Health inspection·July 24, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some training, as everyone is mandated reporter. Stressed to then Abuse is a crime. Our Policy and Procedure on reporting timeframe is within 2 hours to report and complete the SOC 341. The staff involved are put on administrative leave pending investigation. The investigation is started by the reporter, supervisor or DON and Abuse Coordinator is notified. Anyone can file an SOC. The Social Workers check in on patients providing psychosocial support. Nursing monitoring the patient for emotional distress. The summary of investigation is completed by Supervisors or managers and reviewed by Abuse Coordinator. Human Resources is aware of suspension for staff involved in the abuse incident. Police is notified and they come to investigate and a nurse supervisor comes with the Officer to take the report from them. We have 5 business days to send to CDPH the summary of investigation. Review of employee file for CNA 1, CNA certificate number CNA00458104, expires 4/10/2026, active.Employee acknowledgement of Elder Abuse /Reporting - 2/28/22, Abuse, Neglect and Exploitation in the Elder Care 6/24/24. 1:1 Focused Inservice 10/31/2024. on 1/2/15 - Abuse prevention and reporting inservice. Review of employee CNA 2, CNA certificate no. 01240332 expires 5/30/27, active. Abuse Prevention and Reporting -10/2/2024, 1:1 Focused service on Elder Abuse Prevention and Reporting -10/31/24, on 1/28/25 Mandatory Abuse Prevention and Reporting.Not able to interview the 2 staff, not working that time of investigation. 2. Review of SOC , Report of Suspected Dependent Adult/Elder Abuse, date completed 11/8/24, allegation from Resident 2 on November 8, 2024, that a staff member was verbally rude to her on November 6, 2024. Patient denies any physical contact with the staff member. SOC form did not indicate written report mailed or faxed to state agencies.Review of faxed transmission to CDPH, indicate, 11/9/24 at 8:16 AM. Review of admission record, indicated, resident admitted on [DATE] with diagnoses including: Adjustment Disorder with Anxiety and Depressed Mood, Mild Cognitive Impairment, Difficulty in Walking. Review of progress notes, nurses notes dated 11/6/24 at 16:22 PM, indicated, received endorsement from AM sitter that patient expressed that she does not want yesterday's PM sitter (11/5/24) to return d/t being aggressive. Per patient report, 11/5/24 PM sitter said things like, get up by yourself, walk by yourself and reportedly took her bags and left the patient's room. AM sitter endorsed to this to nursing supervisor who gave sitter instructions to report to this RN. Endorsed to PM and AM CN. Continuing plan of care. During an observation on 7/22/25 at 12 noon, Resident 2 up on a chair, volunteer came and left to give me time to talk to resident. I was introduced by her CNA, needs to call her Mademoiselle.Resident wanted to know why I am here. Told her about the incident last year, staff being verbally rude. Per resident, that's been a long time ago, In don't remember. I'm watching a movie right now, if I can do it? I am okay here, don't come again. During an interview on 7/22/25 at 12:14 PM, with CNA, per CNA resident is very particular with ADLs, activities and belongings. She attends almost all activities, she is a speaker for one of those activities which she enjoys. Per CNA she knows the incident last year and the CNA involved is never assigned to her again. she has no complaints with any CNA after that. Interview on 7/23/25 at 11:11 AM with RN 1, per RN1, that sitter reported to her at the end of her shift that resident 2 does not want the NOC shift sitter to come back and supervisor is aware. Per RN she went ahead and documented it, let the AM and PM charge nurses know about the report. per RN, later on (does not remember the date), she was reprimanded for not reporting appropriately.RN started her employment on 4/2024, does not remember if she got the abuse training when I got hired to report in 24 hours. Has not had any training on abuse after that. Review of SOC 341, completed by DON on 11/8/24.indicated, no dates when faxed to mandated agencies. no dates when telephone report made to mandated agencies. Reviewed and confirmed with Unit Supervisor, per Unit supervisor, abuse should be reported within 2 hours, and this one is not done on time per RN. Review of CNA alleged abuser 's Abuse training, indicated training for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055169 If continuation sheet Page 2 of 5 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 07/24/2025 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Identifying and Addressing Older and Dependent Abuse on 10/9/2024.Review of RN 1's license, license expires 8/31/2025. no disciplinary actions against the licensee. During an interview on 7/23/25 at 3:50 PM, with Administrator, per Administrator she is the Abuse Coordinator. Reviews for correct allegations. Notified of all abuse incidents. make sure that the reports are sent to agencies as required. Anybody can fill out the SOC as everyone is a mandated reporter. Investigation summary is a collaborated effort from IDT(Interdisciplinary team) and Administrator summarizes the investigation and have it faxed to agencies within 5 business days. Review of facility Policy and