Every finding on record at Zuckerberg San Francisco General Hosp & Trauma SNF

Based on observation, interview, and record review, the facility failed to store food for 15 out of 15 sampled residents in accordance with professional standards for food service safety when: 1. floors in the building 5 kitchen had a build-up of grease, grime, debris, and food crumbs, this had the potential for microorganism growth and to attract pests. 2. an ice machine had rust-colored residue on the bottom ledge of the ice bin, this had the potential to contaminate the ice 3. correct hand washing procedure was not followed by a food and nutrition services (FNS) employee during tray line (the process of plating meals), this had the potential to contaminate food and cause food-borne illness (illness contracted from eating contaminated food or beverages) These failures have the potential to result in a pest infestation or the spread of foodborne illness that could harm medically compromised residents' health and safety. Findings: 1. During a concurrent observation and interview 07/15/24 at 9:54 AM with the Executive Chef (EC) in the building 5 kitchen dry storage area, there was a build-up of crumbs under the shelves of food. In addition, crumbs were observed in the floor grates of an old drain system in the dry storage room. The EC acknowledged that the floors under the shelves had not been mopped the day before. During a concurrent observation and interview 07/15/24 at 10:20 AM with the Executive Chef (EC) in the building 5 kitchen cooking line near the pizza oven, the floors underneath the cooking ranges had a build-up of grease and grime. The EC stated that because the new cooking ranges are stationary and fixed to the wall, it has been difficult to clean under the equipment. During an observation on 07/15/24 at 10:23 AM inside the building 5 kitchen refrigerator stocked with prepared vegetables, the floor had multiple pieces of vegetables that had fallen. During an interview with the EC on 07/18/24 at 9:12 AM, the EC stated that his expected standard for food contact surfaces and the kitchen floor is everything should be clean. A review of the facility policy and procedure, titled REQUIRED CLEANING AND SANITATION STANDARD OPERATING PROCEDURES, last reviewed November 2015, indicated that Nonfood contact surfaces [surfaces that do not come into direct contact with food] shall be cleaned as often as is necessary to keep equipment free of accumulation of dust, dirt, food particles, and other debris. It further indicated that the cleaning procedure is for staff to Sweep area to be mopped, getting under any equipment or counter, move equipment when possible. This cleaning procedure should be done in Food preparation areas and Food storage areas Once per shift, or more frequently, as needed to reach a defined standard of Free From Dust/Debris, Free from Grease. A review of the FDA (Food and Drug Administration) Federal Food Code, dated 2022, 40601.11 indicated, (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. In addition The objective of cleaning focuses on the need to remove organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted. 2. During an observation on 07/15/24 at 10:57 AM in the building 5 kitchen, there was rust-colored residue on the bottom ledge of the ice bin when wiped with a clean paper towel. A review of facility policy and procedure, titled Ice Machines, last reviewed June 2023, indicated that ice machines and ice chests are maintained in clean condition to prevent transmission of infections. It further indicated that ice machines should be maintained to be visibly clean. A review of the FDA Federal Food Code, dated 2022, 4-602.11 indicated, cleaning should be done (4) In EQUIPMENT such as ice bins and BEVERAGE dispensing nozzles and enclosed components of EQUIPMENT such as ice makers, cooking oil storage tanks and distribution lines, BEVERAGE and syrup dispensing lines or tubes, coffee bean grinders, and water vending EQUIPMENT: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold. In addition, ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. 3. During an observation 07/16/24 at 12:25 PM in the building 25 kitchen, a Food and Nutrition Services (FNS) employee was observed during tray line. The FNS employee picked up an item off the floor, removed their gloves, put on new gloves, and continued working on the tray line without washing their hands. During an interview with the EC on 07/18/24 at 9:12 AM, the EC was asked what his expectations are regarding glove use and handwashing. The EC stated, that is the policy . we wash hands between glove changes. A review of facility policy and procedure titled Food Safety, last reviewed December 2022, indicated under the section Employee Guidelines: Infection Control Practices that staff should Always wash hands before putting on or changing gloves. During a review of the FDA Federal Food Code, dated 2020, 2-301.14 indicated, FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under S 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and: (H) Before donning gloves to initiate a task that involves working with FOOD.

Based on interview, and record review the facility failed to ensure two of 5 sampled residents (Residents 227 and 14) were free from unnecessary psychotropic medications (any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic [a type of psychiatric medication which are available on prescription to treat psychosis]; (ii) Anti-depressant [prescription medicines to treat depression]; (iii) Anti-anxiety [drugs used to treat symptoms of anxiety, such as feelings of fear, dread, uneasiness, and muscle tightness, that may occur as a reaction to stress]; and (iv) Hypnotic [a class of drugs that induce or prolong sleep in people with sleep disorders and are intended to improve the overall quality of sleep]) when: 1. For Resident 227, there was no consent and monitoring of targeted behaviors for Wellbutrin (antidepressant). 2. For Resident 14, there was no specific behavioral monitoring for Celexa (antidepressant). These failures could result in unnecessary use of, ineffective and/or lack of monitoring for psychotropic medications that could negatively affect the residents' highest practicable mental, physical and psychosocial well-being. Findings: 1. Review of Resident 227's clinical record indicated, Resident 227 was admitted to the facility with diagnoses including bacteremia (the presence of bacteria in the blood), alcoholic cirrhosis of liver (a result of liver damage from conditions such as hepatitis B or C, or chronic alcohol use), alcohol use disorder (a chronic disease characterized by uncontrolled drinking and preoccupation with alcohol), and moderate methamphetamine use disorder (stimulant dependence, misuse of methamphetamine that has a high potential for abuse and misuse, which can lead to the development of a substance use disorder, including addiction). Review of Resident 227's Minimum Data Set (MDS, resident assessment tool), dated 7/15/24, indicated, Resident 227 was cognitively intact. Review of Resident 227's doctor's order dated 7/10/24 indicated, . buPROPion XL (WELLBUTRIN XL, Wellbutrin extended release) 24 hr (hour) tablet (pill) 150mg (milligram) . oral . Daily . Indications of Use: amphetamine use disorder . During a concurrent interview and record review on 7/17/24 at 12:02 PM with Registered Nurse (RN) 1, RN 1 could not show the evidence of the consent for Resident 227's Wellbutrin XL when asked. RN 1 stated, they did not have the consent because Wellbutrin XL was given for amphetamine use disorder, not for depression (a common mental disorder) for Resident 227. State Operations Manual titled, Appendix PP, dated 2/3/23 indicated, . Risks associated with psychotropic medications still exist regardless of the indication for their use (e.g., nausea, insomnia, itching), therefore the requirements pertaining to psychotropic medications . apply to the four categories of drugs (anti-psychotic, anti-depressant, anti-anxiety and hypnotic) . without exception . During a concurrent interview and record review on 7/17/24 at 1:58 PM with Clinical Pharmacist (CP), CP stated, The consent will be needed when asked. CP stated, Wellbutrin XL is antidepressant and psychotropic medication. CP acknowledged the need for targeted behavioral monitoring after reviewing Appendix PP together. During a concurrent interview and record review on 7/17/24 at 2:12 PM with RN 1, RN 1 stated, It is not applicable when asked again about the consent for Wellbutrin XL. RN 1 stated, it was because Resident 227 was taking Wellbutrin XL for amphetamine use disorder, not depression. RN 1 confirmed that there was no consent for Resident 227's Wellbutrin XL. RN 1 also verified there was no behavioral monitoring for Resident 227 when asked. 38066 2. Resident 14 was readmitted on [DATE] with diagnoses including seizure disorder and depression. Review of Resident 14's Admission MDS dated [DATE] indicated Resident 14 was cognitively intact. Review of Resident 14's Physician's Orders dated 7/11/24 indicated, .citalopram (Celexa) tablet 40 mg daily . Review of Resident 14's Consent for Psychoactive Oral Medication signed 7/11/24 indicated, .Anti-depressant .Citalopram .Behaviors to Monitor .Monitor s/s (signs and symptoms) of depression . Review of Resident 14's Nursing Note from 7/12/24 to 7/19, indicated, .on Citalopram for MDD (major depressive disorder), monitoring for signs and symptoms of depression . Review of Resident 14's SNF Nursing Weekly Summary dated 7/16/24, indicated, .Target Symptom Order: 1. On Citalopram, monitored for signs and symptoms of depression . During a concurrent interview and record review on 7/17/24 at 11:41 AM, with RN 4, Resident 14's behavioral monitoring for the use of Celexa was reviewed. RN 4 said that depression could be not socializing or showing no interest in care. When queried what behavior Resident 14 was being monitored for, RN 4 acknowledged that there was no specific target behavior to monitor for depression, and stated, No, it doesn't say. Not specific, it should be specific. Review of facility policy titled, Therapeutic Use of Medications revised in October 2023, indicated, .Informed Consent: The Resident or the resident's legal representative when applicable must be provided (informed of) the following information each psychotropic medication by the attending physician or nurse practitioner .2. For Psychotropic Medications Complete all categories on flowsheet record of all patients on psychoactive medications .Response to the psychotropic medication when ordered will be monitored by the nurse every shift and will include the behavior response per resident .

Based on 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 two of eight sampled residents (Residents 14 and 7) when: 1. No individualized person-centered CP was developed for the use of Citalopram (Celexa - brand name of drug used to treat depression) for Resident 14. 2. For Resident 7, the CP did not have specific interventions for end stage renal disease [ESRD - when the kidneys are no longer able to work at a level needed for day-to-day life that requires a regular course of dialysis (a type of treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to)]. This failure had the potential for not meeting the residents' nursing needs and goals, as well as the quality of care and services they receive to attain their highest practicable well-being. Findings: 1. Resident 14 was admitted on [DATE] with diagnoses including seizure disorder and depression. Review of Resident 14's Physician's Orders indicated, .citalopram (Celexa) tablet 40 milligram (mg) daily . During a concurrent interview and record review on 7/17/24 at 11:45 AM, with Registered Nurse (RN) 4, Resident 14's care plans were reviewed. RN 4 confirmed that there was no CP for the use of Celexa, and stated, It's not here. RN 4 said that CP is important, so the team knows the resident's goal of care. 2. Resident 7 was admitted on [DATE] with diagnoses including diabetes (a group of diseases that result in too much sugar in the blood) and ESRD. During an interview on 7/15/24 at 11:45 AM, Resident 7 said he goes to dialysis three times a week, on Monday, Wednesday, and Friday (M-W-F). Resident 7 further said that he has a left upper arm fistula (a connection that's made between an artery and a vein for dialysis access). During a concurrent interview and record review on 7/17/24 at 2:13 PM, with Licensed Vocational Nurse (LVN) 1, Resident 7's ESRD CP was reviewed. LVN 1 confirmed Resident 7 goes to dialysis in the afternoon on M-W-F. LVN 1 acknowledged that Resident 7's ESRD CP did not have specific interventions, and stated, None. Review of facility policy titled, 4A-SNF Interdisciplinary Resident Care Planning last reviewed on 11/23, indicated, .3. During Interdisciplinary team meetings, all clinical issues on the Interdisciplinary Care Plan list as well as triggered CARE ASSESSMENT AREAS (CAA'S) on MDS will be reviewed, and the Interdisciplinary Team (IDT) will determine which problems warrant a care plan, and if any care plans warrant revisions or closure. The RN will document the rationale if a care plan is not initiated for a triggered CARE ASSESSMENT AREAS (CAA'S) .11. Documentation: .c. Approaches/interventions to be utilized by specific disciplines to meet the goal(s) .

