Inspection·May 18, 2021

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not provide pharmacy services to Resident 36 when correct Vitamin D dose was not available for use according to her physician's orders (also See F759). These failures resulted in medications not given in accordance with the prescriber's orders which may result in the residents not receiving the full therapeutic effect of the medication. Findings: Resident 36 was admitted on [DATE], with diagnoses that included osteoporosis (a bone disease that causes a loss of bone density, which increases risk of fractures), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction (or stroke, refers to damage to tissues in the brain due to a loss of oxygen to the area). During a medication pass observation on 5/12/21, at 11:45 AM, with Registered Nurse (RN) 3 , RN3 prepared and administered 1 tab of oyster calcium 500 milligram (mg) to Resident 36. Review of Resident 36's clinical record, the physician's orders, dated 5/12/21, and concurrent interview with RN3, on 5/12/21 at 1:30 PM indicated an order for Oyster Calcium-D3 Tablet 500-200 MG- MCG [micrograms] (calciumCarb-Cholecalciferol) Give 1 tab by mouth three times a day for supplement. RN 3 acknowledged that she gave the wrong medication. RN3 stated It should have the one with Vitamin D 200 micrograms on it. RN3 stated the oyster calcium tablets was from house supply. Upon further inspection of the medication cart, there was only a house supply of Calcium-Vit D 500-5 MG-MCG. The medication cart did not have the Calcium 500 mg with Vitamin D 200 mcg on hand. During an interview on 5/12/21, at 1:35 PM, with RN 2, RN 2 acknowledged the above findings. RN 2 stated they would notify the doctor and obtain the right dose of Vitamin to reflect the dose of the facility's house supply. During an interview with the Clinical Pharmacist (CP) on 5/18/21, at 11:15 AM, the CP stated that licensed staff should triple check the dose on the Medication Administration Record (MAR) versus the dose on the house supply bottles before pouring and administering it to residents to avoid medication errors. Review of facility policy and procedure, titled Pharmacy Services Overview, revised April 2007, indicated . The facility shall accurately and safely provide or obtain pharmacy services, including the provision of routine and emergency medications and biologicals . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056272 If continuation sheet Page 2 of 10 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 056272 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Francisco Health Care 1477 Grove Street 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 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility had 20.69% error rate when six medication errors out of 29 opportunities were observed during a medication pass for Resident 36, Resident 94, Resident 48, and Resident 31. Residents Affected - Some These failures resulted in medications not given in accordance with the prescriber's orders and/or manufacturer's specifications which may result in the residents not receiving the full therapeutic effect of the medications. Findings: 1. Resident 36 was admitted on [DATE], with diagnoses that included osteoporosis (a bone disease that causes a loss of bone density, which increases your risk of fractures), hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction (or stroke, refers to damage to tissues in the brain due to a loss of oxygen to the area. During a medication pass observation on 5/12/21, at 11:45 AM, with Registered Nurse (RN) 3 , RN3 prepared and administered 1 tab of oyster calcium 500 milligram (mg) to Resident 36. Review of Resident 36's clinical record, the physician's orders, dated 5/12/21, and concurrent interview with RN3, on 5/12/21 1:30 PM indicated an order for Oyster Calcium-D3 Tablet 500-200 MG- MCG [micrograms] (calciumCarb-Cholecalciferol) Give 1 tab by mouth three times a day for supplement. RN 3 acknowledged that she gave the wrong medication. RN3 stated It should have the one with Vitamin D 200 micrograms on it. RN3 stated the oyster calcium tablets was from house supply. Upon further inspection of the medication cart, there was only a house supply of Calcium-Vit D 500-5 MG-MCG. The medication cart did not have the Calcium 500 mg with Vitamin D 200 mcg on hand. During an interview on 5/12/21, at 1:35 PM, with RN 2, RN 2 acknowledged the above findings. RN 2 stated they would notify the doctor and obtain the right dose of Vitamin to reflect the dose of the facility's house supply. During an interview with the Clinical Pharmacist (CP) on 5/18/21, at 11:15 AM, the CP stated that licensed staff should triple check the dose on the Medication Administration Record (MAR) versus the dose on the house supply bottles before pouring and administering it to residents to avoid medication errors. 