Health inspection·December 3, 2024

F 0600 5. Showers Level of Harm - Minimal harm or potential for actual harm According to Resident 1 ' s MDS, dated [DATE], she had an external catheter to manage her urine (a non-invasive device that collects urine from the body without being inserted internally) and was continent of bowel. Residents Affected - Few During a concurrent observation and interview of Resident 1 on 12/06/2024 at 11:30 AM, Resident 1 was in bed and on her back. She was not able to move her arms or her legs. Resident 1 stated .I ' m totally dependent on staff. I can ' t scratch an itch. I can ' t turn and reposition my arms and legs and my body. I need someone to feed me and give me water. I need a staff to clean me up when I soil myself. I need a staff to position my (urinary) catheter correctly.(the facility was) Supposed to give me a sitter at least every day to help me with these things. Lately, they are short and now I sit and wait for them.You are calling for help and you don ' t know when someone is coming. Can you imagine how frustrating that makes me feel.They said that I ' m depressed or I have depression. Wouldn ' t you be depressed if you were subjected to this almost every day? With my condition, my body needs to be on a regular schedule. If I don ' t eat and don ' t drink on time. Things starts shutting down. I get constipated, I ' m supposed to go to the commode around 7:00 AM. They didn ' t help me to the commode until 10:00 AM. Another time it got so bad, I was screaming for help no one came and I had to get my brother to call a supervisor .because I was wet for 4 hours. Review of Resident 1 ' s medical records titled Progress Notes indicated entries regarding how staffing was affecting her mental health: 1. Authored by Social Worker (SW) 1, dated 10/29/2024, indicated .she has a sitter who told (Resident 1) .she could not feed or transfer her. (Resident 1) . then asked sitter to leave. SW is clarifying with .(Director of Nursing, Scheduler, Unit Manager) tasks of sitter. During two conversations with .(Resident 1), she speaks of abandonment issues, not doing well alone. 2. Authored by SW 2, dated 10/29/2024, indicated .Much of the time was spent with complaints and frustration over staffing. She reports that her planning each day depends on the knowledge of staffing (who will be available to assist her) 3. Authored by SW 2, dated 10/28/2024, indicated .(interdisciplinary team) met and discussed .(Resident 1) who expressed a desire to die, stating, I just want to die .(because) I don't have a sitter, and I can't manage everything on my own. I am not as important as everybody else. She was distressed, and tearful. 4. Authored by SW 2, dated 10/07/2024, indicated Resident 1 . continues to complain that her needs are not being met especially for toileting . because of staffing needs of .(other residents) . (Resident 1) has reported fears of abandonment and she keeps her door open because she is afraid of being forgotten/ignored.(Resident 1) reports to SW that her day consists of eating .(related to) toileting needs and clarifying scheduling of CNA and sitter to meet the toileting needs. 5. Authored by SW 2, dated 09/20/2024, indicated Resident 1 .continues to report the difficulty in getting timely help with commode, shower, transfer, changing undergarments. She speaks of a fear of abandonment and the effect that has on her . Review of Resident 2 ' s record titled admission RECORD, printed on 01/03/2025, indicated she was admitted with multiple diagnosis including: quadriplegia, muscle spasm, depression, insomnia (sleep (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055169 If continuation sheet Page 2 of 9 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 12/03/2024 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 0600 Level of Harm - Minimal harm or potential for actual harm disturbances), and dysphagia (difficulty swallowing foods or fluids). Review of Resident 2 ' s records titled MDS, dated [DATE], indicated her BIM score was 15 out of 15. According to her MDS, she was totally dependent on staff for: 1. Bed mobility Residents Affected - Few 2. Transfers 3. Dressing 4. Toilet use and personal hygiene 5. Showers According to Resident 2 ' s MDS, dated [DATE], she had a catheter to manage her urine and was always incontinent of bowel. During an interview with Resident 2 on 12/06/2024 at 12:14 PM , she stated Today everything was late. One person on vacation. My (CNA) . has no help. (she is) feeding everybody. It ' s emotionally taxing for me to see that and have to wait for help. Sometimes