Health inspection·October 3, 2025

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, facility staff failed to provide pressure injury services for one of three sampled residents, Resident 1.The facility failed to:1. Accurately monitor and evaluate Resident's 1's pressure injuries. 2. Revise treatment plans to promote healing of pressure injuries (any lesion caused by unrelieved pressure that results in damage to the underlying skin- see full definition below). 3. Evaluate and monitor the impact of interventions to prevent new pressure injuries from developing. 4. Implement, monitor and modify interventions to attempt to stabilize, reduce or remove underlying risk factors. These failures resulted in Resident 1 developing new Moisture Associated Skin Damage (a type of skin irritation or damage caused by prolonged exposure to moisture) on Coccyx (small triangular bone at the base of the spinal column), a Stage II pressure injury on the Coccyx, new open lesions (tissue which has suffered damage through injury or disease,) on both rear (the back part of the thigh) thighs, and a Stage III pressure injury on the left heel. Definition of pressure injuriesStage I: Intact skin with a localized area of non- blanchable redness (non-blanchable: redness persist and does not fade or turn white after removal of fingertip pressure).Stage II: Partial thickness loss of skin with exposed upper skin layer. The wound bed is pink. May also present as an intact or ruptured blister. Fat tissue and deeper tissues (muscle, tendons, bone) are not visible.Stage III: Full thickness loss of skin, in which the subcutaneous fat (a type of body fat that is stored just beneath the skin) may be visible. Slough (Yellow/white dead tissue) and/or eschar (black dead tissue) may be visible but does not obscure the depth of tissue loss. The depth of tissue damage varies by location.Stage IV: Full thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage or bone in the wound.Unstageable pressure injury: Full thickness skin and tissue loss in which the extent of tissue damage cannot be confirmed because the wound bed is obscured by slough or eschar.Deep Tissue Injury (DTI): Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of the underlying soft tissue. This injury results from intense prolonged pressure at the bone-muscle connection. The wound may evolve rapidly to reveal the actual extent of tissue injury.Diabetic (a person who has high blood sugar levels) Foot Ulcer: Open sores that develop on the feet of people with diabetes.During a review of Resident 1's admission Record (document containing a resident's essential demographic, medical, and personal information), (undated), the admission Record indicated, Resident 1 was admitted to the facility on [DATE] with multiple diagnosis including: Hemiplegia (loss of muscle function or weakness on one side of the body) and Hemiparesis (weakness affecting one side of the body) following Cerebral Infarction (a condition where blood flow to the brain is interrupted) affecting right dominant side, Monoplegia (a type of paralysis that affects only one limb) of upper limb following Cerebral Infarction affecting non dominant side, Dysarthria (a motor speech disorder that affects the muscles controlling speech), Type 2 Diabetes Mellitus (a chronic condition where the body does not use insulin effectively ) with diabetic peripheral angiopathy Residents Affected - Few Page 1 of 5 055169 055169 10/03/2025 Jewish Home & Rehab Center D/P Snf 302 Silver Avenue San Francisco, CA 94112

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few (a complication of diabetes that damages the blood vessels in the legs, feet, and arms) without gangrene (a condition where tissue dies due to a lack of blood supply), muscle weakness, peripheral vascular disease (a condition that affects the blood vessels outside the heart and brain), muscle spasms (sudden, involuntary contractions of muscles), and difficulty walking.A review of Resident 1's Minimum Data Set (MDS: a standardized resident assessment tool), dated 08/12/2025, the Minimum Data Set indicated, a Brief Interview of Mental Status assessment (BIMS, a brief memory test to help determine memory, thinking, learning, and decision making ability: a score of 15-13 = intact memory/reasoning; a score of 12-8 = moderate impairment in memory/reasoning; a score of 7-0= severe impairment in memory/reasoning) was completed. Resident 1 scored 15 out of 15, this indicated Resident 1 had intact memory/reasoning. Resident 1's MDS also indicated limitations in range of motion (the extent of movement possible at a joint) that included impairments on one side of her upper extremities (shoulder, elbow, wrist, hand), impairments on both sides of her lower extremities (hip, knee, ankle, foot), and was completely dependent (staff does all of the effort) for toilet hygiene (the ability to maintain perineal [the area of skin located between the anus and the