Health inspection·February 27, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview and record review, the facility failed to prevent an injury to one of one sampled resident (Resident 1) when Resident 1 hit her head during the transfer from the wheelchair to the bed. The facility failure resulted to resident to experience severe pain and sustain a bump on the back of her head. Findings: A review of the face sheet indicated Resident 1 was admitted with diagnoses including left ankle wound, congestive heart failure (when the heart does not pump as strong as it should) and osteopenia (weakened bones). A review of the Minimum Data Set (MDS, a standard assessment tool) dated 3/30/23, Brief interview of mental status (BIMS, a brief memory test to help determine cognitive functioning [thinking, learning, and decision- making abilities]) score of 5 indicated severe cognitive impairment (rarely/never make decisions). Resident 1 required extensive assistance with one-person physical assist to perform activities of daily living including bed mobility, transfer, personal hygiene, and toilet use. Resident 1 was non ambulatory (unable to walk). During an interview on 11/14/23, at 2:36 PM, Certified Nurse Assistant (CNA, care giver) 1 stated that with CNA 2, they attempted to transfer Resident 1 back to bed. The resident was sitting on the wheelchair with the sling underneath. The wheelchair was on the left side of the bed facing the foot of the bed and in front of the hoyer lift. During an interview on 2/27/24, at 2:52 PM, CNA 2 stated that CNA 1 was operating the hoyer lift and had started raising the resident from the wheelchair but unable to roll the hoyer lift due the wound vacuum tubing on the floor blocking the hoyer lift's wheels to roll. CNA 2 stated she left the resident side and went to the right side and under the bed to move the wound vacuum tubing out of the hoyer lift's wheels way. CNA 2 also stated, The resident (Resident 1) panic, screamed, moved backwards, and she flipped. (CNA 2 gestured, and with her left hand down and right hand up moved them to the left hand up and right-hand down position). She (Resident 1) was hanging on the lift. CNA 2 continued that Resident 1, with the lower part of the sling placed under and over between the legs/thighs kept Resident 1 off the floor. CNA 2 further stated, The back of the sling doesn't give enough support. The sling was thrown away. During an interview on 2/27/24, at 3:02 PM, Occupational Therapist (OT, she responded after hearing (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 4 Event ID: 555856 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 555856 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Peninsula Post-Acute 1609 Trousdale Drive Burlingame, CA 94010 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)