Health inspection·April 28, 2023

F 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on interview, and record review, the facility failed to send a copy of the written notice to a representative of the Office of the State Long-Term Care Ombudsman after the facility-initiated discharge for Resident 20. This failure had the potential not to provide added protection to residents from being inappropriately discharged , provide residents with access to an advocate who can inform them of their options and rights, and to ensure that the Ombudsman is aware of facility practices and activities related to transfers and discharges. Findings: Review of Resident 20's Discharge Summary, dated 4/24/23, indicated, he was admitted in the facility on 2/8/23, then discharged on 4/24/23 with discharge diagnoses including heart failure (a condition that develops when your heart does not pump enough blood for your body's needs), acute renal failure (a condition in which the kidneys suddenly cannot filter waste from the blood), and diabetes mellitus (a disease of inadequate control of blood sugar). Review of Resident 20's Care Team Note, dated 4/24/23, indicated, . Left unit via wheelchair, escorted downstairs by hospital staff . During a concurrent interview and record review, on 4/28/23, at 9:34 AM, with Registered Nurse (RN) 1, Resident 20's clinical medical records were reviewed. RN 1 stated, Resident 20 was discharged on 4/24/23 to a shelter with home health and accommodation. RN 1 stated, his discharge was a planned, facility initiated, and safe discharge. But, when asked if staff sent the copy of the written notice to Ombudsman after his discharge, she stated, No. A search of Resident 20's medical record with RN 1 found no evidence of the notice to Ombudsman. During an interview on 4/28/23, at 10:43 AM, with Nursing Operations Manager (NOM), NOM stated, They did not send the notice to the Ombudsman when asked about the notice to Ombudsman. During an interview on 4/28/23, at 10:45 AM, with Interim Director of Care Coordination (IDoCC), IDoCC stated, We were not aware that we have to send the notice to the Ombudsman. During an interview on 4/28/23, at 11:05 AM, with IDoCC, IDoCC acknowledged, We didn't send when asked about the notice to the Ombudsman. During a concurrent interview and record review, on 4/28/23, at 1:20 PM, with NOM, the facility's policy and procedure (P&P) titled, Policy-Discharge of Patients, revised on 4/1/14, was reviewed. A search of the P&P with NOM found no mention of the notice to Ombudsman on it. NOM acknowledged, there was no mention of the Ombudsman notice on the P&P. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056245 If continuation sheet Page 2 of 8 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 056245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Pacific Medical Ctr- Davies Campus Hosp 601 Duboce Ave San Francisco, CA 94117 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 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 interview and record review, the facility failed to measure pressure injuries for 1 of 12 sampled residents (Resident 8) upon admission and on a regular basis. Residents Affected - Few This failure to measure Resident 8's pressure injuries on his left and right heels upon admission and on a regular basis did not ensure the facility was objectively monitoring these pressure injuries over time (102 days). Findings: Review of Resident 8's medical record titled MINIMUM DATA SET (MDS, a standardized resident assessment tool), dated 03/29/2023, indicated he was admitted to the facility on [DATE]. He was totally dependent on two staff for bed mobility, and he was totally dependent on one staff for: dressing, toilet use, and personal hygiene. His MDS indicated he was admitted with unhealed pressure injuries. During an interview and concurrent record review on 04/27/2023 at 10:45 AM, RN 2 (Registered Nurse) stated Resident 8 was originally admitted to the hospital's emergency room with two pressure injuries back in 01/02/2023. On 01/15/2023, Resident 8 was transferred to the hospital's skilled nursing facility (SNF) for care. A search of Resident 8's medical record with RN 2 found no evidence staff measured these pressure injuries upon admission to the SNF. Furthermore, RN 2 could find no documented evidence these pressure injuries were measured on a regular basis (from 01/15/2023 to 04/27/2023, a total of 102 days). RN 2 was asked to search hospital records (prior to the SNF admission) in order to provide a baseline of how large these pressure injuries were prior to his SNF admission. Review of Resident 8's medical record from the hospital titled Wound and Ostomy Care Team Note, dated 01/04/2023, indicated wound size measurements for .right heel 8 x 6 cm left heel 2.5 x 2.5 cm . During an interview on 04/27/2023 at 3:11 PM, RN 4 was asked to explain the facility's pressure injury monitoring process. RN 4 stated he worked as a wound care nurse. RN 4 stated in general, nurses in the SNF will assess and chart on a pressure injury. These nurses may put in a consult for the wound care team depending on the severity of the pressure injury. The assessments of these SNF nurses may or may not involve measuring the pressure injury. However, if the wound care team was consulted, RN 4 stated he would measure the pressure injury as part of his assessment. RN 4 was asked how frequently these pressure injuries should be measured? RN 4 answered, in general, these pressure injuries should be assessed once a week and sometimes longer depending on the clinical conditions of the resident. For example, frequency