genitals] hygiene, adjust clothes before and after urinating or having a bowel movement), Shower/bathing, and both upper and lower dressing. During a record review on 9/16/2025 at 11:23 AM with Medical Records (MR) 1, Resident 1's Skin Check- V12 dated 11/25/2024 was reviewed. The Skin CheckV12 indicated, Resident 1 was admitted with these skin injuries:Right dorsum (back or top) 2nd digit (second toe) amputation (the surgical removal of a body part) site.Right Diabetic Foot Ulcer, size= (initial measurement not documented).Right Heel Diabetic Foot Ulcer, size = (initial measurement not documented).Left transmetatarsal (long bones in the foot located between the ankle) amputation site.Left Diabetic Foot Ulcer, size= (initial measurement not documented).A review of Resident 1's Care Plan Report initiated on 11/26/2024 revised on 4/18/2025 was reviewed. The Care Plan Report indicated, Resident 1 was at risk for impaired skin integrity (the overall health and condition of the skin) due to fragile skin.dry scaley skin on both lower legs.Type 2 Diabetes Mellitus.incontinence (involuntary loss of urine or stool) of bladder and bowel functions. During a review of Resident 1's History and Physical (H&P: a comprehensive assessment by a healthcare provider) dated 11/26/2024, the H&P indicated her Primary Care Physician evaluated Resident 1, and determined she had high risk for skin breakdown and faculty staff were to continue wound care recommendations and follow non weight bearing (supporting a load or your own body weight) on right lower extremity (leg) and follow up care with a local hospital Orthopedics department (a medical division specializing in the diagnosis, treatment, and prevention of diseases, injuries, and conditions affecting the musculoskeletal [bones, muscles, tendons, ligaments, and joints that provides support and movement] system).During a concurrent interview and record review on 9/18/2025 at 10:48 AM with Registered Nurse (RN) 1, RN 1 stated she has worked as a RN at the facility for five years and now functions as a Point Click Care (an electronic medical record system) super user. Resident 1's Skin Issue- V8 evaluation, dated 4/18/2025 was reviewed. The Skin issue evaluation indicated, Resident 1 developed new Moisture Associated Skin Damage (MASD) on the Coccyx which measured 1.5cm by 0.5cm developed in-house (while she was a resident of the facility) with new onset (first-time appearance of a medical condition) RN 1 defined MASD as A wound that is blanchable (blanchable: redness that fades or turn white after removal of fingertip pressure), little excoriation (superficial abrasion of the skin's surface layer) but not open. That is why there is no depth in the measurement.During a review of Skin Issue- V8 evaluation dated 04/27/2025, the Skin Issue evaluation indicated Resident 1 developed a new Stage II pressure ulcer/injury on the Coccyx which measured 2cm by 0.5cm by 0.1cm, developed in-house with new onset.During a review of Skin Issue- V12 evaluation dated 055169 Page 2 of 5 055169 10/03/2025 Jewish Home & Rehab Center D/P Snf 302 Silver Avenue San Francisco, CA 94112

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 08/16/2025, the Skin Issue evaluation indicated Resident 1 developed a new open lesion on the right rear thigh which measured 7cm by 0.8cm by 0cm AND a new open lesion on the left rear thigh which measured 1.5cm by 0.3cm by 0cm both developed in-house with new onset. Additional location information stated skin lesions appear to be from MASD.During a review of Skin Issue- V13 evaluation dated 08/28/2025, the Skin Issue evaluation indicated Resident 1 developed a new Stage III pressure ulcer/injury on the left heel which measured 2.4cm by 3.1cm by 0.1cm, developed in-house with new onset. During concurrent interview and record review on 9/18/2025 at 11:03 AM with RN 1, Resident 1's Skin Check- V15 evaluation dated 08/25/2025 was reviewed. The Skin Check evaluation indicated, Resident 1's Coccyx Stage II pressure injury increased in size from 0.2cm by 0.2cm by 0cm on 8/4/2025 to 0.3cm by 0.3cm by 0cm on 8/25/2025. RN 1 stated all wounds are to be measured weekly to assess progress or decline of wounds and update treatment interventions. During an interview on 9/19/2025 at 10:15 AM with Licensed Vocational Nurse (LVN) 1, LVN 1 stated resident's wounds are monitored weekly and documented on the Skin Check form and new skin issues are documented on the Skin Issue forms as needed. LVN 1 stated wound measurements are to be documented on each form completed. When asked what staff are responsible completing wound care for residents, LVN 1 stated the facility had a designated wound nurse (a licensed nurse specializing in treating complex wounds) that would assess wounds weekly and document wound progress or wound decline. LVN 1 stated the facility's wound nurse stopped working at the facility Sometime in 2024 and the floor nurses were completing wound