Health inspection·June 25, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few AM, and Resident 1 was sleeping at that time, so she did not want to bother Resident 1 around 7 AM. She stated, she cleaned Resident 1 around 8 AM, then changed Resident 1's position at 9 AM. CNA 1 stated, 9 AM was the only time she changed Resident 1's position. During a concurrent interview and record review on 6/25/24 at 10:35 AM with Nurse Manager (NM) 1, Resident 1's pressure ulcer care plan, initiated on 2/25/24 was reviewed. The care plan indicated, . Reposition q (every) 2 hours and PRN (Pro re nata, as needed) . NM 1 verified, the CNA should have followed the care plan. Review of the facility's policy and procedure (P&P) titled, Wound and Skin Management dated 11/2023 indicated, . c. Assure patients are turned and repositioned every 2 hours in bed . Review of the facility's P&P titled, Care Plan Policy dated 3/2024 indicated, . a. The facility must develop and implement a comprehensive person-centered care plan for each resident . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055169 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jewish Home & Rehab Center D/P Snf 302 Silver Avenue San Francisco, CA 94112 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of 3 Certified Nursing Assistants (CNA) 1 was competent when CNA 1 did not know Resident 1 had dementia and urinary tract infection (UTI, a collective term that describes any infection involving any part of the urinary tract, namely the kidneys, ureters, bladder and urethra). This failure had the potential to result in Resident 1 not receiving appropriate treatments and services. Findings: Review of Resident 1's clinical record indicated, Resident 1 was admitted to the facility with diagnoses including nephritis (inflammation of the kidneys), renal and perinephric abscess (a pocket of pus in the kidney and perinephric space, surrounding the kidneys), dementia (memory loss), and pressure ulcer (same as bedsore, an injury to the skin and the tissue below the skin that are due to pressure on the skin for a long time). Review of Resident 1's Minimum Data Set (MDS, resident assessment tool), dated 4/15/24 indicated, Resident 1 was cognitively moderately impaired. During a concurrent observation and interview on 5/1/24 at 11:45 AM with CNA 1 in the nursing unit of [NAME] 1 (F1), there was an enhanced barrier precaution (an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) signage at the door of Resident 1's room. CNA 1 stated, Resident 1 had C-diff (Clostridium difficile, bacteria that cause an infection of the colon, the longest part of the large intestine) when asked. During an interview on 5/1/24 at 12:11 PM with CNA 1 in hallway in F1, CNA 1 stated, I forgot. Let me ask . when asked again if Resident 1 had C-diff. Then she went to the nursing station to ask Registered Nurse (RN) 1, and came back at 12:13 PM to answer. CNA 1 stated, She (Resident 1) has bacteria in urine . No C-diff . CNA 1 acknowledged she was wrong regarding Resident 1's enhanced barrier precaution. She stated, I am float . I thought another patient . During an interview on 5/1/24 at 12:19 PM with CNA 1 in hallway in F1, CNA 1 stated, No when asked if Resident 1 has dementia. Then CNA 1 stated, Hold on a second, then she went to the nursing station to ask Nurse Manager (NM) 1. CNA 1 came back at 12:20 PM to answer the question. CNA 1 stated, I asked my charge nurse. She (Resident 1) is confused, and she has dementia. She stated, I am sorry. I forgot. I am just floating . when asked what she does to take care of residents with dementia. She stated, . I always forgot . She stated, No when asked if she had taken some notes during the shift endorsement since she stated that she always forgets. Then she stated, Everyone (other CNAs) is like that . During an interview on 5/1/24 at 12:49 PM with RN 1, RN 1 verified because Resident 1 had UTI with ESBL (extended spectrum beta-lactamase. It's an enzyme found in some strains of bacteria. ESBL-producing bacteria can't be killed by many of the antibiotics that doctors use to treat infections), the resident was put on the enhanced barrier precaution, not because of C-diff. RN 1 acknowledged, CNA 1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055169 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055169 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/25/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Jewish Home & Rehab Center D/P Snf 302 Silver Avenue San Francisco, CA 94112 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few asked her about Resident 1, and CNA 1 did not know that Resident 1 had dementia and was on the enhanced barrier precaution due to UTI. Review of the facility's policy and procedure (P&P) titled, Enhanced Barrier Precautions dated 4/2024 indicated, . Jewish Home aims to prevent the spread of multi-drug resistant organisms (MDRO) within the facility . MDROs fall under the category of Healthcare Associated Infections (HAI). MDROs are common bacteria that have developed resistance to multiple types of antibiotics . MDROs can contaminate the immediate environment of residents who may need assistance with indwelling medical devices, wounds, and frequent soiling . Review of the facility's P&P titled, Competencies for Nursing Staff dated 12/2023 indicated, . It is the policy of the Jewish Home & Rehab Center (JHRC) to ensure nursing staff are competent to perform their jobs . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055169 If continuation sheet Page 4 of 4