Based on observation, interview, and record review, the facility failed to ensure removal of expired medications when an opened vial of Tuberculin Purified Protein Derivative (Tubersol - a solution injected into the surface layer of the skin to help diagnose tuberculosis infection) was stored in the medication refrigerator beyond its expiration date. This deficient practice had the potential to compromise the integrity and effectiveness of the drug and inaccurate test results. Findings: During an observation of the medication room on 7/16/24 at 12:49 PM, a vial of Tubersol with an opened date of 6/17/24 was stored in the medication refrigerator. The vial did not indicate a discard date. During concurrent interview, Registered Nurse (RN) 1 stated, It's good for 28 days once opened. RN 3 said the medication expired on 7/15/24. RN 2 read the date opened as, 6/17/24 and stated, It should be discarded. Review of facility policy titled, Pharmaceutical Services: Guidelines for Storage and Delivery of Medications last revised on 12/23, indicated, .3. Expiration dates .D. All Multi-dose injectable vials, including vaccines and insulins, are good for a maximum of 28-days after opening and shall be labeled with discard after date .

Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one sampled resident (Resident 79) when Registered Nurse (RN) did not rotate injection sites of insulin glargine (injection that can treat diabetes). This failure had the potential risk of Resident 79 developing thickened skin and localized skin with lumps. Findings: During a medication administration observation on 7/17/24 at 8:51 AM, RN 4 administered insulin glargine injection at the back of Resident 79's left upper arm. Review of Resident 79's Physician Orders indicated, .insulin glargine (LANTUS - brand name) injection 20 units subcutaneous (SQ - injection inserted under the skin) every morning . Review of Resident 79's Medication Administration Record (MAR), dated 7/3/24 to 7/17/24, indicated, insulin glargine was administered on the following dates: On 7/3/24 at 8:30 AM, given in the right lower abdomen; On 7/4/24 at 8:02 AM, given in the right lower abdomen; On 7/5/24 at 8:23 AM, given in the right lower abdomen; On 7/16/24 at 8:00 AM, given in the left upper arm (back); On 7/17/24 at 8:51 AM, given in the left upper arm (back). During a concurrent interview and record review on 7/17/24 at 11:36 AM, with RN 4, Resident 79's MAR for insulin glargine was reviewed. RN 4 said that insulin injection sites should be rotated in the abdomen, back of the arm, and thigh to prevent skin and fatty tissue irritation. RN 4 acknowledged that the injection was administered on the back of Resident 79's left upper arm for two consecutive days, 7/16/24 and 7/17/24, and stated, It should have been rotated. Review of facility policy titled, Pharmaceutical Services: Guidelines for Administration of Medications last revised on 1/23, indicated, .F. Route Specific .2. Intramuscular (IM), subcutaneous (SQ), or Intradermal (ID) medications .b. Do not give IM or SQ medications in the same site for consecutive drug administration unless specified to do so in the provider order . Review of manufacturer's prescribing information for LANTUS injection for subcutaneous use, revised 6/2022, indicated, .Dosage and Administration .Rotate injection sites to reduce risk of lipodystrophy (a disorder of fatty tissue) and localized cutaneous amyloidosis (condition in which clumps of abnormal proteins build up in the skin .Warning and Precautions .Repeated insulin injections into areas of lipodystrophy or localized cutaneous amyloidosis have been reported to result in hyperglycemia .

Based on interview and record review the facility failed to ensure result of the Covid-19 test (nasal swab test to detect the current infection with the virus called SARS-CoV-2) was accurately communicated in the language and manner the resident fully understand for one of three sampled residents (Resident 1) when the preliminary positive Covid result was not communicated in the resident ' s native language and with no explanation that a re-run of the test was needed to confirm the validity of the result. This deficient practice caused Resident 1 to get upset about the result and raised concern among the Family Members. The re-run test was done later on the same day (7/20/23), as per facility policy, and indicated a false positive result (False positive, means that a person was told a positive result, but are not actually infected with the SARS-CoV-2 virus (covid virus). Findings: Record review of the Face sheet indicated Resident 1 was admitted to the facility on [DATE]. The admission H & P dated 7/14/23 indicated, the resident came for rehabilitation therapy following surgery of a fracture (broken) left tibia (define) and fibula (define). Record review of the Minimum Data Set (MDS, an assessment tool) dated 7/31/23 indicated, the resident ' s preferred language was Spanish and the Brief Interview for Mental Status (BIMS) had the score of 15 (15/15 means the person is awake, alert and oriented to person, time, and place). Interview on 10/17/23 at 11:32 AM, with the Nurse Manage (NM) and Director of Nursing (DON) in the presence of the Regulatory Affair Nurse (RAN 1) and the Regulatory Affair Coordinator (RAC), DON stated, the Physicians and License Nurses can disclose results of covid test to the residents and Covid test was done two times per week in the facility, Mondays and Thursdays, each week. When asked, what was her expectations from the staff when covid test were disclosed, the DON stated, staff would informed the residents in a manner that would avoid potentially alarming situation since there was small percentage of small positive results, to take infection control measures while the resident was still in active phase of the infection, and to educate and respond to any questions the residents may have. The NM stated, the resident tested positive for Covid test on 7/20/23, it was initial (or preliminary), and the re-run test was done later on the same day, and it was negative. The NM stated, the staff would disclose the covid-19 test result after the test has been confirmed. Record review of the Covid-19 test (preliminary) result dated 7/20/23 at 7:59 indicated, Detected (means positive). The re-run Covid-9 test result dated 7/20/23 at 4:40 pm indicated, Not detected (means negative) and the re-run Covid-19 test result dated 7/20/23 at 6:21 pm indicated, Not detected. In an interview on 10/17/23 at 1:09 PM, with the Registered Nurse (RN 1), RN 1 stated, she was a Travelling Nurse, this was her 4th month in the facility, and Spanish was not her native language. The RN 1 stated, on 7/20/23 she took care of one resident with positive covid test and that was her first time to disclose a positive result to a resident. Record review of the Nursing Notes, dated 7/20/23, at 4:00 PM indicated, Resident covid test result # 1 came out positive. MD (physician) made aware and ordered a repeat covid test. Resident was asymptomatic. In a concurrent record review of the Covid-19 Laboratory Test (Covid-19 LT) results and interview on 10/17/23, at 1:12 PM, with the Registered Nurse (RN 1), the Covid-19 LT results were reviewed. The Covid-19 LT results indicated, on 7/20/23 at 7:56 am, the covid-19 test result was positive, the re-run test result done on 7/20/23 at 4:40 pm was negative, and the repeat nasal swab covid -19 test result done on 7/20/23 at 6:21 pm was negative. The RN 1 stated, when she received the covid-19 test result for Resident 1 on 7/20/23, she told the Family Member (FM 1) who was in the room with the resident to leave, he could not stay in the room because the covid result could mean the resident was contagious, and the resident needed to be on isolation. The RN 1 stated, she told the resident the Covid-19 test result was positive, the resident questioned her why the FM had to leave, she (Resident 1) had no symptoms, and after that the resident started calling her FMs and the resident was upset being positive at that time. The RN 1 stated, she did not document the test result was a preliminary positive and confirmed there was no documentation the education was provided to the resident. Interview on 10/17/23, at 12:43 PM, with the Infection Control Program Manager (ICPM) and the Certified Infection Control Nurse (CICN), IPCM stated, nasal swab test was done via PCR (polymerase chain reaction, it ' s a test to detect genetic material from a specific organism, such as a virus). If the preliminary test comes back positive, the test would be re-run on the same day. If the test becomes negative, another nasal swab specimen would be obtained on the same day. If the result was negative, then it ' considered false positive result. Review of the facility ' s undated Protocol handed by the IPMG titled, 4 A Skilled Nursing Facility, Response to Covid-19 positive Event, indicated, Procedure: .12. For resident positive RT-PCR: . c. Lab (laboratory) contacted by Infection Control . to re-run specimen . Second specimen ordered, and run . d. If 2 out of 3 of above results negative, then a false + (positive) is confirmed. Interview on 10/17/23, at 11:01 AM, with the FM 2, FM 2 stated, Resident 1 told her the staff came all panicking, disturbing, and told the FM 1 he had to leave in an abrupt panicky manner. The FM 2 stated, the way the Covid-19 test result was delivered was unprofessional, the resident left the hospital uncomfortable, and was not well. Review of the facility ' s Policy and Procedure titled, Resident ' s Rights and Responsibilities, with the last review date of 2/22 indicated, The resident . 4. To be treated with respect and dignity . 9. To be fully informed in a language that she or he understands . medical condition.