care, weekly skin check evaluations, and notify Primary Care Providers (PCPs) if a wound consult is needed. When asked how are wound treatment orders re-evaluated or assessed, LVN 1 stated I think it is up to the Medical Doctor (MD) or the Physician Assistant (PA) to reassess and change treatment orders based on the information from the weekly skin evaluation forms. LVN 1 stated he was not aware of any routine scheduled days when the MDs or PAs reviewed weekly skin check or skin issue evaluations. When asked how the impact of wound care treatments or pressure injury prevention measures were evaluated by MD/PA's, LVN 1 stated It would just be if the PCP's would happen to be here, then they would take a look for themselves whenever they could. LVN1 reported new wound care team, which includes a MD and PA began working at the facility approximately One month ago. LVN 1 added, When we didn't have anyone (wound care nurse), I think it did affect our wound progress. The new wound PA's wound assessments and care has improved. When asked if LVN 1 participated in interdisciplinary team (IDT: a healthcare team made up of staff from various departments such as nurses, physical therapy, registered dietitian, social worker etc.) meetings to discuss resident care needs or care refusals, LVN 1 stated Floor nurses are not involved with that process. We do not sit in on those meetings.During a phone interview on 9/19/2025 at 11:45 AM with Certified Nursing Assistant (CNA) 1, CNA 1 stated she has worked at the facility for 11 years and was familiar with Resident 1's care, when asked what tasks were included in caring for Resident 1, CNA 1 stated Make sure she is always dry, make sure she gets repositioned every two hours, that's all. CNA 1 stated on approximately three (3) separate outings Resident 1 returned to the facility from the outing with family Soaking wet. CNA 1 stated the Licensed Nurse (LN) was made aware after each outing and the LN evaluated Resident 1's skin after each notification. When asked if any new interventions or changes in Resident 1's care was made after the three reports of Resident 1 returning to the facility soaking wet, CNA 1 replied, No. The same thing. Clean her and put her back to bed.During a phone interview on 9/19/2025 at 12:20 PM with Licensed Vocational Nurse (LVN) 2, LVN 2 stated she has worked at the facility for over 15 years, and We (LNs) monitor (wounds) every two weeks, then inform the PCP. Every time I do the weekly skin check I see if the treatment is effective. When asked if there was documentation of PCP notification when wounds were evaluated, LVN 2 055169 Page 3 of 5 055169 10/03/2025 Jewish Home & Rehab Center D/P Snf 302 Silver Avenue San Francisco, CA 94112

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few stated Honestly no. LVN 2 stated also Resident 1 had MASD On and off while a resident at the facility. When asked if pressure injury prevention interventions were impactful in reducing new pressure injuries, LVN 2 stated They are effective if we put barrier cream on after every pericare (the act of cleaning the genital and anal areas). When asked if she applied barrier cream on Resident 1 to prevent further skin breakdown, LVN 2 stated, The CNAs are the ones putting the barrier cream, so I am not sure if it was applied every time. LVN 2 verified Resident 1 was incontinent of her bowels and bladder and dependent on staff for all repositioning and personal hygiene needs. When asked what she believed were possible contributing factors that could have increased Resident 1's skin injuries, LVN 2 stated, Her family would take her out for multiple hours without pericare When asked if LVN 2 made her Nursing Supervisor aware of concerns, LVN 2 stated, Honestly no. When asked if Resident 1 was provided barrier cream or extra continence supplies while out of the facility, LVN 2 stated No. When asked if she was aware if Resident 1 or (family) were given any training or education on perineal care, LVN 2 stated No, only at the time of discharge. When asked if LVN 2 recalled participating in any care conferences or IDT meetings with Resident 1 or family, LVN 2 stated No we (licensed nurses) do not participate in IDT meetings. During a review of the facility's policy and procedure titled, Wound and Skin Management dated 11/2005 last revised on 07/2025, indicated, .Procedure A. Assessments: .3. IDT and Licensed nurse will assure that treatment plan and progress notes reflect patient's current status and appropriate interventions. The treatment plan will have an interdisciplinary approach.6. Licensed nurse will refer newly identified pressure ulcers to IDT for further assessment and treatment planning.During a concurrent interview and record review on 9/30/2025 at 3:16 PM with Nursing Supervisor (NSP) 2, Resident 1's Wound Consult Referral dated 4/28/2025 was reviewed. The Wound Consult Referral indicated Resident 1's PCP placed an order for a wound