when they are short, they are not able to put me back to bed in time. I have to wait and if I wait too long, sometimes it affect my sleep. I remember one time they put me to bed late and I was in pain the whole night. Review of Resident 3 ' s record titled admission RECORD, printed on 01/03/2025, indicated he was admitted with multiple diagnosis including: muscular dystrophy (genetic diseases that cause muscles to weaken and degenerate over time), bipolar disorder (mental condition causing extreme mood swings. Periods of elations, irritability and periods of sad depressed moods), and constipation. Review of Resident 3 ' s records titled MDS, dated [DATE], indicated his BIM score was 15 out of 15. According to his MDS, he was totally dependent on staff for: 1. Bed mobility 2. Transfers 3. Dressing 4. Toilet use and personal hygiene 5. Showers According to Resident 3 ' s MDS, dated [DATE], he had a catheter to manage his urine and was always incontinent of bowel. During an interview with Resident 3 on 12/06/2024 at 12:36 PM , he stated .Call lights are a problem when they are short. You can wait 25 minutes to have a call light answered. The longest was one hour wait. I need help with meals. When they are short, I have to wait maybe more than 25 minutes for them to help me with my meals. By then, the food is almost always cold. During an interview on 12/20/24 at 12:20 PM, Charge Nurse (CN) 1 stated CNA staffing on her unit (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055169 If continuation sheet Page 3 of 9 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 12/03/2024 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 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few has gotten worse since July 2024. CN 1 stated on her unit on AM shift there used to be six CNA and CNA staffing was reduced to five CNAs and sometimes as low as four CNAs. CNA staffing was reduced with no reduction in resident census and/or change in resident acuity/level of care. CN 1 stated sometimes when she was working late to finish her charting, she could hear Resident 2 screaming for staff to come help her. During an interview on 12/23/2024 at 10:53 AM, Certified Nursing Assistant (CNA) 2 stated she usually worked AM shift and sometimes her unit is short. CNA 2 stated The residents (who are) alert are mad at us because they have to wait. While we attend to others. Sometimes . (Resident 1) has to wait at least 45 minutes. The residents who cannot talk are the ones who suffer. AM shift (used to have) six CNAs now it ' s down to five CNA. Even if we divide the time between these residents, it ' s not enough. During an interview on 01/18/2025 at 10:00 AM, CNA 1 stated she mostly worked on one unit in the AM shift. On that unit, they were normally staffed with six CNAs. Sometimes CNA staffing can be as low as four. When the unit is short, residents have to wait for services/care. CNA 1 stated .Resident have to wait yeah it depends. We are .(given) more .(residents) than usual.(longest wait was) 40 minutes to 1 hour wait. They needed to get changed. There are some patients that needs 2 people.some .are frustrated some are mad . I can understand .(Resident 1 ' s) frustration.she shows frustration thru shouting and crying. During an interview with the Unit Manager (UM) on 01/15/2025 at 11:55 AM, she stated the census on her unit has been very stable and the acuity/care requirement for each resident has been very stable. The UM admitted sometimes the unit was short staff with only four CNAs. The UM stated residents .are going have to wait when we are short. The UM stated the facility implemented safety monitors but the safety monitors cannot function as CNA. The UM stated the safety monitors are not allowed to do tasks involving direct patient care like feeding, giving water, repositioning, providing incontinent care etc. During an interview on 01/22/2025 at 11:05 AM, CNA 3 stated she worked AM shift. CNA 3 stated prior to July 2024, AM shift used to be staffed with six CNA after July, CNA staffing was cut to five and can be as low as four CNAs. CNA 3 stated unfortunately, residents have to wait, up to 30-45 minutes for care. CNA 3 confirmed that Residents 1, 2, 3 have complained about waiting when the unit was short staffed. CNA 3 stated these Residents 1, 2, and 3 were not happy, mad, frustrated, and accused staff of ignoring their needs. CNA 3 stated Resident 1 and 2 sometimes reported discomfort/pain when staff was not able to reposition them or put Resident 2 back to bed in a timely manner. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055169 If continuation sheet Page 4 of 9 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 12/03/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not report allegations of neglect for Resident 1, one of three sample residents. Resident 1 sent four emails to the facility alleging sub-par quality of care issues such as: delayed response to request for care, no care, not getting enough food and water, and getting minimal care. This has the potential to place Resident 1 and other residents at risk for abuse/neglect. Findings: Review of Resident 1 ' s record titled admission RECORD, printed on 01/03/2025, indicated she was admitted with multiple diagnosis including: quadriplegia (partial or total loss of function in all four limbs and the torso), constipation (difficulty in emptying bowel, usually due to hardened feces), depression, muscle spasms, and limitation of activities due to disability. Review of Resident 1 ' s records titled Minimum Data Set (MDS, a standardized resident assessment tool), dated 12/26/2024, indicated her BIM score was 15 out of 15 (BIM=Brief Interview for Mental status, a standardized test for memory and reasoning functions. A score of 13-15 indicated no impairment in memory and reasoning). According to her MDS: she was totally dependent on staff for: 1. Bed mobility 2. Transfers 3. Dressing 4. Toilet use and personal hygiene 5. Showers According to Resident 1 ' s MDS, dated [DATE], she had an external catheter to manage her urine and was continent of bowel. Review of emails provided by Resident 1 indicated: 1. Resident 1 emailed the facility ' s grievance web portal, on 12/23/2024, and wrote .I was not put on the commode before dinner as I am scheduled to do every day. Toileting is the worst problem, but other needs are not being met as well. Some issues are manifesting as painful symptoms and a week-long admission to the hospital because of an internal infection. 2. Resident 1 emailed the Administrator, and the Unit Manager, on 12/6/2024. Resident 1 wrote .for commode/ bowel movement. Without a sitter, a second CNA for the two person assist . I suffer with cramps and chills because I cannot be put on the commode. The issues continue to be that almost all of those scheduled care times are delayed by hours or not done at all when the regular AM CNA is off. The other challenge has been getting enough food and water around commode times. Without a sitter most of it does not happen at all. 3. Resident 1 emailed the Director of Nursing (DON) and the Administrator on 12/03/2024. Resident 1 wrote .when the regular CNAs are off, everyone thinks I have a sitter and no one takes care of me! (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055169 If continuation sheet Page 5 of 9 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 12/03/2024 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 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few No one was assigned to feed me my usual yogurt that I am supposed to eat because of the antibiotics, and worse, no one was assigned to feed me dinner! I am supposed to go to the commode around 3:45 PM, and no one was available. I have had a Sitter since every CNA has been hired and for years, no one thought about me, answered call lights, or entered my room until it 8 PM when it is my scheduled time to go to the commode. in this environment that I don't eat and my body shuts down. I end up in the hospital, and then I am blamed for the extra effort required by the CNAs when I returned. Thank goodness I'm not sick today as I was yesterday. I can't even imagine being as sick as I was without a sitter here. With my sensitive stomach, perhaps it's better that I don't eat or drink. I don't know how else to stress the importance of having a sitter/aide. I cannot eat, drink, or get help by myself, yet I need all three every day. Please, I need help. 4. Resident 1 emailed the DON, the Administrator, and the Director of Social Services on 11/29/2024. Resident 1 wrote .If the regular CNA . is not here, I have no regular schedule. I don't drink water as there is no one to give me any, I may or may not eat dinner, and my commode times may or may not happen or be on schedule! I am barely getting minimum care here! . One or two sitters a week along with my private pay, still leaves days when my body either functions as it should but in pain without care, or shutting down until I end up in the hospital again. Review of the facility ' s policy titled Grievance/Complaint Process, Revised on 11/2017, indicated .The responsibility to review and resolve grievances has been delegate to the designated Grievance Official who is responsible for: .Ensuring the immediate reporting of all alleged violations involving neglect, abuse, .to all agencies required by law.This is a shared by all facility staff. The Administrator was made aware of these emails on 12/08/2025 at 3:19 PM and the facility was asked if: 1. Any contents within Resident 1 ' s emails were treated as grievances (documented and logged as grievances, investigated as grievances, changes presented to Resident 1 and implemented to address Resident 1 ' s grievance). 