Based on observation, interview, and record review the facility failed to ensure safe and sanitary food service operations were carried out according to standards of practice when: 1. expired foods were found in two walk-in refrigerators located in the main food production kitchen and basement food service kitchen, 2. ceiling panels and an air vent in the nourishment pantry room were dirty with large gray and black stains, and thick gray lint particles were hanging out, 3. resident foods were not stored separately from staff foods, and 4. a pink sticky substance was found inside the rim of the ice machine chute located in the nourishment pantry room. These failures had the potential to expose 23 of 23 residents to harmful contaminants that could cause foodborne illness. (Cross reference F 801) Findings: 1. During an observation and interview, on [DATE], at 10:10 AM, in a main kitchen walk-in refrigerator, with Executive Chef (EXC) and Foodservice Director (FSD), expired milk cartons were found with the use by date of [DATE]. The EXC stated these milk cartons should have been taken out of the fridge and unavailable for use. The FSD acknowledged the milk cartons were expired and should have been thrown out. During an observation and interview with the EXC, on [DATE], at 11 AM, in the basement kitchen walk-in refrigerator, a large metal pan on a food cart with other prepared foods, was found with cooked ground meat and a use by date of [DATE]. The EXC stated that the ground meat should not be in the refrigerator and should have been thrown out. During an observation and interview, on [DATE], at 11:30 AM, in the kitchen with the FSD, it was observed that a bottle of black pepper was on the shelf available to use with an expiration date of [DATE]. Per the FSD, this bottle should have been thrown away and a new bottle should have been opened and labeled. Per the 2022 Federal Food and Drugs Administration (FDA) Food Code section ,d+[DATE].11, titled Food and Dating labeling, .(A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 Code of Federal Regulation (CFR) 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement . Per the 2022 Federal FDA Food Code section ,d+[DATE].17, titled Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking, .refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by which the FOOD shall be consumed on the PREMISES . 2. During an observation and interview, on [DATE], at 1:15 PM, in the Skilled Nursing Unit nourishment pantry room with Licensed Nurse (LN) 1, it was observed the ceiling panels and vents had brown stains with dust, and the vents had thick gray lint particles blowing out. Additionally, a brown substance was found on most of the floor. LN 1 acknowledged the brown substance on the floor and stated it was from a coffee spill. LN 1 further stated the ceiling panels and vents should be clean and not have stains or dust on them. During an interview with the Environmental Services Supervisor (EVS) and Environmetal Services Technician (EVT) on [DATE] at 1:00 PM in the nourishment pantry room, the EVS stated the ceiling panels and vents had not been cleaned in awhile and should be replaced. During an observation and interview on [DATE] at 10:50 AM in the nourishment pantry room with RD 1 and DTR, the RD stated she was unaware of the dirty ceiling panels and vent with dust and thick gray lint. The RD stated the panels and vents should be clean because it could affect the food stored in the pantry. Per the 2022 Federal FDA Food Code, sections ,d+[DATE].11, ,d+[DATE].13 and ,d+[DATE].16, titled Clean - Non-Food Contact Surfaces, .Non-food contact surface equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Additionally, the presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests.Non-FOOD-CONTACT SURFACES shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance. 3.During an observation and interview, on [DATE], at 1:30 PM, in the Skilled Nursing Unit staff lounge with LN 1, there were forty-five ice cream cups for residents stored in the staff freezer alongside staff foods. LN 1 stated this freezer is where they keep the resident's ice cream because there are no other freezers on the unit. LN 1 further stated this practice does pose an infection control issue. During an observation and interview, on [DATE], at 10:50 AM, in the staff lounge with Registered Dietician (RD) 1 and Registered Dietician Technician (DTR), the RD 1 stated the resident's ice cream cups should not be stored with the staff's food in the freezer due to potential food safety concerns. 4. During an observation and interview, on [DATE], at 1 PM EVS and EVT in the Nourishment room, a pink substance was found around the inside of the ice machine chute. The EVS and EVT both stated the ice machine was last cleaned in [DATE] and is due to be cleaned again [DATE], as it is cleaned semi-annually. Per the 2022 Federal FDA Food Code section ,d+[DATE].11, titled Clean - Food Contact Surfaces, Equipment food contact surfaces shall be cleaned at any time during the operation because any contamination may have occurred. Per the 2022 Federal FDA Food Code, section ,d+[DATE].13, titled Ice and Food Dispensing, Dispensing Equipment, Protection of Equipment and Food, In EQUIPMENT that dispenses or vends liquid FOOD or ice in unpackaged form: (A) The delivery tube, chute, orifice, and splash surfaces directly above the container receiving the FOOD shall be designed in a manner, such as with barriers, baffles, or drip aprons, so that drips from condensation and splash are diverted from the opening of the container receiving the FOOD. (B) The delivery tube, chute, and orifice shall be protected from manual contact such as by being recessed. (C) The delivery tube or chute and orifice of EQUIPMENT used to vend liquid FOOD or ice in unpackaged form to self-service CONSUMERS shall be designed so that the delivery tube or chute and orifice are protected from dust, insects, rodents, and other contamination . Review of the facility policy revised ,d+[DATE], titled Ice machine, indicated .the ice machine should be cleaned semiannually according to manufacturer's guidelines. Review of the ice machine manufacturers guidelines tilted .[NAME] Symphony plus 12 series ice and water dispensers' operation and service manual (undated), indicated .Periodic cleaning/descaling and sanitizing of [NAME]'s ice and water dispenser and ice machine system is required to ensure peak performance and delivery of clean, sanitary ice. The recommended cleaning procedures that follow should be performed at least as frequently as recommended and more often if environmental conditions dictate . Review of the policy titled Patient food services. D5. Patient pantries revised ,d+[DATE], indicated FNS clean pantries according to cleaning schedule items include microwave, ice machine, countertops, and cooler. Engineering department is responsible for cleaning the ice machine to manufactures standards. EVS is responsible for cleaning the floors and garbage cans. Unit staff accessing the pantry should maintain cleanliness of the pantry (cleaning up any spills, etc . Review of the facility policy revised on ,d+[DATE], titled Food and nutrition services. Section: production, purchasing, storage .dating and labeling food, indicated .foods sealed by the manufacturer are labeled by them with a date beyond which the food should not be consumed. These foods are discarded on that date. Spices are dry goods placed in rotation are good for six months. Month labels will be placed on items reflecting a date six months out from the time it is placed in rotation. Discard items no later than the end of the designated month . Review of the undated policy titled 4a.SNF Resident meals and food management indicate that between meal snacks and beverages are prepared and delivered to the 4A-SNF by ZSFG dietary department. The snacks and beverages are stored near the nurse's station and are available to the residents upon request . Review of the facility policy dated ,d+[DATE], titled Patient Food Services, indicated .unit pantries are stocked and rotated by FNS staff .FNS staff checks .foods .nourishment pantry food list does not contain ice cream cups .

Based on interview and record record review, the facility failed to have a full time Infection Preventionist designated for the facility. The facility failure has the potential for the lack of oversight to the infection control prevention and control program. Findings: During an interview on 6/7/23, at 2:34 PM, Infection Preventionist (IP) stated, I am the Infection Preventionist for the whole hospital, both for the Skilled nursing facility and the general acute care part of the hospital. I spend five to ten hours a week in the skilled nursing facility. During an interview on 6/8/23, at 7:42 AM, Registered Nurse (RN) 3 was unable to identify the IP for the SNF. During an interview on 6/8/23, at 7:45 AM, RN 4 was unable to identify the IP for the SNF. During an interview on 6/8/23, the Medical Director and Director of Nursing acknowledged the facility has no full time IP designated for the Skilled Nursing unit. A review of the undated facility document titled, Orders by Department and Patient indicated, Resident 2 was on vancomycin (used to treat infection) for psoas (muscles located in the lower back, the hip and thigh bone) abscess (infection), Resident 3 was on erythromycin (used to treat infection) ophthalmic (eye) ointment and moxifloxacin (used to treat infection) ophthalmic solution for conjunctivitis (eye infection), Resident 4 was on bacitracin (use to treat skin infection) ointment for wound care, Resident 5 was on cefazolin (used to treat infection) for bacteremia (presence of bacteria in the blood) , Resident 6 was on ciprofloxacin (used to treat infection) for osteomyelitis (inflammation or swelling that occurs in the bone, can result from an infection) and bacitracin for wound care . Resident 1 and Resident 7 were both in contact precaution for Extended-Spectrum Beta-Lactamases (ESBL, produced by bacteria resistant to many of the antibiotics that are use to treat infections. According to the Centers for Medicare and Medicaid Services (CMS) Updated Guidance for Nursing Home Resident Health and Safety released on 6/29/22, The IP must physically work onsite in the facility. He/she cannot be an off-site consultant or perform the IP work at a separate location such as a corporate office or affiliated short term acute care facility. (https://www.cms.gov/newsroom/fact-sheets/updated-guidance-nursing-home-resident-health-and-safety)

Based on observations, interviews, and document reviews the facility failed to ensure full-time Dietetic Services oversight for sufficient hours to effectively carry out the day-to-day functions of safe dietetic operations to meet the nutrition needs of 23 residents according to standards of practice when: 1. A nourishment pantry room had dirty ceiling panels and a vent with gray lint blowing out, 2. Resident's ice cream cups were stored and comingled in the staff lounge freezer, 3. A pink substance found in the nourishment pantry room ice machine chute, 4. A full-time qualified Dietetic Nutrition professional did not work in the skilled nursing unit when the Registered dietitian (RD) worked eight to ten hours a week and the Registered Dietetic Technician (DTR) worked five and half hours a week, on average, in the skilled nursing unit. (Cross reference F 726 and F 812) Findings: 1. On 6/7/23 at 10:50 AM, a concurrent observation and interview in the nourishment pantry room with the Registered Dietitian (RD) 1 and Registered Dietitian Technician (DTR) was conducted. The RD acknowledged the ceiling panels had a lot of black and gray stains on them, along with debris hanging off both the panels and vent edges. Both the RD and DTR stated they were unaware of how often the ceiling panels and vent in the nourishment pantry room were cleaned. The RD stated she does not check the nourishment pantry room for food stock levels or cleanliness during work time on the unit. Per the 2022 Federal FDA Food Code, sections 4-601.11, 4-602.13 and 4-202.16, titled Clean - Non-Food Contact Surfaces, Non-food contact surface equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Additionally, the presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests. Hard to clean substances .Non-Food-Contact Surfaces shall be free of unnecessary ledges, projections, and crevices, and designed and constructed to allow easy cleaning and to facilitate maintenance. 2. During an observation and interview with Licensed Charge Nurse (LN) 1, on 6/5/23, at 1:30 PM, in the skilled nursing unit staff lounge, the staff freezer had forty-five ice cream cups stored inside. LN 1 stated the ice cream cups were for the residents in case they ask for it. The freezer also had opened staff food stored along with the resident ice cream cups. LN1 stated this practice does pose an infection control issue. During an observation and interview, on 6/6/23, at 11:15 AM, in the staff lounge with RD 1 and the DTR, the RD 1 and DTR both stated they were unaware the residents ice cream cups were stored in the staff's freezer. RD 1 further stated the resident's food should not be stored with staff food because it poses an infection control risk. Both the RD 1 and DTR stated they do not check the refrigerators or freezers for resident food in the skilled nursing unit. Review of the facility policy dated 2/22, titled 4a.SNF Resident meals and food management indicated .between meal snacks and beverages are prepared and delivered to the 4A-SNF by ZSFG [[NAME] San Francisco General] dietary department. The snacks and beverages are stored near the nurse's station and are available to the residents upon request . Review of the facility policy dated 12/22, titled Patient food services. D5. Patient pantries indicated .FNS [Food and Nutrition Services] clean pantries according to cleaning schedule items include microwave, ice machine, countertops, and cooler. Engineering department is responsible for cleaning the ice machine to manufactures standards. EVS [Environmental Services Staff] is responsible for cleaning the floors and garbage cans. Unit staff accessing the pantry should maintain cleanliness of the pantry (cleaning up any spills etc.) 3. During an observation and interview on 6/6/23 at 1:00 PM with Environmental Services Supervisor (EVSS) and the environmental Services Technician (EVT) in the Nourishment room, it was observed that a pink substance was around the ice machine chute. It was stated by EVSS and EVT that the ice machine was last cleaned on 1/23 and is due to be cleaned again in 6/23, as it is only cleaned semi-annually. EVSS and EVT stated the ceiling panels had black dust on them could be replaced and/or cleaned. Per the 2022 Federal Food and Drugs Administration (FDA) Food Code, section 4-602.11, titled Equipment Food-Contact Surfaces and Utensils .Surfaces of .equipment contacting food .such as .ice makers and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms .the person in charge should develop a cleaning regimen that is based on the soil that may accumulate in those items of equipment . Per the 2022 Federal FDA Food Code, section 4-204.13, titled Ice and Food Dispensing, Dispensing Equipment, Protection of Equipment and Food, In EQUIPMENT that dispenses or vends liquid FOOD or ice in unpackaged form: (A) The delivery tube, chute, orifice, and splash surfaces directly above the container receiving the FOOD shall be designed in a manner, such as with barriers, baffles, or drip aprons, so that drips from condensation and splash are diverted from the opening of the container receiving the FOOD. (B) The delivery tube, chute, and orifice shall be protected from manual contact such as by being recessed. (C) The delivery tube or chute and orifice of EQUIPMENT used to vend liquid FOOD or ice in unpackaged form to self-service CONSUMERS shall be designed so that the delivery tube or chute and orifice are protected from dust, insects, rodents, and other contamination . Review of the policy revised 1/20 titled Ice machine, indicated .the ice machine should be cleaned semiannually according to manufacturer's guidelines . Review of the undated ice machine manufacturers guidelines titled [NAME] Symphony plus 12 series ice and water dispensers' operation and service manual, indicated .Periodic cleaning/descaling and sanitizing of [NAME]'s ice and water dispenser and ice machine system is required to ensure peak performance and delivery of clean, sanitary ice. The recommended cleaning procedures that follow should be performed at least as frequently as recommended and more often if environmental conditions dictate . 4. During an observation and interview, on 6/6/23, at 11:00 AM, in the staff lounge with RD 1 and DTR, the RD 1 stated she is the designated Registered dietician for the skilled nursing facility and has another Registered dietician covers for off days. RD 1 stated that they spend eight to ten hours a week in the skilled nursing facility, and work on the acute side of the hospital during the remaining hours of the week. RD 1 stated that once or twice a month they spend time checking the nutrition room for par levels. The DTR stated she worked 40 minutes a day in the skilled nursing facility and another 2 hours a week to join the interdisciplinary team meetings (a team meeting where multiple disciplines including doctors, nurses, therapist, social worker, dietician, family, and other departments to discuss the residents' plan of care), for a total of five to seven hours a week. During an interview with the Food Services Director (FSD), on 6/7/23, at 11:25 AM, the FSD stated the skilled nursing unit does not have a designated nutrition services manager of dietetic operations. The FSD stated she was unaware of the unsanitary food safety practices in the skilled nursing unit. Per the 2019 California Retail Food Code chapter 3, titled Management and Personnel, Article 1. Supervision section 113945, The .person in charge .is present at the .facility during all hours of operation .section 113947, .the person in charge .has knowledge of safe food handling practices . as they relate to the specific food preparation activities that occur at the food facility. Review of the facility job description document dated 11/24/15, titled City and County of San Francisco Dietitian #2624 indicated, .Examples of Important and Essential Duties 2. Supervises food service to .patients .supervises food handling, sanitation, and cleaning procedures .