Procedure, Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property, dated 8/24, indicated, Purpose: The purpose of this policy is to describe the measures the Jewish Home and Rehab Center takes to prevent residents from abuse, neglect, mistreatment, exploitation, and misappropriation of property through screening, training and education, supervision, assessment, investigation and reporting. POLICY: It is the policy of Jewish Home .to ensure that each resident will be free from abuse, neglect, mistreatment, exploitation, and misappropriation of property . In any allegation of abuse the Administrator, Director of Nursing and Clinical Operations, nurse manager, nursing supervisor or any mandated reporter will notify the California Department Of Public Health, the Ombudsman and San Francisco Police Department immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury . Event ID: Facility ID: 055169 If continuation sheet Page 3 of 5 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 07/24/2025 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 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to report the result of investigations to the State Survey Agency (SSA) within 5 working days of the incident for four (4) of 12 residents' (Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5) abuse allegations .Resident 1 alleged 2 CNAs rough handling during change of bedsheet on 10/29/24Resident 2 alleged 1 CNA on 11/5/24 was aggressive and said get up by yourself, walk by yourselfResident 3 alleged a nurse on the night of 8/27/24 was rude, harsh, and hit her. Resident 5 went to Resident 4's room, grabbed his face and pushed it back.This failure may cause delay in taking all necessary actions to protect the residents and prevent further occurrences.1. Review of Resident 1's document titled, Report of Suspected Dependent Adult/Elder Abuse, known as SOC (State of California) 341, with a completed date of 10/31/24, indicated, an allegation of staff to resident abuse was reported to law enforcement on 10/30/24, to Ombudsman on 10/30/24, California Department of Public Health on 10/31/24. The SOC 341 indicated, staff reports alleged patient abuse reported on 10/30/24 from patient's wife that 2 CNAs were handling him roughly while changing his bedsheets on 10/29/24. Residents Affected - Some Review of the facility's Fax Cover sheet indicated, the facility faxed the Abuse Allegation Investigation - 5 day Follow -Up (result of investigation) to CDPH on 11/9/2024 at 8:20 AM. 2. Review of Resident 2's document titled, Report of Suspected Dependent Adult/Elder Abuse, known as SOC (State of California) 341, with a completed date of 11/08/24, indicated, an allegation of staff to resident abuse, no indication of reported to : law enforcement, Ombudsman, California Department of Public Health. The SOC 341 indicated, on 11/8/24 Resident 2 alleging that a staff member was verbally rude to her on 11/6/24. Review of the facility's Fax Cover sheet indicated, the facility faxed the Abuse Allegation Investigation - 5 day Follow -Up (result of investigation) to CDPH on 11/9/2024 at 11:27 AM. 3. Review of document titled, Report of Suspected Dependent Adult/Elder Abuse, known as SOC (State of California) 341, with a completed date of 8/28/24, indicated, an allegation of staff to resident abuse was reported to the law enforcement, California Department of Public Health (CDPH), and Ombudsman on 8/28/24. The SOC 341 indicated, on 8/27/24, a night nurse was rude, harsh and hit Resident 3. Review of the facility's Fax Cover Sheet indicated, the facility faxed the Abuse Allegation Investigation - 5 Day Follow-Up (result of investigation) to CDPH on 9/6/24 at 10:56 AM. 4. Review of the Resident 4 and Resident 5's SOC 341 report, with a completed date of 9/9/24, indicated, an allegation of resident to resident altercation was reported to the law enforcement, CDPH, and Ombudsman on 9/9/24. The SOC 341 indicated, on 9/9/24 at 1:20 PM, Resident 5 went to Resident 4's room, grabbed his face and pushed it back. Review of the facility's Fax Cover Sheet indicated, the facility faxed the Abuse Allegation Investigation - 5 Day Follow-Up to CDPH on 9/17/24 at 9:53 AM. During an interview on 7/23/25 at 3:50 PM, the Administrator stated the 5-Day Follow-Up (result of investigation) should be reported to the state agency within five working days of the incident. Review of the facility's policy and procedure titled, Abuse, Neglect, Exploitation, Mistreatment, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055169 If continuation sheet Page 4 of 5 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 07/24/2025 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 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete and Misappropriation of Resident Property, revised 08/2024, indicated, .Compliance: . 7. Reporting/Response: It is the policy of the [SNF Name] to report all abuse allegations to the administrator/designee, California Department of Public Health, San Francisco Police Department if appropriate, Ombudsman, and any other required agencies . f. The administrator will follow up with government agencies to confirm the initial report was received and to report the results of the investigation when final within 5 working days of the incident as required by state agencies . Event ID: Facility ID: 055169 If continuation sheet Page 5 of 5