2. Any contents within Resident 1 ' s emails were treated as neglect allegations and were reported and investigated per State regulations. The facility was unable to provided documentations regarding items 1 or 2. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055169 If continuation sheet Page 6 of 9 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 12/03/2024 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 0675 Honor each resident's preferences, choices, values and beliefs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility did not provide the necessary care to maintain the highest practicable mental and psychosocial wellbeing for Resident 1, one of three sample residents. Resident 1 was totally dependent on staff for Activities of Daily Living (ADL) and other care needs. Starting July 2024, the facility unilaterally reduced direct care giver hours by 41.67% to Resident 1. This resulted in Resident 1 expressing feelings of frustrations, abandonment, and suicidal ideation. Residents Affected - Few Findings: Review of Resident 1 ' s record titled admission RECORD, printed on 01/03/2025, indicated she was admitted with multiple diagnosis including: quadriplegia (partial or total loss of function in all four limbs and the torso), constipation (difficulty in emptying bowel, usually due to hardened feces), depression, muscle spasms, and limitation of activities due to disability. Review of Resident 1 ' s records titled Minimum Data Set (MDS, a standardized resident assessment tool), dated 12/26/2024, indicated her BIM score was 15 out of 15 (BIM=Brief Interview for Mental status, a standardized test for memory and reasoning functions. A score of 13-15 indicated no impairment in memory and reasoning). According to her MDS: she was totally dependent on staff for: 1. Bed mobility 2. Transfers 3. Dressing 4. Toilet use and personal hygiene 5. Showers According to Resident 1 ' s MDS, dated [DATE], she had an external catheter to manage her urine and was continent of bowel. During a concurrent observation and interview of Resident 1 on 12/6/24 at 11:30 a.m., Resident 1 was in bed and on her back. She was not able to move her arms or her legs. Resident 1 stated .As you can see, I ' m totally dependent on staff. I can ' t scratch an itch. I can ' t turn and reposition my arms and legs and my body. I need someone to feed me and give me water. I need a staff to clean me up when I soil myself. I need a staff to position my (urinary) catheter correctly.(the facility was) Supposed to give me a sitter at least every day to help me with these things. Lately, they are short and now I sit and wait for them. You are calling for help and you don ' t know when someone is coming. Can you imagine how frustrating that makes me feel. Sometimes they don ' t have enough staff to put me on the commode. I ' m forced to hold my bowel or if I know they are short staffed, I either don ' t eat or don ' t eat as much. Because I don ' t know if there ' ll be enough staff to put me on the commode. Another thing they need to do is reposition me on a regular basis. It gets uncomfortable if they leave me in one position for a long time. If they are short, I wait .even if I ' m in pain, I have to wait. I have no other choice. They said that I ' m depressed or I have depression. Wouldn ' t you be depressed if you were subjected to this almost every day? During an interview on 01/15/2025 at 11:55 a.m., the Unit Manager (UM) stated Resident 1 care needs (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055169 If continuation sheet Page 7 of 9 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 12/03/2024 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 0675 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few has not changed. Resident 1 was totally dependent on staff for ADLs and other care. The UM stated the facility implemented Safety Monitors (SM) but the SM cannot function as Certified Nursing Assistant (CNA). The UM stated the SM are not allowed to do tasks involving direct patient care like feeding, giving water, repositioning, providing incontinent care etc. During an email communication with Resident 1, dated 01/20/2025 at 5:31 a.m., Resident 1 wrote she enjoyed working with SM 1 because SM 1 was providing direct patient care. Resident 1 wrote SM 1 .was not a .