Based on observations, interviews, and document reviews the facility failed to ensure licensed nursing personnel verified the skilled nursing unit residents' meals were appropriate according to their physician's order and matched the resident's meal tray ticket prior to receiving their meal. This failure had the potential to negatively affect the nutrition status of 23 out of 23 residents who have chronic medical conditions such as diabetes (inability to manage blood sugar levels), dysphagia (difficulty swallowing), heart disease, and other conditions by receiving an incorrect therapeutic diet meal, which may further impair medical and nutrition status from weight loss, weight gain, and other complications. (Cross reference F801) Findings: During a test tray observation and interview with Foodservice Worker (FSW) 1, on 6/6/23, at 12 PM, on the skilled nursing unit, FSW 1 was in the hallway delivering meal trays to rooms A14 and A15. FSW 1 stated the normal practice for meal tray delivery was for him to serve the residents trays after he brought the meal tray cart to the unit from the kitchen. FSW 1 stated no one checks the trays before he delivers them to the resident. FSW further stated he checked the tray ticket name and verify the resident name on the door and with the resident inside the room to make sure the correct meal tray is served to the correct resident. During an observation and interview with FSW 2, on 6/7/23, at 9 AM, of the breakfast meal tray delivery, FSW 2 stated he delivers the meal trays to residents as soon as he pushes the meal tray food cart to the skilled nursing unit. FSW 2 stated the nursing staff does not check the meal trays before he serves them to the resident. FSW 2 stated he checks the meal tray ticket with the room name, then delivers the meal tray in the room to the resident. During an interview with Registered Nurse (RN) 1, on 6/7/23, at 10:03 AM, RN 1 stated kitchen staff serve food trays to the residents, except for residents that are on isolation precautions (precautions help prevent the spread of germs) or have aspiration (food, liquid, or other material enters a person's airway) risk. RN 1 further stated, kitchen staff check the name on the resident's room and matches it to the tray ticket name to ensure the right meal tray goes to the right resident. RN 1 explained, the licensed nurses do not check trays to ensure the residents are being served the correct diet that was ordered by the providers, but it was important for the residents to receive the correct therapeutic diet. During an interview with Certified Nursing Assistant (CNA) 1, on 6/7/23, at 10:10 AM, CNA 1 stated that the dietary service personnel serve the trays to the residents, and when the residents are finished eating, the dietary service personnel will remove the trays from the rooms, except if the resident is on isolation risk. During an observation and interview with Registered Dietician (RD) 1 and the Food Service Director (FSD) on 6/7/23 at 10:42 AM, the FSD stated the FSWs has always delivered the meals to residents in the skilled nursing unit. The FSD further stated it may be helpful for the nursing staff to check the meal trays for accuracy when they arrive on the unit. Review of the facility policy dated 2/22, titled 4A-Skilled Nursing Facility Department Policy # S4.2.46, Resident meals and food management, indicated .All meals must be delivered by ZSFG [[NAME] San Francisco General] dietary department staff. Nursing staff will ensure that each resident receives appropriate diet . Per the State of California, Health and Safety Code, sections 1275, 100275 and 131200, Title 22- 72311 (c) Nursing Service, Licensed nursing personnel shall ensure that patients are served the diets as ordered by the attending licensed healthcare practitioner acting within the scope of his or her professional licensure.

Based on observation, interview and record review, the failed to implement their infection prevention and control program when the personal protection equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace illnesses) cart was in close contact with two linen hampers containing soiled linens. This facility failure has the potential for the spread of infection to residents and staff. Findings: A review of the Physician notes dated 6/6/23, indicated, Resident 1 requires contact isolation for the duration of skilled nursing course due to Extended-Spectrum Beta-Lactamases (ESBL, produced by bacteria's resistant to many of the antibiotics that are use to treat infections). According to the CDC Guidelines for Isolation Precaution, retrieved from https://www.cdc.gov/infectioncontrol/guidelines/isolation/precautions.html, on 8/9/18, .Contact Precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or the patient ' s environment . During observation with the Director of Staff Development (DSD), on 6/6/23, at 3:31 PM, outside Resident 1's room, the PPE cart was placed beside the two hampers filled with soiled linens. During concurrent interview, the DSD acknowledged the PPE cart was in close contact with two hampers containing filled with soiled linens. The DSD stated, I just turned my back and this happens and removed the two hampers filled with soiled linens away from the PPE cart. A review of the facility Policy and Procedure titled, ZSFGH SNF Skilled Nursing Facility Infection Control Plan dated 11/16. indicated, Purpose: To establish and maintain infection control program designed to provide s safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection .

Based on observation, interview, and record review, the facility failed to ensure medical supplies were properly stored when expired blood collection tubes were found in the medication storage room. This deficient practice had the potential to cause unsafe and/or inappropriate use of medical supplies to residents. Findings: During an observation on [DATE], at 1:50 PM, with Registered Nurse (RN) 1, there were eight gray top and one light green top expired blood collection tubes found in a small plastic bin in the medication storage room. During an interview, on [DATE], at 2:14 PM, RN 2 said, the blood collection tubes are used for residents with orders for blood draw. RN 2 read the date on the tubes as [DATE] and stated, All are expired and should be tossed out. The ZSFGH ([NAME] San Francisco General Hospital) Clinical Laboratories Test Directory, under Specimen and Lab Test Procedures, indicated, .Clinical Laboratory: Laboratory Administration Date of Original: [DATE] Collection, Labeling and Delivery of Laboratory Specimens . III. PROCEDURE A. Collection and Labeling Specimens . 3. The collection tube or container required for collecting a specimen for individual tests is specified in the online Lab Manual. Use only containers with in-date expiration dates [www.testmenu.com/zsfglab/TestDirectory .accessed on [DATE]]

Based on observation, interview, and record review, the facility failed to keep the ice machine in the kitchen free of foreign debris in the ice bin section. This failure had the potential of causing food-borne illness. Findings: During a concurrent observation and interview on 03/09/2020 at 11:54 a.m., with the senior food service supervisor (SFSS), during a tour of the main kitchen, the ice deflector in the ice bin of the ice machine had a pink substance on the bottom edge. The SFSS was asked to, and wiped the bottom of the ice deflector with a clean paper towel. There was a pink substance observed on the paper towel, which the SFSS acknowledged. The SFSS stated the ice deflector should have been cleaned by kitchen staff during daily cleanings. During a review of the facility's policy and procedure, Ice Machines, dated 4/24/19, indicated Ice machines will be kept clean and serviced according to manufacturers' instructions by Food & Nutrition Services and Facilities/Engineering.

Based on observation, interview, and record review, the facility failed to monitor appropriate target behaviors for three of 12 sampled residents (20, 6, 22). This failure had a potential for unnecessary [MEDICAL CONDITION] (medications capable of affecting the mind, emotions, and behavior) use for the residents. Findings: During a concurrent interview and record review on 3/10/2020 at 10:56 a.m., with the director of nursing (DON), Resident 20's physician's orders [REDACTED]. The DON confirmed behavior being monitored was not specific enough for Resident 20. During a concurrent interview and record review, on 3/10/2020 at 11:07 a.m., with the DON, Resident 6's physician's orders [REDACTED]. The DON confirmed behavior being monitored was not specific enough for Resident 6. During a concurrent interview and record review on 3/10/2020 at 11:12 a.m., with the DON, Resident 22's physician's orders [REDACTED]. The DON confirmed behavior being monitored was not specific enough for Resident 22. During a review of the facility's policy and procedure, Therapeutic Use of Medications, dated 12/04, indicated each resident's drug regimen must be free from unnecessary drug. An unnecessary drug is any drug when used: c. without adequate monitoring.

Based on interview and record review, the facility failed to ensure pain management was provided for three of 12 sampled residents (20, 4, 10) when reassessment of pain medication efficacc was not documented. This failure can potentially lead to pain inappropriately manage and can impact resident health and well-being. Findings: During a review of Resident 20's physician's orders [REDACTED]. During a concurrent interview and record review, on 3/10/2020 at 11:25 a.m., with the director of nursing (DON), Resident 20's pain was not reassessed after an hour on several occasions of providing a PRN topical pain medication. The DON confirmed she was not able to find documentation from the nurses related to pain reassessment after a PRN medication was administered on several occasions. During a concurrent interview and record review, on 3/10/2020 at 11:30 a.m., Resident 4's pain was not reassessed after an hour of providing Tylenol (used to relieve pain) 1000 mg (milligrams, a unit of measurement) every eight hours as needed for pain on 3/1/2020, 3/4/2020, 3/6/2020. The DON stated pain should be reassessed after an hour of administration of PRN medication. During a concurrent interview and record review, on 3/10/2020 at 11:51 a.m., with the DON, Resident 10's pain was not reassessed after an hour of providing [MEDICATION NAME] (a controlled substance used for moderate to severe pain) 5 mg as needed for pain on 3/1/2020, 3/3/2020, 3/5/2020, 3/8/2020, 3/9/2020, 3/10/2020. The DON stated pain should be reassessed after an hour of administration of PRN medication. During a review of the facility's policy and procedure, Pain Management, dated 1/05, indicated if as needed pain medications are given, the licensed staff will re-assess the resident within 1 hour after the dose is given and document the results in the MAR (Medication Administration Records).

