow-Up Investigation Report, related to the abuse allegation incident that involved Resident A and Resident B on 5/7/23 was reviewed. DSS confirmed she wrote the follow up investigation report. The report indicated, Within five (5) business days of the incident, the facility must provide in its report sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified. It is important that the facility provide as much information as possible, to the best of its knowledge at the time of submission of the report. The facility should include any updates to information provided in the initial report and the following additional information, which should include, but are not limited to the following: 1. Additional/Updated Information Related to the Reported Incident, 2. Steps taken to investigate the allegation, 3. Conclusion, 4. Corrective Action(s) Taken 5. Facility Investigator and 6. Submitted by. Further review of the report titled, Exhibit 359 Follow up Investigation Report, written by the DSS, the report did not indicate a detailed summary of all steps taken to investigate the allegation such as the summary of interviews with the alleged victim and any visual cues from the resident of psychosocial distress and harm, summary of interviews with witnesses and what the individual observed or knowledge of the alleged incident or injury, summary information from the investigation related to the incident from the resident's clinical record such as relevant portions of the RAI, the resident's care plan, nurses' notes, social services note, physician or other practitioner reports or reports from other disciplines that are related to the incident, summary information of other documents obtained, such as hospital/medical progress notes/orders and law enforcement reports as applicable, detailed summary of all corrective actions taken, the name of the facility individual/s who had the primary responsibility for conducting the investigation, name of the administrator or designee who submitted the report, and time the report was submitted to the state survey agency. DSS acknowledged the report did not include sufficient information as indicated in the follow up investigation form or report she used. DSS said, I will be more clear. I was not nearly thorough and descriptive enough. DSS stated the assistant to the previous Director of Social Services taught her how to use the follow up investigation form or report submitted to the state survey agency. During an interview with the Director of Staff Development (DSD) on 6/1/23 at 2:01 PM, DSD stated she was not responsible for providing training of staff in completing and submission of the 5-day follow up investigation report on abuse allegation incidents. DSD stated she was not aware if there was a training provided to staff on how to investigate and submit a follow up report on abuse allegation incidents to appropriate agencies to meet the regulations. DSD said, I just know that the Administrator, DON [Director of Nursing] and Social Services would always be the key people to do the investigation. Review of the facility's Policy and Procedures (P&P), titled, Abuse Prevention & Reporting, revision dated 1/13, the P&P indicated, . Policy . C. All staff will be oriented at time of hire and in-serviced at least annually regarding the topic of Abuse Prevention and Reporting. This training will include a review and discussion of . What, when, and to whom to report suspected, reported, or observed abuse . Employees will receive a copy of the facility's Mandated Reporter template . F. The facility Administrator will be responsible for: Ensuring that a thorough investigation of all suspected, reported, or observed abuse is completed in a timely manner and documented appropriately . Timely and accurate reporting to the appropriate agencies of any/all abuse incidents according to state and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555657 If continuation sheet Page 13 of 14 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 555657 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Belmont Healthcare Center 2140 Carlmont Drive Belmont, CA 94002 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 0943 federal regulations . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555657 If continuation sheet Page 14 of 14