(CNA. However,) she .feed, assisted with (mechanical lift for transfers) and help with some ADLs. During an interview on 01/23/2025 at 3:25 p.m., SM 1 provided information she was hired as a safety monitor but was functioning as a direct care giver. SM 1 stated .(Resident 1 was) still in the commode sometimes I help the CNA to . change the diaper. I feed her, and clean her. After feeding her .(dinner) I go on my break. During a concurrent interview and record review on 01/28/2025 at 11:01 a.m., with the UM, the UM was made aware the facility provided two documents titled June 2024 Sitter Schedule for .(Resident 1) and December 2024 Sitter Schedule for .(Resident 1). Both these documents were not dated. The June 2024 document indicated 216 hours of sitter were provided to Resident 1 and the December 2024 document indicated 216 hours of sitter were provided to Resident 1. The UM was made aware these total hours were in error because: 1. During the interview the UM defined safety monitors as staff who do not provide direct patient care such as feeding, providing water, cleaning residents after an incontinent episode, repositioning. 2. Safety monitors were counted as sitters/CNA (direct care givers) in error. 3. One safety monitor (SM 1) admitted she was functioning as a CNA and providing direct patient care. The UM was made aware after analysis, in June 2024, the facility provided 192 hours/month of sitter/CNA hours to Resident 1. In December, the facility provided 112 hours/month of sitter/CNA hours to Resident 1. This was a reduction of 41.67% in direct patient care hours to Resident 1. Additionally, the UM was made aware these reduction in direct patient care levels may have resulted in Social Services notes documenting Resident 1 reported feelings of frustrations, abandonment, wanting to keep her door open because she was fearful of being ignored/forgotten, and suicidal ideation. Review of Resident 1 ' s medical records titled Progress Notes indicated these entries: 1. Authored by Social Worker (SW) 1, dated 10/29/2024, indicated .(Resident 1) has a sitter who told .(Resident 1) she could not feed or transfer her.(Resident 1) then asked sitter to leave. SW is clarifying with .(Director of Nursing, Scheduler, Unit Manager) tasks of sitter. During two conversations with .(Resident 1), she speaks of abandonment issues, not doing well alone. 2. Authored by SW 2, dated 10/29/2024, indicated .Much of the time was spent with complaints and frustration over staffing. She reports that her planning each day depends on the knowledge of staffing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055169 If continuation sheet Page 8 of 9 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 12/03/2024 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 0675 (who will be available to assist her) Level of Harm - Minimal harm or potential for actual harm 3. Authored by SW 2, dated 10/28/2024, indicated .(interdisciplinary team) met and discussed .(Resident 1) who expressed a desire to die, stating, I just want to die .(because) I don't have a sitter, and I can't manage everything on my own. I am not as important as everybody else. She was distressed, and tearful. Residents Affected - Few 4. Authored by SW 2, dated 10/07/2024, indicated Resident 1 . continues to complain that her needs are not being met especially for toileting . because of staffing needs of .(other residents) . (Resident 1) has reported fears of abandonment and she keeps her door open because she is afraid of being forgotten/ignored.(Resident 1) reports to SW that her day consists of eating .(related to) toileting needs and clarifying scheduling of CNA and sitter to meet the toileting needs. 5. Authored by SW 2, dated 09/20/2024, indicated Resident 1 .continues to report the difficulty in getting timely help with commode, shower, transfer, changing undergarments. She speaks of a fear of abandonment and the effect that has on her . On 01/28/2025 at 2:09 p.m., the facility was asked to provide clinical rationale(s) regarding why there was a reduction in Resident 1 ' s direct patient care hours when Resident 1 ' s acuity level/care needs remained the same. The facility was unable not provide the requested documents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055169 If continuation sheet Page 9 of 9