Based on interview and record review, the facility failed to establish policies that investigate abuse allegations when reporting instructions of abuse did not include reporting all incidents of resident abuse. This failure would result in unreported resident abuse. Findings: Review of the facility's policy on Abuse on 2/27/19, adopted 1/22/16, Title: Victims of Dependent Adult/Elder Abuse, Child Abuse, Assaultive and Abusive Conduct, and Rape/Sexual Assault, Purpose: The purpose of this policy is to delineate the procedures for mandated reporting of abuse to local law enforcement officials in accordance with California law .Mandated Reporters include physicians and surgeons, psychiatrists, psychologists, clergy, care custodians, dentists, residents, interns, podiatrists, licensed nurses, licensed clinical social workers, and all other administrators, supervisory and licensed staff of a public facility that provides care or services for elder or dependent adults .D. WHEN REPORTING IS NOT REQUIRED: 1. A mandated reporter need not report an incident where all of the following conditions exist. a. The mandated reporter has been told by an elder or dependent adult that he or she has experienced behavior constituting physical abuse, abandonment, isolation, financial abuse, or neglect; b. The mandated reporter is not aware of any independent evidence that corroborates the statement that the abuse has occurred; c. The elder or dependent adult has been diagnosed with [REDACTED]. The mandated reporter reasonably believes that the abuse did not occur . Review of latest abuse policy, received on 2/28/19, revised 6/2018, indicated the same above information. During an interview on 2/28/19, at 9:25 AM, Licensed Staff 1 stated the policy was being reviewed at this time and needed correction.