of assessments may be longer for residents on comfort care, use of a specialty wound dressing or if the resident was experiencing a lot of pain. During an interview on 04/28/2023 at 10:52 AM, RN 4 was asked to clarify his expectations on pressure injury assessments and how he was trained as a wound care nurse regarding pressure injury documentation. RN 4 stated he was trained to describe pressure injuries and measure pressure injuries as part of his assessments. RN 4 stated serial pressure injury measurements is one of the parameters clinicians look at to determine if a pressure injury was healing or deteriorating. Review of the facility's policy titled Procedure - Pressure Injury Intervention, revised on 03/18/2021, found no mention of pressure injury measurements or frequency of pressure injury measurements. Additionally, the facility did not have a pressure injury policy that clearly states when and how often pressure injuries should be measured. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056245 If continuation sheet Page 3 of 8 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 056245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Pacific Medical Ctr- Davies Campus Hosp 601 Duboce Ave San Francisco, CA 94117 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 0686 Level of Harm - Minimal harm or potential for actual harm During an interview on 04/28/2023 at 1:00 PM, the DAL (Director of Accreditation and Licensing) was asked to clarify the facility's pressure injury assessment/monitoring policy. The DAL stated the facility does not currently have policies regarding pressure injury measurements nor how frequently these pressure injuries should be measured. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056245 If continuation sheet Page 4 of 8 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 056245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Pacific Medical Ctr- Davies Campus Hosp 601 Duboce Ave San Francisco, CA 94117 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were met for food storage when nine expired nutrition supplements were found in the kitchen storage room. This failure had the potential to put residents at risk for foodborne illnesses. Findings: During a concurrent observation and interview on 4/25/23, at 11:20 AM, with Registered Dietitian (RD), there were nine items of nutrition supplements labeled, Katefarms Peptide 1.5 cal/mL plain in the kitchen storage room, with marks indicating Best if used by: [DATE]. When asked if these nine items were expired, RD stated, Expired. Yes, correct. During an interview on 4/25/23, at 11:24 AM, with Food and Nutrition Manager (FNM) who was witnessing this incident stated, Yes, I agree . when asked if these nine items were expired. During an interview on 4/25/23, at 11:33 AM, with Nursing Operations Manager (NOM) who was also witnessing this incident acknowledged, these nine items were expired. Review of the facility's policy and procedure (P&P) titled, Receiving and Storage Standards, revised on 5/19/22 indicated, . Storage . 4. Discard out-of-date products . Review of the Guidance of Appendix PP, revised on 10/21/22, from Centers for Medicare and Medicaid Services (CMS) indicated, the facility should follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness. Appendix PP also indicated, unsafe food handling practices represent a potential source of pathogen exposure for residents. Review of U.S. Food and Drug Administration's 2022 Food Code indicated, . The Food Code states the person in charge of a food establishment is accountable for developing, carrying out, and enforcing procedures aimed at preventing food-borne illness . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056245 If continuation sheet Page 5 of 8 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 056245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Pacific Medical Ctr- Davies Campus Hosp 601 Duboce Ave San Francisco, CA 94117 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure a refuse (solid waste not carried by water through the sewage system) container had a lid and refuse were disposed in a proper manner. Residents Affected - Few This failure had the potential to promote development and spread of communicable diseases and infections that could jeopardize the health of the residents in the facility. Findings: During a concurrent observation and interview on 4/26/23, at 8:53 AM, with food service supervisor (FSS), outside of the facility building far enough from the kitchen, there was a green plastic garbage container full of trash. There was no lid attached to the garbage container. There were also several very tiny flies flying around the garbage container. FSS stated, It should be shut when asked about the policy of the garbage container. When asked if he could see the tiny flies around the garbage container, FSS stated, Yes. Observation of another metal garbage container nearby indicated, it was closed but a garbage bag with dark brownish wet material inside was protruding outside the closed lid. FSS also acknowledged, refuse was not disposed in a proper manner when asked about the garbage bag hanging outside the garbage container. During an interview on 4/26/23, at 8:55 AM, with Nursing Operations Manager (NOM) who witnessed this incident, NOM acknowledged, Yes . I did when asked if she saw the green plastic garbage container without the lid, tiny flies around it and the garbage bag hanging outside the closed lid of another metal garbage container. During an interview on 4/26/23, at 8:59 AM, with Food and Nutrition Manager (FNM) who also