Health inspection·August 8, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to ensure the environmrnt of one of one sampled resident (Resident 1) was free of potential accident hazards (falls and injuries from a lift) when they transferred Resident 1 in a lift to a commode and left her hanging a foot above the commode for several hours several times per day rather than lowering her to the toilet seat of the commode as instructed in the manual from the manufacturer (Invacare). Although Resident 1 chose this procedure and staff came to check on her while she was hanging from the lift, this does not prevent: the lift from failing; Resident 1 from falling; Resident 1 from injury; the facility from responsibility for Resident 1's safety. Findings: In an interview and record review with SN 1 on 8/8/25 at 10:45 a.m., SN 1 stated Resident 1 was admitted to the facility (over 10 years ago). SN 1 said Resident 1 was dependent on staff to turn and reposition her in bed, transfer her to a commode or wheelchair, and feed her. In an interview with SN 2 on 8/8/25 at 11:41 a.m., SN 2 said Resident 1 takes a shower in a chair with a seat like a commode and can sit in the shower chair for 30 minutes. SN 2 stated Resident 1 likes to hang over the commode in the sling of the lift for one to one and a half hours three times a day at 7 a.m., 10 a.m., and 7 p.m. In an interview with SN 3 on 8/8/25 at 11:35 a.m., SN 3 stated Resident 1 is fully dependent on staff and two people transfer her in the lift from her from her bed to the commode. SN 3 stated she hangs in the air sitting in the sling about one foot above the seat of the commode. SN 3 stated she hangs in the sling several times a day for up to one hour. Her preferred times to do this are at 7 a.m., 11 a.m. and 3:30 p.m. SN 3 said staff check on her and she lets them know when she is ready to go back to bed with a voice activated call light. In an interview with SN 2 and SN 4 on 8/8/25 at 2:33 p.m. SN 4 said Resident 1 called 911 last week because she said she was hanging in the sling too long. SN 4 said the police explained why she should not call them for this. SN 2 stated Resident 1 calls a family member who then calls SN 2 to complain that Resident 1 is hanging over the commode for too long a period. SN 2 said often Resident 1 does not have a bowel movement each time she hangs in the sling over the commode. In a discussion with SN 2 and SN 4 regarding the safety and responsibility issues of using a lift that was not designed to dangle a resident 12 inches above the seat of a commode for one to two hours three times a day, they said they understood these issues. In an observation and interview with Resident 1 on 8/8/25 at 4:30 p.m., there was a lift against the wall on the left at the entrance to the dark room. Resident 1 was in bed covered neatly with blankets. Only her face from her forehead to her lower lip could be seen. She talked about her concerns and mentioned dangling in the lift over the commode. When told by the surveyor that it was a safety issue, she said she was not concerned. She stated she was concerned staff broke her phone four times. In an interview with SN 5 on 8/8/25 at 3:03 p.m. regarding the safety and facility responsibility issues discussed above with SN 2 and SN 4, SN 5 was asked to provide documents that the manufacturer of the lift approves the manner in which they are using it for Resident 1. SN 5 stated the paperwork would be provided by the end of (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055169 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 08/08/2025 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)