Based on observation, interview, and record review, the facility failed to ensure the comprehensive assessment of residents before the use of bed rails (adjustable ridged bars attached to the bed) for 28 of 28 sampled residents. The deficient practice resulted in a Substandard Quality of Care (SQC) deficiency when the facility failed to: Identify alternatives prior to using bedrails Review the risk and benefits for use of bed rails for each residents or their representatives Obtain informed consent prior to use Develop and implement policy and procedure to monitor the use of bed rails This deficient practice had the potential to put the residents at significant risk of injuries, from accident such as a body part being caught between the rails, falls from attempts to climb over, around, between, or through the rails. Findings: During the initial tour on the fourth floor on 2/4/19 beginning at 9:00 AM, 28 residents were observed to have bed rails in the up position. During an observation and concurrent interview on 2/4/19 at 9:00 AM Resident 14 was lying in bed, with the head of his bed slightly elevated. The right and left bed rails on the top half of the bed and the lower left bed rail on the bottom half of the bed were in the up position. Resident 14 stated that the risk and benefits of bed rail use had not been explained and he had not signed a consent. During a review of the clinical record for Resident 14 the Registration and (&) Admission Record, Resident Admission History and Physical indicated date of admission was 12/20/18, with the following pertinent [DIAGNOSES REDACTED]. During a review the clinical record for Resident 14, the minimum data set (MDS, a resident assessment tool) with an assessment reference date (ARD, the last date of the observation period for obtaining the assessment) of 12/28/18 for Resident 14, indicated a brief interview for mental status (BIMS, a short scanner to help detect cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life.)) score of 11 indicating moderate cognitive impairment. During an observation on 2/4/19 at 9:05 AM Resident 225 was lying in bed, with the covers pulled up to his neck, eyes closed, and head of the bed slightly elevated. The right bed rail on the top half of the bed was in the up position. During a review of the clinical record for Resident 225, the Registration & Admission Record, Resident Admission History and Physical indicated that the date of admission was 1/30/19, with the following pertinent [DIAGNOSES REDACTED]. During a review of the clinical record for Resident 225, the MDS with an ARD date of 2/6/19 indicated a BIMS score of 14 indicating no cognitive impairment. During an observation and concurrent interview on 2/4/19 at 9:10 AM Resident 19 was sitting up in a chair next to the bedside. The right and left bed rails on the top half of the bed and one bed rail on the lower half of the bed were in the up position. Resident 19 was alert and stated the staff is excellent. Resident 19 denied having a discussion with the staff regarding the risk and benefits of bed rail use or having signed a consent. During a review of the clinical record for Resident 19 the Registration & Admission Record, Resident Admission History and Physical indicated date of admission was 1/10/19, with [DIAGNOSES REDACTED]. During a review of the clinical record for Resident 19, the MDS with an ARD date of 1/21/19 indicated a BIMS score of 15 indicating no cognitive impairment. During an observation and concurrent interview on 2/4/19 at 9:15 AM Resident 20 was lying in bed and watching television. The right and left bed rails on the top half of the bed were in the up position. Resident 20 stated everything is fine. Registered Nurse 8 (RN 8) stated she did not know the policy on the use of bed rails, she would have to check. During a review of the clinical record for Resident 20, the Registration & Admission Record, Resident Admission History and Physical indicated date of admission was 1/15/19, with the following pertinent [DIAGNOSES REDACTED]. During a review of the clinical record for Resident 20, the MDS with an ARD date of 1/23/19 indicated a BIMS score of 15 indicating no cognitive impairment. During an observation and concurrent interview on 2/4/19 at 9:30 AM, Resident 18 was lying in bed with the head of the bed slightly elevated, Resident 18 stated there had not been any discussion regarding the benefits and risks of bed rail use and he had not signed a consent. Resident 18 stated, usually all four bed rails are up. Observed three bed rails were in the up position. During a review of the clinical record for Resident 18 the Registration & Admission Record, Resident Admission History and Physical indicated date of admission was 1/8/19, with the following pertinent [DIAGNOSES REDACTED]. During a review of the clinical record for Resident 18, the MDS with an ARD date of 2/6/19 indicated a BIMS score of 15 indicating no cognitive impairment. During an observation on 2/4/19 at 9:50 AM Resident 226 was lying in bed, slightly turned on his right side, eyes closed. All four bed rails were in the up position. During a review of the clinical record for Resident 226 the Registration & Admission Record, Resident Admission History and Physical indicated date of admission was 1/24/19, with the following pertinent [DIAGNOSES REDACTED]. (a break in the bone in the neck close to the head), obesity (excessive body fat) . During a review of the clinical record for Resident 226, the MDS with an ARD date of 2/6/19 indicated a BIMS score of 15 indicating no cognitive impairment. During an observation and concurrent interview on 2/4/19 9:55 Resident 12 was lying in bed facing the door. All four bed rails were in the up position. The daughter of Resident 12 was sitting in a chair next to the bed. Resident 12 and his daughter denied having a conversation with staff regarding risk and benefits of bed rail use, or of signing a consent for bed rails. During review of the clinical record for Resident 12 the Registration & Admission Record, Resident Admission History and Physical indicated date of admission was 10/24/18, with the following pertinent [DIAGNOSES REDACTED]. During a review of the clinical record for Resident 12, the MDS with an ARD date of 12/21/18 indicated a BIMS score of 10 indicating moderate cognitive impairment. During an observation and concurrent interview on 2/4/19 at 9:59 AM Resident 9 was lying in bed, awake and alert. All four bed rails were in the up position. Resident 9 denied having discussed the risks and benefits of bed rail use with anyone and did not sign a consent. Resident 9 stated no one has talked to me about that. During a review of the clinical record for Resident 9 the Registration & Admission Record, Resident Admission History and Physical indicated date of admission was 9/8/18, with the following pertinent [DIAGNOSES REDACTED]. During a review of the clinical record for Resident 9, the MDS with an ARD date of 12/21/18 indicated a BIMS score of 9 indicating moderate cognitive impairment. During an observation on 2/4/19 at 10:04 AM Resident 22 was not in the room. Both bed rails on the top half of the bed were in the up position. During a review of the clinical record for Resident 22 the Registration & Admission Record, Resident Admission History and Physical indicated date of admission was 1/11/19, with the following pertinent [DIAGNOSES REDACTED]. During a review of the clinical record for Resident 22, the MDS with an ARD date of 1/23/19 indicated a BIMS score of 15 indicating no cognitive impairment. During an observation on 2/4/19 at 10:06 AM Resident 17 was sitting in a chair, listening to music. Right and left bed rails on top half of the bed were in the up position. Resident 17 denied having had any discussion with staff about risk and benefits of bed rail use and denied having signed a consent. During a review of the clinical record for Resident 17 the Registration & Admission Record, Resident Admission History and Physical indicated date of admission was 1/8/19, with the following pertinent history status [REDACTED]. During a review of the clinical record for Resident 17, the MDS with an ARD date of 1/15/19 indicated a BIMS score of 14 indicating no cognitive impairment. During an observation and concurrent interview on 2/4/19 at 10:10 AM Resident 224 was sitting in the wheelchair next to the bed. Right and left bed rails on the top half of the bed were in the up position. Resident 224 denied having had a conversation with anyone regarding the use of bed rails or having signed a consent. During a review of the clinical record for Resident 224 the Registration & Admission Record, Resident Admission History and Physical indicated date of admission was 1/24/19, with the following pertinent history of poorly controlled diabetes mellitus, right distal lower extremity gangrene (localized death and decomposition of body tissue), status [REDACTED]. During a review of the clinical record for Resident 224, the MDS with an ARD date of 1/31/19 indicated a BIMS score of 14 indicating no cognitive impairment. During an observation on 2/4/19 at 10:18 AM Resident 6 was lying in bed, eyes were closed. All four bed rails were in the up position. During a review of the clinical record for Resident 6 the Registration & Admission Record, Resident Admission History and Physical indicated date of admission was 12/1/18, with the following pertinent [DIAGNOSES REDACTED]. During a review of the clinical record for Resident 6, the MDS with an ARD date of 12/10/18 indicated a BIMS score of 15 indicating no cognitive impairment. During an observation on 2/04/19 at 10:00 AM, Resident 174 was awake, in bed, with right and left bed rails on the top half of bed in the up position. During review the clinical record for Resident 174, the MDS with a ARD of 1/29/19 indicated a BIMS score of 06 indicating severe cognitive impairment. During and observation on 2/04/19 at 10:30 AM, Resident 15 was in bed with right and left bed rails on the top half of bed in the up position. During review of the clinical record for Resident 15, the MDS with a ARD of 01/02/19 indicated a BIMS score of 06 indicating severe cognitive impairment. During an observation on 2/04/19 at 10:40 AM, Resident 13 was up in room, with right and left bed rails on the top half of bed in the up position. During review of the clinical record for Resident 13, the MDS with a ARD of 12/31/19 indicated a BIMS score of 01 indicating severe cognitive impairment. During an observation on 2/04/19 at 10:50 AM, Resident 2 was in bed with the right and left bed rails on top half of bed in the up position. During review of the clinical record for Resident 2, the MDS with a ARD 2/12/19 indicated a BIMS score of 14 indicating no cognitive impairment. During an observation on 2/05/19 at 10:00 AM, Resident 21 was in bed with the right and left bed rails, on the top half of the bed, in the up position. During review of the clinical record for Resident 21, the MDS with a ARD 1/23/19 indicated a BIMS score of 12 indicating moderate cognitive impairment. During an observation on 2/04/19 at 09:45 AM, Resident 175 was in a wheelchair at bedside, the right and left bed rails on the top half of the bed, were in the up position. During review of the clinical record for Resident 175, the MDS with a ARD of 4/04/19 indicated a BIMS score of 14 indicating no cognitive impairment. During an observation on 2/04/19 at 09:50 AM, Resident 4 was sitting up in bed, the right and left bed rails, on the top half of the bed, were in the up position. During review of the clinical record for Resident 4, the MDS with ARD of 11/30/18 indicated a BIMS score of 15 indicating no cognitive impairment. During an observation on 2/04/19, Resident 176 was lying in bed, the right and left bed rails, on the top half of the bed, in the up position. During review of the clinical record for Resident 176, the MDS with an ARD of 2/07/19 indicated a BIMS score of 14 indicating no cognitive impairment. During an observation on 2/04/19, Resident 177 was lying in bed, with the right and left bed rails on the top half of the bed in the up position. During review of the clinical record for Resident 177, the MDS with an ARD of 2/05/19 indicated a BIMS score of 14 indicating no cognitive impairment. During an observation on 2/4/19 at 10:23 AM, Resident 3 was in bed, with right and left bed rails on top half of bed in the up position. In a concurrent interview, when asked about the use of bed rails, and if the facility obtained his consent and informed him of the risks and benefits of using the bed rails, Resident 3 stated, I guess so I wouldn't fall out of bed . I don't care one way or the other but no, no one spoke with me about it . I didn't know it could be dangerous. During a review of the clinical record for Resident 3, the Registration & Admission Record dated 2/19/19 at 1:07 PM indicated Resident 3 was readmitted on [DATE]. During a review of the clinical record for Resident 3, the MDS with ARD of 11/28/18 indicated Resident 3 had a BIMS score of 15 indicating no cognitive impairment. During a review of the clinical record for Resident 3, on 2/4/19 at 1:20 PM, no documentation was found that indicated prior to using bed rails, the facility attempted to use alternatives, assessed for risk of entrapment, obtained informed consent, and reviewed risks and benefits of the use bed rails with the resident. During an observation on 2/4/19 at 10:26 AM, the bed of Resident 5 had the right and left bed rails on top half of the bed in the up position and the left bed rail on the bottom half of the bed in the up position. Resident 5 was not in the room at the time of observation. During an observation on 2/5/19 at 9:50 AM, Resident 5 was in his room in bed with all four bed rails in the up position. In a concurrent interview, when asked about the use of bed rails, Resident 5 stated, I want them up . When asked if the facility explained the risks and benefits of using the bed rails and obtained his consent prior to the use of bed rails, Resident 5 stated, No . no one talked to me about it . During a review of the clinical record for Resident 5, the Registration & Admission Record dated 2/19/19 at 1:07 PM indicated Resident 5 was readmitted on [DATE]. During a review of the clinical record for Resident 5, the MDS with ARD of 2/4/19 indicated Resident 5 had a BIMS score of 15 indicating no cognitive impairment. During a review of the clinical record for Resident 5, on 2/4/19 at 3:03 PM, there was no documentation that indicated that prior to using bed rails, the facility attempted to use alternatives, assessed for risk of entrapment, obtained informed consent, and reviewed risks and benefits of the use of bed rails with the resident. During an observation on 2/4/19 at 10:29 AM, Resident 10 was sitting in a wheelchair. The bed of Resident 10 had right and left bed rails on top half of the bed in the up position. In a concurrent interview, when asked about the use of bed rails, Resident 10 stated, I use them to get up . turn . When asked if the facility obtained his consent prior to using the bed rails, Resident 10 stated, No . they did not ask for my consent ., and stated, No, when asked if the staff reviewed with him the risks and benefits of the bed rails. During a review of the clinical record for Resident 10, the Registration & Admission Record dated 12/6/18 at 3:44 PM indicated Resident 10 was readmitted on [DATE]. During a review of clinical record for Resident 10, the MDS with ARD of 12/12/18 indicated Resident 10 had a BIMS score of 15 indicating no cognitive impairment. During a review of the clinical record on 2/4/19 at 11:50 AM, there was no documentation that indicated prior to using bed rails, the facility attempted to use alternatives, assessed for risk of entrapment, obtained informed consent, and reviewed risks and benefits of the use of bed rails with the resident. During an observation on 2/4/19 at 10:42 AM, Resident 23 was in his room lying in bed, and had right and left bed rails on top half of the bed in the up position. In a concurrent interview, when asked if the facility obtained his consent prior to using the bed rails and informed him of risks and benefits of bed rail use, Resident 23 stated, No, they just put them up. I use them to get up. During a review of the clinical record for Resident 23, the MDS with ARD of 1/3/19 indicated a BIMS score of 6 indicating severe cognitive impairment. During a review of the clinical record for Resident 23, the Registration & Admission Record dated 9/27/18 at 4:22 PM indicated Resident 23 was admitted on [DATE] and readmitted on [DATE]. During a review of the clinical record for Resident 23, on 2/4/19 at 11:45 AM, there was no documentation that indicated that prior to using bed rails, the facility attempted to use alternatives, assessed for risk of entrapment, obtained informed consent, and reviewed risks and benefits of the use of bed rails with the resident or the resident representative. During an observation on 2/4/19 at 10:57 AM, Resident 7 was in his room sitting on the bed with right and left bed rails on top half of the bed in the up position. In a concurrent interview, when asked if the facility obtained his consent prior to using the bed rails and informed him of risks and benefits of bedrail use, Resident 7 stated, No. they've been here since I got here. I use them to move, get off from bed . During a review of the clinical record for Resident 7, the MDS with ARD of 12/12/18 indicated a BIMS score of 10 indicating moderate cognitive impairment. During a review of the clinical record for Resident 7, the Registration & Admission Record dated 1/20/19 at 3:16 PM indicated Resident 7 was readmitted on [DATE]. During a review of the clinical record on 2/4/19 at 1:54 PM, there was no documentation that indicated that prior to using bed rails, the facility attempted to use alternatives, assessed for risk of entrapment, obtained informed consent, and reviewed risks and benefits of bed rails with the resident. During an observation on 2/4/19 at 11:24 AM, Resident 124 was in her room sitting in a wheelchair. The bed of Resident 124 had right and left bed rails on top half of the bed in the up position. In a concurrent interview, Resident 124 stated, No consent. No review of risks . don't remember them talking to me about it . when asked if the facility explained the risks and benefits of using bed rails and obtained her consent prior to the use of bed rails. During a review of the clinical record for Resident 124, the Registration & Admission Record dated 12/19/19 at 1:07 PM indicated Resident 124 was readmitted on [DATE]. During a review of the clinical record for Resident 124, the MDS with ARD of 2/1/19 indicated Resident 124 had a BIMS score of 13 indicating no cognitive impairment. During a review of the clinical record on 2/4/19 at 3:07 PM, there was no documentation that prior to using bed rails, the facility attempted to use alternatives, assessed for risk of entrapment, obtained informed consent, and reviewed risks and benefits of the use of bed rails with the resident. g. During an observation on 2/4/19 at 11:30 AM, Resident 16 was in her room lying in bed with right and left bed rails on top half of bed in the up position. In a concurrent interview, Resident 16 stated, It was not explained . I don't think so . when asked if the facility explained the risks and benefits of using bed rails and obtained her consent prior to the use of bed rails. During a review of the clinical record for Resident 16, the Registration & Admission Record dated 2/19/19 at 1:09 PM indicated was Resident 16 readmitted on [DATE]. During a review of the clinical record for Resident 16, the MDS with ARD of 1/11/19 indicated Resident 16 had a BIMS score of 15 indicating no cognitive impairment. During a review of the clinical record on 2/4/19 at 3:11 PM, there was no documentation that prior to using bed rails, that the facility attempted to use alternatives, assessed for risk of entrapment, obtained informed consent, and reviewed risks and benefits of the use of bed rails with the resident. During an interview on 2/7/19 at 8:52 AM, RN 4 stated that risks and benefits of bed rail use were not explained to the residents and the facility did not obtain informed consents from the residents or their responsible party prior to using the bed rails because they (bed rails) are not being used as restraints. During an interview on 2/8/19 at 9:08 AM, when the facility ' s policy for the use of bed rails was requested, RN 6 stated, . We don't have one for bed rails. On 2/19/19 at 9 AM, the Director of Regulatory Affairs (DRA) was notified of the substandard quality of care deficiency for failure to attempt to use appropriate alternatives, assess the residents for risk of entrapment from bed rails, review the risks and benefits of bed rails with the residents or resident representatives, and obtain informed consent prior to the use of bed rails. During an interview with RN 4 on 2/19/19 at 10:56 AM, when asked if the facility attempted to use alternatives prior to using the bed rails, RN 4 stated, . Basically there is none . When asked if the residents were assessed for risk of entrapment prior to using the bed rails, RN 4 stated, . I don't think so .

Based on observation, interview and record review, the facility failed to maintain a safe and sanitary environment when opened, unpackaged, and unlabeled emergency equipment were found in one of 28 sampled residents' room (Resident 7). This deficient practice has the potentially to result in the transmission and spread of infection causing harm to the residents. Findings: Review of clinical records for Resident 7, the Registration and Admission Record dated 1/20/19 indicated Resident 7 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. During an observation on 2/4/19 at 11:03 AM, in the room of Resident 7 an open resuscitation bag (RB, device used to provide artificial breathing to someone who is not breathing or who is barely breathing) with an attached face mask and open and unlabeled oxygen tubing (OT) were found hanging on the wall mounted oxygen regulator (a device used to deliver medical oxygen). The OT was connected to the wall mounted oxygen regulator, neither had a label. In a concurrent interview, when asked about the RB and the OT, Resident 7 stated, I don't know, I've never used them. They've been there since I got back . During an observation and concurrent interview on 2/4/19 at 11:06 AM, RN 7 acknowledged the unlabeled RB and OT hanging at the bedside of Resident 7. RN 7 stated, .Two weeks ago, he (referring to Resident 7) had a [MEDICAL CONDITION] . staff opened them in case it's needed . put them (referring to the RB and the OT) there just in case we need them . he (Resident 7) didn't use them . they (staff) called code blue (term used to indicate that a person has sudden unexpected loss of heart function and breathing and immediate life saving steps are needed). We should have removed them after . supposed to dispose them right away for infection control. During a review of the clinical record for Resident 7, the .Interdisciplinary Progress Notes . Nursing dated 1/18/19 at 11:00 PM indicated At 20:00 (10 PM) PCA (patient care assistant) . found the res (Resident 7) lying on his abdomen, unresponsive, code blue was activated . Res was transferred to ED (Emergency Department) . During an interview on 2/7/19 at 8:52 AM, when asked about the RB and the OT found in Resident 7's room, RN 4 stated, . It was part of the MERT (medical emergency response team) situation that happened on 1/18/19 . The resident (Resident 7) did not use it . he was sent to the ED . The expectation after code blue/MERT is the supplies should be discarded after the incident had occurred. We follow the hospital policy for the MERT and code blue. When asked for the importance of discarding the supplies after the incident, RN 4 stated, . In an emergency event, there is a possibility a staff might grab it and use it for another resident. The policies titled Medical emergency Response Team revised on 5/2016 and the Code Blue Response revised on 2/2018 did not address disposal of supplies that were opened and prepared for emergency use.