witnessed this incident together, FNM also acknowledged, there was no lid with the green plastic garbage container and refuse was not disposed in a proper manner. During an interview on 4/26/23, at 9:12 AM, with EVS (environmental services) Lead Manager (EVSLM), EVSLM acknowledged, the garbage container should have been closed with a lid when this surveyor showed the garbage containers. EVSLM stated, . Always (covered) . when asked the policy of the garbage container. He also acknowledged, refuse was not disposed in a proper manner with the metal garbage container. During an interview on 4/26/23, at 9:19 AM, with EVS Senior Manager (EVSSM), EVSSM stated, That should be covered when asked about the policy regarding the garbage containers. He also acknowledged, refuse was not disposed in a proper manner. Review of the facility's policy and procedure (P&P) titled, Policy-Infection Control: Solid Waste Disposal in Food & Nutrition Services, revised on 6/23/21 indicated, . Garbage containers are kept covered . Review of U.S. Food and Drug Administration's 2022 Food Code indicated, . 5-501.15 Outside Receptacles. (A) Receptacles and waste handling units for REFUSE . and used outside the FOOD ESTABLISHMENT (any operations, including without limitation schools, farmers markets and other public venues that store, prepare, package, serve, vend or otherwise provide food for human consumption) shall be designed and constructed to have tight-fitting lids, doors, or covers . 5-501.110 Storing Refuse, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056245 If continuation sheet Page 6 of 8 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 056245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Pacific Medical Ctr- Davies Campus Hosp 601 Duboce Ave San Francisco, CA 94117 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 0814 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Recyclables, and Returnables. REFUSE . shall be stored in receptacles or waste handling units so that they are inaccessible to insects and rodents . 5-501.113 Covering Receptacles . (B) With tight-fitting lids or doors if kept outside the FOOD ESTABLISHMENT . Proper storage and disposal of garbage and refuse are necessary to minimize the development of odors, prevent such waste from becoming an attractant and harborage or breeding place for insects and rodents . Improperly handled garbage creates nuisance conditions, makes housekeeping difficult, and may be a possible source of contamination of food, equipment, and utensils . All containers must be maintained in good repair . in order to store garbage and refuse under sanitary conditions as well as to prevent the breeding of flies . Outside receptacles must be constructed with tight-fitting lids or covers to prevent the scattering of the garbage or refuse by birds, the breeding of flies, or the entry of rodents . Event ID: Facility ID: 056245 If continuation sheet Page 7 of 8 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 056245 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Pacific Medical Ctr- Davies Campus Hosp 601 Duboce Ave San Francisco, CA 94117 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, a nurse failed to follow facility policy regarding disinfecting a shared device after medication administration. Failure to disinfect a shared device did not ensure other residents were protected from infection. Residents Affected - Few Findings: Review of Resident 12's medical records titled INFECTIOUS DISEASES FOLLOW UP PROGRESS NOTE, dated 04/17/2023, indicated he has a history of infections with MDRO (multi drug resistant organism) and was currently on three antibiotics to treat a bacterial infection. Review of the front page of Resident 12's electronic medical record with RN 2 on 04/28/2023 at 11:49 AM indicated Resident 12 was on contact precaution. Review of the facility's policy titled Policy - Infection Control Strategies- Guidelines for Use of Transmission Based Precautions: Airborne, Droplet, Contact Precautions, and Enhanced Contact Precautions, revised on 01/20/2022, indicated .Contact, or touch, is the most common and most significant mode of transmission of infectious agents. Contact transmission can occur by directly touching the patient, through contact with the patient's environment, and by contaminated gloves or equipment. During medication administration observation on 04/26/2023 at 9:31 AM, RN 3 was administering a medication to Resident 12 and brought a (shared) ID bar code scanner into Resident 12's room. These ID bar code scanners are used to scan a resident ID band and to scan in the resident's medications prior to medication administration. Each scanner is electronically tethered to a specific mobile workstation. After medication administration, RN 3 did not disinfect the scanner and placed the scanner on her mobile workstation and later on she placed the scanner back onto the charging port behind her mobile workstation. The Director of Nursing (DON) was present during the medication administration observation. The DON was asked to comment on the observation. The DON stated RN 3 should have disinfected the scanner prior to placing the scanner on her mobile workstation. Review of the facility's policy titled Policy - Infection Control Strategies- Guidelines for Use of Transmission Based Precautions: Airborne, Droplet, Contact Precautions, and Enhanced Contact Precautions, revised on 01/20/2022, indicated .If shared equipment is used, it must be cleaned with hospital disinfectant after each use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056245 If continuation sheet Page 8 of 8