2. During a medication pass observation on 5/13/21, at 9:25 AM, with Licensed Vocational Nurse (LVN) 2, LVN 2 was preparing medication for Resident 94. LVN 2 used a plastic teaspoon and used it to scoop one and half teaspoon of polyethylene glycol powder (a medication to prevent constipation) and mixed it with a small cup of water. LVN 2 then gave this mixture to Resident 94 along with her morning medications. Review of Resident 94' clinical record, the physician orders, indicated polyethylene glycol powder, give 17 grams by mouth everyday for constipation, mix with 6-8 ounce of fluids. During an interview with LVN 2 on 5/13/21, at 1 PM, LVN 2 acknowledged she should have used the miralax bottle cap to measure the correct amount of miralax powder to ensure it was 17 grams as per (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056272 If continuation sheet Page 3 of 10 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 056272 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Francisco Health Care 1477 Grove Street 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 0759 physicians' order. Level of Harm - Minimal harm or potential for actual harm 3-4. During a medication pass observation on 5/13/21, at 9:25 AM, with Licensed Vocational Nurse (LVN) 2, LVN 2 was preparing medication for Resident 94. LVN 2 prepared dorzolamide hydrochloride (HCL) eye drops, LVN 2 administered one drop for each eye. LVN 2 did not press the tear duct for approximately one minute or instructed the resident to close her eyes for three minutes for each eye. Residents Affected - Some Review of Resident 94's physician's orders, on 5/13/21, indicated trusopt solution 2% (dorzolamide HCL) instill 1 drop both eyes two times a day for glaucoma (abnormal high pressure in the eye). During an interview with LVN 2, on 5/13/21, at 1:10 PM, LVN 2 acknowledged the above findings. LVN 2 stated Resident 94 could sometimes press her tear ducts when instructed, at other times she could not. Review of facility document, titled Med Pass Report, dated 9/22/17, indicated .XI. Eye Preparations .C. Tear duct is pressed for approximately one minute or eyes are closed for three minutes to reduce systemic effects . 5. During a med pass observation on 5/13/21, at 10:17 AM, with LVN 2, LVN 2 was administering an inhaler to Resident 48. LVN 2 administered 1 puff of Breo ellipta 100/25 milligram (mg) metered-dosed inhaler. LVN 2 did not instruct or assisted Resident 48 to rinse his mouth. During an interview with LVN 2, on 5/13/21, at 1:15PM, LVN 2 acknowledged the above findings. LVN 2 stated she should have made the Resident 48 rinse his mouth to prevent thrush. Review of Resident 48's clinical record, the physician's orders, on 5/14/21, at 10:51 AM, indicated Breo Ellipta aerosol powder breath activated 100-25 MCG/INH (inhalation) (Fluticasone Furoate-Vilanterol) - 1 puff inhale orally one time a day for COPD (Chronic Obstructive Pulmonary Disease, a chronic inflammatory lung disease that caused obstructed airflow from the lungs). Rinse mouth and throat with water after treatment . 6. During a med pass observation, on 5/13/21, at 10:45 AM, LVN 2 was preparing medication for Resident 31. LVN 2 poured 1 tablet from a house supply bottle with a label that indicated Risenivat [Vit D 120 IU- Ca 100mg - Phosphorus 80mg and an opened date of 5/10/21. LVN 2 administered this medication along with Resident 31's other medications. Review of Resident 31's clinical record, the physician's orders, indicated . Risacal-D tablet 105-81-120MG-UNIT (Calcium-Phosphorus-Vitamin D) Give 1 tablet PO QD for supplement . During an interview with LVN 2 on 5/13/21, at 1:20 PM, LVN 2 acknowledged the above findings. LVN 2 stated that they would notify the physician to get an order for the right dose of Risacal. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056272 If continuation sheet Page 4 of 10 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 056272 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Francisco Health Care 1477 Grove Street 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review, the facility failed to ensure safe storage of medications when: 1. Resident 246's insulin was stored with rectal suppositories on 3rd floor medication cart. 2. Resident 246's nystatin powder medication was being kept and placed on top of his bedside table. This deficient practice could lead to contamination of medication; and failure to secure medications in a locked storage could lead to unwanted residents accessing and ingesting medications that could lead to clinically significant adverse consequences. Findings: 1. During a med cart inspection on 5/12/21, at 11:40 AM, and concurrent interview with Registered Nurse (RN) 3, in 3rd floor medication cart, observed Resident 246's insulin medication was found stored together with house supply rectal suppositories. RN 3 acknowledged the above findings and stated the insulin should be stored separately from rectal suppositories to prevent possible contamination. During an interview with Clinical Pharmacist (CP), on 5/18/21, at 11:15 AM, the CP acknowledged the above findings and stated the licensed staff should store the insulin separate from the rectal suppositories for infection prevention. Review of facility document, titled Storage of Medications, revised April 2007, indicated Policy Statement . The facility shall store drugs and biologicals in a safe, secure and orderly manner . 