Based on interview and record review, the facility failed to ensure residents were free from unnecessary [MEDICAL CONDITION] medications when there was no monitoring for specific target behavior for the use of [MEDICAL CONDITION] medications for six of six sampled residents (Residents 10, Resident 4, Resident 2, Resident 9, Resident 17, and Resident 19). This failure had the potential for residents to be exposed to adverse health consequences which could negatively impact the residents' mental, physical, and psychosocial well-being. Findings: During a review of the clinical record for Resident 10, the Registration & Admission Record dated 12/6/18 at 3:44 PM indicated Resident 10 was admitted on [DATE] with [DIAGNOSES REDACTED]. During a review of the clinical record for Resident 10, the San Francisco Behavioral Health Center (SFBHC) Renewal Orders dated 2/4/19 at 10:30 AM indicated . Duloxetine (a drug to treat depression) . 30 milligram(mg) taken by mouth (po) daily . for depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily functioning) . During a review of the clinical record of Resident 10 on 2/6/19 at 1:22 PM, the Behavioral Monitoring Record dated (MONTH) 2019 indicated . Duloxetine 30 mg po daily . Specific behavior to be monitored: Depressed mood . In a concurrent interview, when asked if depressed mood is a specific behavior, Registered Nurse 5 (RN 5) stated, . It's pretty generalized. During a review of the clinical record for Resident 10, the Behavioral Monitoring Record dated for the month of (MONTH) 2019 a zero was marked for behavior, indicating no depressed mood. During a review of the clinical record for Resident 10, the Medication Administration Record [REDACTED]. 30 mg . po daily for depression . was administered daily from 2/1/19 to 2/4/19. During a review of the clinical record for Resident 10, the Resident Care Plan- Psychoactive Medications dated 12/16/18 indicated . Start Date .12/6/18 . Duloxetine 30 mg po daily . Behavior to be Monitored . Depressed Mood . During an interview on 2/6/19 at 3:06 PM, RN 4 reviewed the Behavioral Monitoring Record for Resident 10, dated (MONTH) 2019, and acknowledged that the behavioral monitoring for the use of Duloxetine was not specific, and stated, It's (referring to depressed mood) an umbrella for symptoms . symptoms for one patient may be different from another patient . It should be specific for the patient . During review of the clinical record for Resident 2, the Registration & Admission Record dated 9/28/18 indicated Resident 2 admitted with [DIAGNOSES REDACTED]. During a review of the clinical record for Resident 2, the San Francisco Behavioral Health Center (SFBHC) Renewal Orders dated 1/31/19, indicated .[MEDICATION NAME] HCL (a drug to treat depression) 25 mg po daily for mood. During a review of the clinical record for Resident 2, the monthly Behavioral Monitoring Record for [MEDICATION NAME] 25 mg po daily dated (MONTH) and (MONTH) 2019 indicated under Specific Behavior Being Monitored: Depressed mood . During the review of the clinical record for Resident 2 the Behavioral Monitoring Record dated (MONTH) and (MONTH) 2019 indicated zero was marked for behavior, indicating no depressed mood. During an interview with RN 3 on 2/05/19 at 4:00 PM she stated, since she (Resident 2) is better her mood is better, she is up and out of her room. This is why her behavior for mood is marked zero. During an interview with Pharmacist 1, on 2/07/19 at 10:22AM, she stated, I don't know the regulations regarding specific behavior monitoring. During review of Clinical Record for Resident 4, the History and Physical Exam dated 8/24/18, indicated [DIAGNOSES REDACTED]. During review of Clinical Record for Resident 4, the San Francisco Behavioral Health Center (SFBHC) Renewal Orders dated 1/18/19 indicated .[MEDICATION NAME] (a drug to treat mental disorders) 2.5 mg po twice a day (BID) .for major [MEDICAL CONDITION] (MDD, a mental health condition characterized by constant feeling of sadness or loss of interest in activities, causing significant impairment in daily life), with substance abuse (SA, harmful or hazardous use of mood altering substances). During review of Clinical Record for Resident 4 the monthly Behavioral Monitoring Record for [MEDICATION NAME] 2.5mg po twice a day dated (MONTH) 2019 indicated under Specific Behavior Being Monitored: .Paranoia (the irrational and persistent feeling that people are 'out to get you). During a review of the clinical record for Resident 4 the Behavioral Monitoring Record dated (MONTH) 2019 indicated zero was marked for behavior, indicating no paranoia. In a concurrent interview with RN 4, when asked if Paranoia is a specific behavior, RN 4 stated, .it ' s pretty generalized. During a review of the clinical record for Resident 9, the Resident Admission History & Physical dated 9/10/18 indicated a [DIAGNOSES REDACTED]. Continue [MEDICATION NAME] (a drug used to treat depression). During a review of the clinical record for Resident 9, the Skilled Nursing Facility Consent for Psychoactive Oral Medication indicated a consent was signed by the Resident on 9/8/18 for [MEDICATION NAME] 45 mg .monitor for depressed mood. During a review of the clinical record for Resident 9, the Behavioral Monitoring Record for the months of (MONTH) 2019 and (MONTH) 2019 indicated specific behavior being monitored: depressed mood. During a review of the clinical record for Resident 9, the Behavioral Monitoring Record dated (MONTH) 2019 and (MONTH) 2019, indicated zero was marked for behaviors observed, indicating no depressed mood. During a review of the clinical record for Resident 9, the Medication Administration Record [REDACTED]. During a review of the clinical record for Resident 9, the San Francisco General Hospital & Trauma Center 4A-Skilled Nursing Facility Resident (SNF) Care Plan - Psychoactive Medications dated 9/8/18, indicated [MEDICATION NAME] 15mg .PO (by mouth) .bedtime .depression .depressed mood. During a review of the clinical record for Resident 17, the Resident Admission History & Physical dated 1/3/19 indicated a [DIAGNOSES REDACTED]. features .stable. Continue Aripiprazole (a drug used to treat [MEDICAL CONDITION]), duloxetine. During a review of the clinical record for Resident 17, the Skilled Nursing Facility Consent for Psychoactive Oral Medication indicated a consent was signed by Resident 17 on 1/2/19 for Duloxetine .monitor for depressed mood, Aripiprazole .monitor for delusions. During a review of the clinical record for Resident 17, the Behavioral Monitoring Record dated (MONTH) 1, 2019 to (MONTH) 7, 2019, indicated specific behaviors being monitored for Aripiprazole was delusions and the specific behavior being monitored for duloxetine was depressed mood. During a review of the clinical record for Resident 17, the Behavioral Monitoring Record dated (MONTH) 1, 2019 to (MONTH) 7, 2019, indicated zero was marked for behaviors observed, indicating no delusions and no depressed mood. During a review of the clinical record for Resident 17, the San Francisco General Hospital & Trauma Center 4A-SNF Resident Care Plan-Psychoactive Medications dated 1/2/19, indicated Aripiprazole 2mg .PO .daily .depression with [MEDICAL CONDITION] .delusions and Duloxetine 30mg .PO .daily .depression .depressed mood. During a review of the clinical record for Resident 17, the Medication Administration Record [REDACTED]. During a review of the clinical records for Resident 19, the 4A Skilled Nursing Facility Resident Admission History & Physical dated 1/11/19, indicated a [DIAGNOSES REDACTED]. During a review of the clinical record for Resident 19, the Skilled Nursing Facility Consent for Psychoactive Oral Medication indicated a consent was signed by the Resident on 1/10/19 for [MEDICATION NAME] .monitor for depressed mood. During a review of the clinical record for Resident 19, the Behavior Monitoring Record for the month of (MONTH) 2019, indicated [MEDICATION NAME] for depression with the specific behavior being monitored was depressed mood. During a review of the clinical record for Resident 19, the Behavioral Monitoring Record dated (MONTH) 2019 for days one through five, indicated zero was marked for behaviors observed, indicating no depressed mood. During a review of the clinical record for Resident 19, the San Francisco General Hospital & Trauma Center 4A-SNF Resident Care Plan - Psychoactive Medications dated 1/10/19 .[MEDICATION NAME] .monitor for depressed mood. During a review of the clinical record for Resident 19, the Medication Administration Record [REDACTED]. During a review of the clinical record for Resident 19, the San Francisco General Hospital & Trauma Center 4A-SNF Resident Care Plan - Psychoactive Medications dated 1/10/19 .[MEDICATION NAME] 100 mg .monitor for depressed mood. During an interview with RN 8 on 2/6/19 at 2:53 PM, RN 8 acknowledged that the behavioral monitoring for the use of [MEDICATION NAME] was not specific and stated I agree, monitoring for depressed mood is too broad. It needs to be more specific. Review of the facility policy titled Therapeutic Use of Medications approved on 1/19 indicated . Statement of Policy: 1. The 4A- SNF (skilled nursing facility) provides Residents with an environment of care that enables them to maintain or enhance, to the highest practical level, their physical, mental and psychosocial wellbeing . Procedure: 1. Each Resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used: . c. without adequate monitoring .