consult referral for Wound consult with Skilled Care Surgical Group until wounds resolve.coccyx bed sore (skin damage that occurs when pressure is applied to the same area of the body for an extended period). NSP 2 verified no follow up wound consult or updated treatment orders were documented. A review of Medical Staff- Podiatry (a medical specialty that diagnoses and treats conditions of the foot, ankle, and lower leg) Note dated 6/18/2025, indicated no updates were made to current treatment orders for multiple skin injuries. A review of Progress Notes- Medical staff Consultation dated 7/15/2025 indicated PLAN/RECOMMENDATIONS: Continue present care. A review of Progress Notes- Medical staff Consultation dated 7/22/2025 indicated PLAN/RECOMMENDATIONS: Continue current dressing and keep wounds moist.Coccyx wound- continue current dressing changes. During an interview on 9/30/2025 at 3:16 PM with NSP 2, NSP 2 verified the facility currently has a new wound care group assessing and treating residents with wounds. NSP 2 stated the new wound care group began approximately July 2025 and prior to the new wound care group there was a gap when licensed nurses were responsible for completing all wound care. NSP 2 stated, the new wound care group now provides consults for wounds that were identified on newly admitted residents and monitors the progression of wounds for residents with complicated wounds.During an interview on 9/29/2025 at 5:02 PM with Resident 1's Emergency Contact (EM) 1, when asked if the facility staff provided any wound care training or education about pressure injury development or increased risks factors, EM 1 stated No. The only thing they told us was it (pressure injuries) was because she peed a lot. We asked for more frequent diaper changes and no improvements (were made). When asked if Resident 1 and/or emergency contacts were involved in reviewing Resident 1's wound care interventions or participated in updates to plans of care, EM 1 stated, No. When asked if Resident 1's wounds caused a change in her mood/behavior or ability to function, EM 1 stated, It kept her uncomfortable most of the time she was there.During a review of IDT Meeting Note dated 5/30/2025, the IDT 055169 Page 4 of 5 055169 10/03/2025 Jewish Home & Rehab Center D/P Snf 302 Silver Avenue San Francisco, CA 94112

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few meeting note indicated The family and the resident.also report that she (Resident 1) is unable to stand up due to foot ulcer and the resident reports that her left leg pain and pain on (her) coccyx due to pressure ulcer prevent her from standing up and spending more than five minutes in the w/c (wheelchair).During a concurrent interview and record review on 9/30/2025 at 12:57 PM with the Nursing Supervisor (NSP) 1, Resident 1's Care Plan Report- Risk for impaired skin integrity. initiated on 11/26/2024 revised on 4/18/2025 was reviewed. NSP 1 verified, Resident 1's Coccyx pressure injury was reopened on 4/18/2025 and stated This wound (pressure injury) was on and off. When asked if there were any updates to the interventions for the focus/goals, NSP 1 stated, No. There were no updated interventions for this reported wound (pressure injury), but the old interventions were resumed.During a concurrent interview and record review on 9/30/2025 at 1:10 PM with the Director of Long Term Care/Quality Assurance (DLTC/QA), Resident 1's Care Plan Report- Risk for impaired skin integrity. initiated on 11/26/2024 revised on 4/18/2025 was reviewed. DLTC/QA verified interventions were resumed from 11/26/24, with no additional revisions made for the pressure injury on Resident 1's Coccyx. DLTC/QA agreed interventions should have been revised. A review of Resident 1's care plan titled SKIN ISSUES initiated on 04/18/2025 last revised on 8/17/2025 AND Resident 1's care plan titled Care Plan Report- Risk for impaired skin integrity. initiated on 11/26/2024 revised on 4/18/2025, DLTC/QA and NSP 1 agreed the Risk and Skin Issue care plans are two separate documents and have two different focus and goal outcomes. DLTC/QA agreed the goals identified in the Risk care plan focused on addressing risk factors with interventions to reduce risk of future ongoing pressure injuries, while the Skin Issue care plan and interventions focus on healing/treating the identified skin issues. DLTC/QA agreed that interventions for risk care plan should have been updated at least with every new inhouse pressure injury and more frequently throughout resident's stay.During a review of Resident 1's IDT meeting note(s) throughout her stay, dated 12/8/2024, 5/30/2025, 6/10/2025, 7/29/2025, 7/31/2025, 8/17/2025, and 8/19/2025, no indication of updated treatment orders, review of impact of current wound treatment orders, or collaboration with Resident 1 and/or family for new interventions to reduce risk for continued impaired skin integrity were discussed. 055169 Page 5 of 5