2. During a medication pass observation on, 5/12/21, at 11:45 AM, and concurrent interview with RN 3, in Resident 246's room, a bottle of nystatin powder was found in Resident 246's bedside table. RN 3 stated Resident 246 self administered the nystatin powder that was why the nurses left the medication inside the Resident 246's room. During an interview with the CP, on 5/18/21, at 11:18 AM, the CP stated Resident's 246's medication should be in a locked container inside the room to prevent other residents from accessing it and potentially ingesting the medication. Review of facility policy and procedure, titled Self-administration of Medications, revised December 2012, indicated . Storage of medications . Self-administered mediations must be stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer will be stored in a central medication cart or in the medication room. Nursing will transfer the unopened medication to the resident when the resident requests them . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056272 If continuation sheet Page 5 of 10 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 056272 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Francisco Health Care 1477 Grove Street 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 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. 2e. During an observation on 5/11/21 at 10:15 AM, a cup filled with white colored liquid was on top of the overhead table in Resident 57's room. The cup was covered and unlabeled. Residents Affected - Some During another observation on 5/11/21 at 12:29 PM, the same cup filled with white colored liquid was on top of the overbed table in Resident 57's room. In a concurrent interview, while pointing at the cup, CNA5 stated, That's milk from breakfast. She drinks it during lunch. CNA5 further stated that breakfast was served at 7:30 AM and added, If she doesn't like to drink it, I'll take it out in 30 minutes. During an interview on 5/13/21 at 10:33 AM, Registered Dietitian (RD) stated, Milk is good for only four hours at room temperature. You should discard it after that. Review of Resident 57's undated meal tray ticket indicated that milk was served for breakfast. Review of facility policy titled, Assisting the Resident Meals revised on 7/19/20 indicated, .Meals Delivery and Temperature .7. To minimize the risk of foodborne illness, the time that potentially hazardous foods remain in the danger zone (41 degrees to 135 degrees Fahrenheit) will be kept to a minimum. 8. Meals or parts of meals should never be left out at room temperature for extended periods. Meals that are left on trays .longer than 4 hours will be discarded. Based on dietary services observation, dietary staff interview, and dietary document review, the facility failed to ensure dietetic services were implemented in accordance with acceptable standards of practice when: 1. Yogurt with temperature of 48 degrees was found sitting on the night stand for Resident 246. 2. Milk was found sitting on the overhead table for more than four hours for Residents 246, 78, 32, 90 and 57. Failure to ensure safe and sanitary food handling practices had the potential to subject residents to foodborne illnesses. Findings: 1. During a follow up visit on a concern and concurrent interview with Resident 246 on 5/12/21, at 10 AM, 2 cups of yogurt was on the top of the overbed table next to the residents bed. Resident 246 stated they brought those earlier. During observation and concurrent interview with the Dietary Supervisor (DS) on 5/12/21, at 10:05 AM, the DS dipped the thermometer in one of the cups of yogurt. The temperature of the yogurt was 48 degrees. The DS stated, The staff should have offered to keep the yogurt in the refrigerator or should have tossed them. 2a. During an observation on 5/11/21, at 9:55 AM, an unlabeled cup filled with white liquid was on the overbed table in Resident 78's bedside. Certified Nurse Assistant (CNA) 3 stated, That's milk. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056272 If continuation sheet Page 6 of 10 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 056272 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Francisco Health Care 1477 Grove Street 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 - Some During another observation on 5/11/21 at 11:33 AM, an unlabeled cup filled with white liquid was on the overbed table in Resident 78 bedside. CNA3 stated, It's from breakfast served at 7:30 AM. I'll take it out. 2b. During an observation on 5/11/21, at 9:59 AM, an unlabeled cup filled with white liquid was on the overbed table in Resident 90's bedside. CNA4 stated, That's milk from breakfast. We served breakfast at 7:30 AM. During observation on 5/11/21, at 11:37 AM, an unlabeled cup filled with white liquid was on the overbed table in Resident 90's bedside. CNA3 stated, She (Resident 90) drinks it throughout the day. 2c. During an observation on 5/11/21 at 10:01 AM, an unlabeled cup filled with white colored liquid was on top of the overhead table in front of Resident 32. CNA 7 stated, That's milk from breakfast. During another observation and concurrent interview on 5/11/21 at 11:45 AM, an unlabeled cup of milk was on top of the overhead table in front of Resident 32. Resident 32 stated, It just sits there. 2d. During a follow up visit for an unrelated concern and concurrent interview with Resident 246 on 5/12/21, at 10 AM, a half cup of white liquid and 2 cups of yogurt was on top of the overbed table next to the residents bed. Resident 246 stated that's milk from last night. I asked for it last night. During an observation and concurrent interview with the DS on 5/12/21, at 10:05 AM, the DS dipped the thermometer in the cup of the white color liquid. The temperature of the white liquid was 72 degrees. The DS stated, Milk is only good for four hours. It should have been tossed out. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056272 If continuation sheet Page 7 of 10 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 056272 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Francisco Health Care 1477 Grove Street 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement its infection prevention and control program when: Residents Affected - Some 1. Registered Nurse (RN) 3 did not disinfect the glucometer in between patient use. 2. Staff did not used the appropriate disinfectant product on resident care equipment; 3. Used suction canister and yankuer tip catheter were unlabeled and undated; 4. Staff food was found on the residents overbed table. This facility failure has the potential to spread infection to residents and staff. Definitions: Disinfectant: usually a chemical agent (but sometimes a physical agent) that destroys disease-causing pathogens or other harmful microorganisms but might not kill bacterial spores. It refers to substances applied to inanimate objects. Disinfection: thermal or chemical destruction of pathogenic and other types of microorganisms. Disinfection is less lethal than sterilization because it destroys most recognized pathogenic microorganisms but not necessarily all microbial forms (e.g., bacterial spores). Findings: 1. During a medication pass observation on 5/12/21, at 11:24 AM, and concurrent interview with RN 3, RN 3 used a multi-use glucometer and took Resident 44's blood sugar. RN 3 did not disinfect the glucometer after using it for Resident 44. Then, RN 3 went to Resident 246's room and was about to obtain Resident 246's blood sugar when she was stopped by the surveyor and was notified of the deficient practice. RN 3 acknowledged that she did not disinfect the glucometer after using it for Resident 44. RN 3 stated I forgot. RN 3 stated she should disinefect it to prevent spread of blood-borne pathogens. During an interview with the Director of Staff Development (DSD) on 5/14/21, at 10:31 AM, the DSD stated licensed nurse should disinfect the glucometer with the approved disinfectant to prevent spread of infection. Review of facility policy and procedure, titled Cleaning and Disinfection of Resident-Care Items and Point of Care Equipment, revised October 2009, indicated Policy Statement . Point of care equipment, including resuable items are durable medical equipment will be cleaned and disinfected according to manufacturer's and current CDC [Centers of Disease and Control] recommendations, of applicable . 2a. During observation and concurrent interview with Registered Nurse 3 (RN 3) on 5/12/21, at 10 AM, RN 3 put out Good and Clean disinfectant wipes from the medication cart and used it to wipe the blood pressure wrist cuff and the pulse oximeter (a device placed on a finger tip and used to measure the oxygen level). RN 3 stated, this is what we use to clean and disinfect. RN looked at the package (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056272 If continuation sheet Page 8 of 10 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 056272 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Francisco Health Care 1477 Grove Street 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 and stated it needs to be disinfected for 15 seconds. Level of Harm - Minimal harm or potential for actual harm 2b. During a concurrent interview with Certified Nurse Assistant 1 (CNA 1, caregiver) and