Based on observation, interview, and record review, the facility failed to ensure one of 28 sampled residents (Resident 23) received adequate supervision when the care plan for fall risk was not fully implemented. This deficient practice had the potential to result in inadequate observation and monitoring which could compromise the safety of Resident 23. Findings: During a review of the clinical record for Resident 23, the Registration & Admission Record dated 9/27/18 at 4:22 PM indicated Resident 23 was admitted on [DATE] and readmitted on [DATE] with [DIAGNOSES REDACTED]. During a review of the clinical record for Resident 23, the Interdisciplinary Progress Notes dated 10/1/18 at 11:00 AM indicated Pharmacy Fall Assessment . Patient fell on ,[DATE] at around 7:20 PM . and the Interdisciplinary Progress Notes dated 11/26/18 at 2:36 PM indicated Nurse Practitioner (NP) Note: . Pt (Resident 23) calling for help and was found on the bathroom floor . During a review of the clinical record for Resident 23, the Resident Care Plan titled Potential for Injury/Fall Risk dated 12/28/18 indicated . Problem/Issues: High Risk for Fall . related to: Unsteady gait, weakness, . impaired vision, . as evidenced by: history (hx) of falls, unable to transfer without assistance . not steady, only able to stabilize with human assistance . Goal: Resident will remain free from injuries . Approach . Make sure that all staff members are aware that resident is at high risk for falls . Falling star (FS) resident's door & board . During an observation on 2/6/19 at 1:36 PM with Registered Nurse 5 (RN 5), there was no FS sign affixed to Resident 23's door. RN 5 acknowledged the observation. During an observation and concurrent interview with RN 5 on 2/6/19 at 1:38 PM, there was no FS sign on the communication board. RN 5 acknowledged the observation. RN 5 stated that a FS sign should also be placed on the communication board after Resident 23's name so that we know if they are at risk for fall . During an interview with RN 4 on 2/6/19 at 3:31 PM, she reviewed Resident 23's care plan for fall risk and stated that the FS sign . is a visual cue for nurses, for physical therapist (PT), and other disciplines if a patient is a high risk for fall. During an interview on 2/7/19 at 8:52 AM, RN 4 stated that the missing FS sign on the communication board and on Resident 23's door was . an unmet part of the CP on our part. It's an expectation on our part to have the sign on the door and on the board. The facility policy titled . 4A-SNF (skilled nursing facility) Interdisciplinary Resident Care Planning . Date Approved: . 8/18 indicated . Statement of Policy: It is the policy of the 4A-SNF to utilize an interdisciplinary approach to assess, plan, implement and evaluate the Resident's care. The Care Plan encompasses an interdisciplinary approach .specifying care and treatment planning based upon a systematic assessment of the Resident's physical, . environmental, . needs . The facility policy titled Falls Risk Assessment and Intervention Guidelines . Approved: . 11/16 indicated . Purpose: The purpose of this policy is to describe the . 4A-SNF falls prevention program which establishes the processes that strive to prevent falls and the processes for post-fall management .Procedure: .3. 4A- SNF Specific Falls Prevention Interventions: .Nursing staff will place visual indicator of fall risk with falling star sign on communication board .

The facility failed to ensure Resident 1 received the appropriate treatment and services to prevent deterioration in the range-of-motion of his left hand. During the time from Resident 1's admission (8/14/07) to the day of the observation (4/1/11), Resident 1 had a loss in the range-of-motion of his left hand without evidence that the facility had accurately assessed the physical functioning of his left hand, without evidence that the facility had developed an Integrated Treatment Plan (ITP - care plan) to prevent range-of-motion decline, and without evidence that the facility had implemented, evaluated, and changed interventions as necessary to prevent Resident 1's development of significant contractures (permanent shortening of the muscles which control joint mobility) of four of the fingers of his left hand. Resident 1 was admitted to the facility 8/14/07 with [DIAGNOSES REDACTED]. The Nursing Assessment Database, dated 8/4/07, indicated Resident 1 had weakness of his left lower extremity, but no mention was made of upper extremity weakness. During the initial history and physical examination [REDACTED]. The MD did note that Resident 1 had a history of [REDACTED]. In an observation on 4/1/11 at 10:00 AM, Resident 1 was seated at a table in the activity room. He was holding a cup of juice in his unbraced right hand. Resident 1's left hand had no splints, braces, or Kerlix (roll of gauze dressing) lifting his fingers away from the palm of his hand. When asked Resident 1 turned his left hand palm up. Resident 1's four fingers, excluding his thumb, had the fingernails pressed tightly against the palm of his hand. The index finger and the fifth finger could be lifted slightly with some discomfort noted by Resident 1's grimacing, but the middle and ring fingers could not be moved without pain and Resident 1's immediate withdrawal of his hand. The fingernails extended approximately three-eighths of one inch from the nail bed. In an interview on 4/1/11 at 10:30 AM, the Medical Director stated Resident 1 clearly had a stroke but it was prior to his admission at the facility. The Medical Director said he recalled Resident 1 had left sided weakness (arm and leg) since admission. During Resident 1's initial Integrated Treatment Conference on 9/4/07, there was no documentation regarding the status of Resident 1's left hand or the need to care plan for the left hand weakness identified by the Medical Director. Record review of Resident 1's Minimum Data Set (MDS) Annual assessment dated [DATE], and the most recent MDS assessment dated [DATE], both indicated Resident 1 had no impairment of the functional range-of-motion of his left hand. In an interview on 4/1/11 at 10:30 AM, the MDS Nurse who completed the 2/12/11 MDS Assessment, stated both of these MDS assessments of Resident 1's range-of-motion were incorrect and she thought Resident 1 first showed signs of decreased left hand range-of-motion in 2009. The facility policy and procedure "Interdisciplinary Resident Assessment/Reassessment", dated 10/07 stated "Data gathered in assessment and reassessments will be utilized in prioritizing patient care needs, identifying appropriate interventions...The Registered Nurse (RN) assessment includes the psychosocial, behavioral and physical/functional status of the Resident." The policy also stated the assessment/reassessment process for the Minimum Data Set assessments was due quarterly with a multidisciplinary assessment due annually. The policy and procedure "Resident Care Planning", dated 8/10, stated the facility utilized "an interdisciplinary approach to assess, plan, implement and evaluate Resident care." Four months after admission the meetings of the Interdisciplinary Team (IDT) would be held quarterly and would determine if "individual care plans shall be opened, revised, renewed, re-opened, or closed." The policy stated the RN was responsible "for documenting the IDT's care plan decisions, and any changes in goals or interventions on the Integrated Treatment Plan (ITP) form." Record review indicated physician orders [REDACTED]. Record review indicated on 7/20/10 a physician ordered an Occupational Therapy left hand evaluation and splint. The Occupational Therapy (OT) hand evaluation on 8/9/10 indicated Resident 1 needed splinting for the decreased functional use of his left hand. A splint was made and the instructions were provided for the nursing unit which included "discontinue for any signs of intolerance and call therapist." On 8/9/10 a Nurse Practitioner clarified the splinting instructions by suggesting the splint would be best tolerated during the night and could be off during the day. The facility did not use the OT evaluation information and recommendations of this left hand evaluation and the Nurse Practitioner's suggestion to develop an Integrated Treatment Plan (ITP) for Resident 1 in order to restore range-of-motion and/or prevent further decline of function. There was nothing in Resident 1's chart to indicate the therapist had been consulted after 8/9/10. The letter sent by the OT Therapist containing the results of the evaluation and the OT recommendations to the physician who had ordered the hand evaluation for Resident 1 had no documented acknowledgement signed by this referring physician. In an interview on 4/1/11 at 10:35 AM, the Director of Nursing (DON) acknowledged Resident 1 had contractures of the four fingers of his left hand causing them to be continuously pressed against the palm of Resident 1's hand. The DON stated he had reviewed Resident 1's medical record and concluded the MDS Assessments were inaccurate when they stated Resident 1 had no impairment in the range-of-motion of his left hand. The DON stated there were no Integrated Treatment Plans (care plans) developed from admission until 4/1/11 which addressed Resident 1's problem with left handed weakness (2007), the first indications of a decrease in range-of-motion (2009), the use of the splint (2010), the use of the brace (2011), and Resident 1's progressive loss of the function of his fingers. The DON stated there were no ITPs developed which addressed the pain Resident 1 experienced when the fingers of his left hand were moved, The DON was unable to find any documentation that the therapist had been called when Resident 1 could not/would not use the splint. The Lippincott Manual "Best Practices: Evidence Based Nursing Procedures", Second Edition, 2007, stated "Passive range- of-motion exercises (PROM) improve or maintain joint mobility and help prevent contractures...Whether the cause of immobility is permanent or temporary, the patient must receive some type of exercise to prevent [MEDICAL CONDITION] (the muscles decrease in size, losing most of their strength and normal function) and joint contractures." The Merck Manual Professional "Stroke Rehabilitation", 2/2009, stated "Flexor [DIAGNOSES REDACTED] (Flexion - bending the muscles to close the fingers; [DIAGNOSES REDACTED] - continuous resistance to stretching by the muscle due to increased tension) develops in most [DIAGNOSES REDACTED] (weakness on one side of the body) hands and wrists. Unless patients with flexor [DIAGNOSES REDACTED] do range-of-motion exercises several times a day, flexion contracture (permanent shortening of the muscles which control joint mobility) may develop rapidly, resulting in pain...A hand splint or wrist splint may be useful, particularly at night." The facility policy and procedure "Restorative Nursing Program", dated 10/07 and in effect at Resident 1's admission to the facility, stated "The Skilled Nursing Facility Resident will be provided with the restorative care necessary to actualize his/her optimal level of functioning...An individual restorative care plan will be developed for each Resident and may include, but is not limited to:...range of motion exercise program." The facility policy and procedure "Contracture Prevention", dated 10/07, stated "Skilled Nursing Facility residents shall be provided with appropriate nursing care to prevent the formation and progression of contractures." The DON was unable to produce any "Restorative Care Plans" for Resident 1. The DON reviewed the Integrated Treatment Conference Notes for 2/28/11 and acknowledged Resident 1's left hand contractures were not addressed. Record review indicated Resident 1 was examined in the facility's Orthopedic Clinic on 3/15/11, and he was fitted for a left hand brace. An Integrated Treatment Plan (ITP - care plan) developed on 3/15/11 identified Resident 1's problem as a "Contracture of R (Right) hand, potential for pain and discomfort." The ITP indicated the problem was opened 3/15/11. A handwritten note under the problem statement was undated and unsigned; it read "Resident seen in ortho clinic, has (R) hand brace but refuse to wear it." The interventions in this care plan were directed at pain relief rather than contracture prevention. There were no changes made to the ITP interventions based on Resident 1's refusal to wear the brace. During an interview on 4/1/11 at 10:35 AM, the DON stated the ITP was probably for Resident 1's left hand but he acknowledged there was no evaluation of Resident 1's refusal to wear the brace and the interventions on the ITP were not changed. Record review of Resident 1's Treatment Records for January 1, 2011, through March 31, 2011, indicated there were no times in which the staff used the [MEDICATION NAME] balm to relieve the pain of Resident 1's left hand. Resident 1 had some weakness of his left hand on admission based on the Medical Director's statement. The MDS Nurse recalled Resident 1 first showed signs of a loss of range-of-motion in 2009. The facility consistently made incorrect MDS assessments of Resident 1's left hand range-of-motion even though they did send Resident 1 for an Occupational Therapy Hand Evaluation on 8/9/10 and an Orthopedic Clinic evaluation on 3/15/11; both of these evaluations noted decreased left hand mobility. The facility did not develop a care plan for Resident 1's left hand weakness which included a minimal intervention such as passive range-of-motion as recommended in the nursing literature and the facility's policies. As Resident 1's left hand mobility continued to decline, the facility failed to develop care plans which included the recommendations of the hand experts for splints and braces. Therefore, the facility failed to ensure Resident 1 received the appropriate treatment and services to prevent loss of the range-of-motion of the four fingers of his left hand which caused these fingers to be continuously pressed against the palm of his hand. Resident 1 had a decline in the range-of-motion of his left hand without evidence that the facility had accurately assessed the physical functioning of his left hand, without evidence that the facility had developed an Integrated Treatment Plan (ITP - care plan) to prevent range-of-motion decline, and without evidence that the facility had implemented, evaluated, and changed interventions as necessary to prevent Resident 1's development of contractures of four of the fingers of his left hand. The above violations presented either an immediate danger that death or serious physical harm would result, or a substantial probability that death or serious physical harm would result.