Health inspection·January 9, 2026

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function. Based on interview and record review the facility failed to ensure as needed (PRN) psychotropic medications (a class of psychiatric drugs that helps manage severe mental health symptoms) for two out of three residents (Residents 10 and 30) were limited to 14 days and/or attending physician or prescribing practitioner documentation to support medication order extension.This failure had the potential to result in adverse consequences ranging from functional decline, hospitalization, permanent injury, or death.Findings:During a concurrent interview and record review on 1/08/2025 at 1:45 PM with Pharmacy Manager (Pharm), Resident 30's Hospital Medication Detail (undated) was reviewed. The hospital medication detail indicated, an order for Lorazepam (ATIVAN) tab 2 mg.Frequency: Bedtime PRN for Anxiety, Trouble Sleeping.Start Date/Time:01/02/26.End Date/Time: --. Pharm stated, the order was a low dose psychotropic medication, that was appropriately prescribed as needed (PRN) for anxiety and insomnia (trouble sleeping). When asked if as needed (PRN) medications required a specific duration, Pharm stated, Oh yes. I'm sorry. The system just puts the medication in, but we should be able to manually go in and add a 14-day stop date. I'll look into that. Pharm acknowledged no stop date was noted on Resident 30's current order. Pharm was unable to locate clinical documentation to support use beyond 14-day limit. During a concurrent interview and record review on 1/08/2025 at 2:37 PM with Nurse Manager (NM), Resident 10's Hospital Medication Detail undated was reviewed. The hospital medication detail indicated, an order for Lorazepam (ATIVAN) tab 2 mg.Frequency: Every 5 minutes PRN for Seizures (a sudden burst of electrical activity in the brain), If develops convulsive (irregular movement of a limb or of the body) seizure > 2 minutes, administer 2mg IV Ativan.Start Date/Time:03/07/25.End Date/Time: -- . NM stated, the reviewed medication order was currently active on Resident 10's electronic medical record and indicated for as needed use. When asked if as needed (PRN) medications required a specific duration, NM stated, My understanding is that a 14 day stop date is needed for this anti-anxiety medication, so if I were to see this order then I would call the pharmacy and ask them to add a stop date. NM was unable to locate clinical documentation to support use beyond 14-day limit. During an interview on 1/8/2026 at 2:42 PM with Pharm, Pharm provided confirmation that pharmacy staff has access to manually add stop dates to as needed (PRN) psychotropic medication orders, unless attending physician or prescribing practitioner rationale is documented. Pharm stated, Yes. We will do that moving forward. That will be our fix.During a review of the facility's policy and procedure titled, Procedure- Post Acute Services- Behavior Monitoring and Psychotherapeutic Drug Use, Protocol, last revised on 12/19/2019, indicated, .2. PRN Psychotherapeutic Drug; PRN Psychotherapeutic drugs should be limited to 14 days, unless appropriate documentation is provided in the medical record. 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 4 Event ID: 056245 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 01/09/2026 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)