CNA 6 on 5/12/21, at 10:12 AM, CNA 1 stated, I use the good clean wipes from the yellow package. I only use one wipe since it is small (BP wrist cuff) and wait for it to dry. Maybe two minutes, then use it on the next resident. CNA 6 acknowledged CNA 1's response and stated we use whatever they give us. Residents Affected - Some 2c. During an interview with the CNA 2 on 5/13/21, at 10:20 AM, CNA 2 stated I use the wipe from the yellow package to clean BP cuff. I do not know what wet time or contact time is. 2d. During an interview with the Director of Nursing (DON) on 5/12/21 at 2:30 PM, the DON stated, Those (good and clean disinfectant wipes in yellow pack) are not for patient care equipments. Those wipes are for surfaces only, on tables, chairs. Do not tell me that they use those (good and clean disinfectant wipes in yellow package). They are supposed to use the clorox wipes on the resident care equipments. The Administrator provided Material Safety Data Sheet for Clorox Bleach. A review of the facility Policy and Procedure titled, Cleaning and Disinfection of Resident -Care item and Point of Care Equipment dated 10/2009, indicated .Point of care equipment including reusable items and .will be cleaned and disinfected according to manufacturer and current Centers for Disease Control (CDC) recommendations . The facility policy and procedure did not address procedure to clean and disinfect resident care equipments. The facility provided a manufacturer's instruction manual (pharmacy label). It did not address disinfection of the BP wrist cuff. The facility did not provide manufacturers instruction manual for cleaning and disinfection of the pulse oximeter. 3a. During observation on 5/11/21, at 9:30 AM, in room [ROOM NUMBER] bed 2, a suction canister with cloudy contents and an open package of yankuer tip catheter was found at the bedside, undated and unlabeled. RN 3 acknowledged the suction canister with cloudy liquid content and open package of yankuer tipped catheter was unlabeled and undated. RN 3 stated The canister and the suction catheter should be dated. When used it need to be changed within 24 hours. 3b. During an interview with Licensed Vocational Nurse (LVN) 2 on 5/12/21, at 11 AM, LVN 2 stated used suction canister and yankuer catheter should be discarded after use. 3c. During an interview with LVN 1 on 5/14/21, at 2 PM, LVN 1 stated the suction canister and suction catheters should be labeled and dated. It is used to remove respiratory secretions. When used, it should be discarded and replaced with a new one. It is infection control. Bacteria can grow there. 3d. During an interview with the DON on 5/14/21, at 1:45 PM, the DON stated The suction canisters and suction catheters should be dated. During a review of facility Policy and Procedure titled, undated, indicated Respiratory Equipment Change Schedule indicated . will date the following equipment . suction canister .yankuer tipped catheter . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056272 If continuation sheet Page 9 of 10 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 056272 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/18/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE San Francisco Health Care 1477 Grove Street 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 Level of Harm - Minimal harm or potential for actual harm 4a. During observation and concurrent interview on 5/11/21, at 9:50 AM, in room [ROOM NUMBER] bed 3, a plastic cup filled with cream and dark brown colored contents and a small brown bag with food was found on the overbed table. CNA 4 stated that is mine. Let me take it out. The CNA quickly grabbed the cup and the small brown bag and left the room. Residents Affected - Some 4b. During an interview with CNA 7 on 5/11/21, at 10:20 AM, CNA 7 stated No, we cannot bring food in resident's room. We have a staff room by the nurses station where we keep our food. 4c.During an interview with RN 1, on 5/12/21, at 10 AM, RN 1 stated No, we are not allowed to bring our food, eat or drink in the resident's room or here in the nurse's station. It's infection control. 4d. During an interview with the Director of Staff Development (DSD) on 5/14/21, at 1:30 PM, the DSD stated I have told them how many times that they are not to bring food in the resident's room. A review of facility Policy and Procedure titled, Handling Outside Food in Clinical Areas and Resident Rooms indicated .The facility staff is not allowed to consume foods that may cause infection control issues in the clinical areas . Occupational Safety and Health Administration (OSHA) 1910.1030 indicated, Eating, drinking, smoking, applying cosmetics or lip balm, and handling contact lenses are prohibited in work areas where there is a reasonable likelihood of occupational exposure. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056272 If continuation sheet Page 10 of 10