Health inspection·April 10, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few plan for activities of daily living related to showering/bathing, dressing, and personal hygiene was not individualized and updated. 2. During a concurrent interview and record review of Resident A ' s medical records on 3/6/23 at 3:33 PM, with the ADON, ADON stated Resident A had no care plan developed for Out-on-Pass ordered by the physician on 11/30/22. ADON said, I don ' t see it. ADON stated there should be a care plan on Resident A ' s OOP order. Review of the facility ' s Policy and Procedures (P&P), titled, Care Plans, Comprehensive Person-Centered, revision dated 3/2022, the P&P indicated, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident . The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident . The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well-being . Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident ' s problem areas and their causes, and relevant clinical decision making . interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers . Assessments of residents are ongoing and care plans are revised as information about the residents and the residents ' conditions change . The interdisciplinary team reviews and updates the care plan . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056272 If continuation sheet Page 2 of 23 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 04/10/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure treatment and care was provided to Resident A when: Residents Affected - Few 1.Resident A ' s order for Out-on-Pass (OOP, off-premise activities) was not clear and clarified with the physician 2.Resident A ' s OOP was not followed and monitored by staff. Cross reference F689. 3.Resident A did not have a person-centered, comprehensive care plan developed for OOP 4.There was no documented evidence the Interdisciplinary Team (IDT) discussed and evaluated effectiveness and monitoring of Resident A ' s OOP order 5.Resident A ' s OOP order was not discontinued immediately These failures had the potential to put Resident A at risk for avoidable harm and injury, and to not meet Resident A ' s highest practicable physical, mental, and psychosocial well-being. Findings: 1. During a review of the facility ' s admission record, the record indicated Resident A ' s medical diagnoses included, below knee amputee on the right leg, type II diabetes (abnormal blood sugar levels), anxiety disorder, depression, chronic pain syndrome, cocaine dependence and nicotine dependence. During a review of the Minimum Data Set (MDS, an assessment tool), dated 12/21/22, Resident A ' s Brief Interview for Mental Status (BIMS), indicated a score of 15, which indicated the resident was cognitively intact. During a review of the Physician ' s Active Orders, printed 3/6/23 at 11:41 AM, the verbal order indicated, Resident A May OOP [Out-on-Pass] up to 4 hrs every week. The OOP was ordered on 11/30/22. During a concurrent interview and record review of Resident A ' s physician orders on 3/6/23, at 11:52 AM, with the Director of Nursing (DON), and the Assistant Director of Nursing (ADON) present, DON and ADON acknowledged Resident A ' s OOP order was not clear. DON was not able to determine if the order was up to 4 hours maximum per pass every week or up to 4 cumulative hours maximum every week. DON stated the order had to specify how many hours per day. DON stated the order did not indicate the frequency of passes per week. DON stated it was important for staff to ensure there was a clear OOP order to ensure the resident did not go over the required hours or frequency allowed per week for safety reasons. ADON stated OOP order monitoring was important for the facility to be aware that the resident did not elope and provided a safety net if the resident was not located. Review of the facility ' s Policy and Procedures (P&P), titled, Verbal Orders, revision dated 2/2014, the P&P indicated, . The individual receiving the verbal order will: a. read the order back to the practitioner to ensure that the information is clearly understood and correctly transcribed; b. record the ordering practitioner ' s last name and his or her credentials . and c. record the date and time of the order . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056272 If continuation sheet Page 3 of 23 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 04/10/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility ' s Policy and Procedures (P&P), titled, Medication and Treatment Orders, revision dated 7/2016, the P&P indicated, Orders for medications and treatments will be consistent with principles of safe and effective order writing. Review of the facility ' s Policy and Procedures (P&P), titled, Physician Orders Related to Activities, revision dated 6/2018, the P&P indicated, .The facility obtains activities-related physician orders . The activity director/coordinator reviews the physician ' s orders upon admission, during the activity assessment period, and within progress or change of condition reviews for the following areas which may impact activities . b. Participation in activities off facility grounds, including resident outings with family, friends or by self (off-premise activities) . 2. During a concurrent observation and interview on 3/6/23 at 10:20 AM, Resident A was in her room and sat in a wheelchair. Resident A was awake and alert. Resident A had a small dressing applied on the front of her right hand. When asked, Resident A explained the red color noted on the dressing was dry blood from an abrasion sustained when she visited a friend in the city. Resident A explained she was in a hurry to get back to the facility after the visit. Resident A stated it was 6 PM at the time, and it started to get dark. Resident A explained she did not notice a pole along the sidewalk and stated that she could have brushed or scraped her hand with something on the pole. Resident A stated this incident occurred a few days ago. During a review of the Out-on-Pass Log, dated 2/26/23, the log on Resident A indicated the following: Date: 2/26/23 Time Out: 10:30 AM Expected Return: 2/26/23 – no time indicated Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank During a review of the nurse ' s note, dated 2/26/23, at 10:52 PM, the note indicated, Resident A was on OOP this AM and came back at 1915 [7:15 PM] with a skin tear on the right dorsal hand which was bleeding moderately . The site was cleansed . MD [medical doctor] was informed . During a review of the facility ' s Out-on-Pass Binder, the log from 1/10/23 through 3/6/23 was reviewed. The log indicated, Nurses on duty must ensure each resident OUT on PASS is reported in the Nurses 24 Hours Report, PCC and COMPLETE ALL COLUMNS in this LOG, ACTUAL RETURN Date and Time must be filled in immediately on return. Do NOT forget to sign on Leave and Return. During a review of the social services note, dated 11/30/22 at 10:47 AM, the note indicated, Resident A was informed that the order for her out-on-pass will be once a week and within 4 hrs only. For the week of 1/8/23 to 1/14/23, the log indicated Resident A was OOP two times, on 1/10/23 and 1/12/23. The following were missing from the log. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056272 If continuation sheet Page 4 of 23 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 04/10/2023 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 0684 Date: 1/10/23 Level of Harm - Minimal harm or potential for actual harm Time Out: 9:40 AM Expected Return: Date/Time – Blank Residents Affected - Few Location of Event: Blank Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank Date:1/12/23 Time Out: 11 AM Expected Return: Date – Blank, Time – unclear Phone Number: Blank Location of Event: Blank Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank For the week of 1/15/23 to 1/21/23, the log indicated Resident A was OOP two times, on 1/18/23 and 1/19/23. The following were missing from the log. Date:1/18/23 Time Out: 11 AM Expected Return: Date/Time - Blank Location of Event: Blank Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank Date:1/19/23 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056272 If continuation sheet Page 5 of 23 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 04/10/2023 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 0684 Time Out: 10:15 AM Level of Harm - Minimal harm or potential for actual harm Expected Return: Date/Time – 1/19/23 at 1 PM Actual Leave Date/Time: Blank Residents Affected - Few Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank For the week of 1/29/23 to 2/4/23, the log indicated Resident A was OOP three times, on 1/29/23, 2/1/23, and 2/3/23. Resident A also had one entry logged for this period that had no date. The following were missing from the log. Date:1/29/23 Time Out: 11:10 AM Expected Return: Date/Time – 1/29/23 at 3:30 PM Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank Date:2/1/23 Time Out: Blank Expected Return: Date/Time – 2/1/23 at 4 PM Location of Event: Blank Actual Leave Date/Time: 2/1/23 – no time indicated Actual Return Date/Time: 4 PM - no date indicated Nurse Signature for Actual Leave and Return: Blank Date: Blank Time Out: Blank Expected Return: Date/Time – Blank Actual Leave Date/Time: Blank Actual Return Date/Time: Blank (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056272 If continuation sheet Page 6 of 23 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 04/10/2023 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 0684 Nurse Signature for Actual Leave and Return: Blank Level of Harm - Minimal harm or potential for actual harm Date:2/3/23 Time Out: 10:28 AM Residents Affected - Few Expected Return: Date/Time – Blank Location of Event: Blank Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank For the week of 2/5/23 to 2/11/23, the log indicated Resident A was OOP three times, on 2/5/23, 2/9/23, and 2/10/23. The following were missing from the log. Date:2/5/23 Time Out: 11:45 AM Expected Return: Date/Time – Blank Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank Date:2/9/23 Time Out: 10:40 AM Expected Return: Date/Time – Blank Phone Number: Blank Location of Event: Blank Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank Date:2/10/23 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056272 If continuation sheet Page 7 of 23 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 04/10/2023 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 0684 Time Out: 11:30 AM Level of Harm - Minimal harm or potential for actual harm Expected Return: Date/Time – Blank Phone Number: Blank Residents Affected - Few Location of Event: Blank Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank For the week of 2/12/23 to 2/18/23, the log indicated Resident A was OOP three times on 2/12/23, 2/16/23, and 2/17/23. The following were missing from the log. Date:2/12/23 Time Out: 11 AM Expected Return: Date/Time – Blank Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank Date:2/16/23 Time Out: 8:30 AM Expected Return: Date/Time – Blank Location of Event: Blank Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank Date:2/17/23 Time Out: Blank Expected Return: 2/17/23 at 3 PM (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056272 If continuation sheet Page 8 of 23 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 04/10/2023 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 0684 Actual Leave Date/Time: Blank Level of Harm - Minimal harm or potential for actual harm Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank Residents Affected - Few For the week of 2/19/23 to 2/25/23, the log indicated Resident A was OOP two times, on 2/19/23 and 2/24/23. Resident A also had one entry logged for this period that had no date. The following were missing from the log. Date:2/19/23 Time Out: Blank Expected Return: 2/19/23 at 4 PM Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank Date: Blank Time Out: Blank Expected Return: Date/Time – Blank Location of Event: Blank Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank Date: Blank Time Out: Blank Expected Return: Date/Time – Blank Location of Event: Blank Actual Leave Date/Time: 2/24/23 at 1:30 PM Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056272 If continuation sheet Page 9 of 23 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 04/10/2023 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 0684 For the week of 2/26/23 to 3/4/23, the log indicated Resident A was OOP two times, on 2/26/23 and 3/2/23. The following were missing from the log. Level of Harm - Minimal harm or potential for actual harm Date: 2/26/23 Residents Affected - Few Time Out: 10:30 AM Expected Return: 2/26/23 – no time indicated Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank Date: 3/2/23 Time Out: 10:05 AM Expected Return: Date/Time - Blank Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank During an interview on 3/6/23 at 11:42 AM, with the Assistant Director of Nursing (ADON), ADON explained the nurses were responsible for the OOP log including monitoring of residents when OOP. During a concurrent interview and record review of the OOP Log on 3/6/23 at 12:04 PM, with the Director of Nursing (DON), and the Assistant Director of Nursing (ADON) present, DON stated the OOP log was in place to ensure the resident ' s safety as per the physician ' s order.DON stated Resident A ' s OOP was not followed and monitored as ordered by the physician. DON confirmed the lack of monitoring by staff on Resident A ' s departure and return to and from the facility while OOP. ADON acknowledged the findings and stated improvement was needed on the facility ' s OOP process. Review of the facility ' s Policy and Procedures (P&P), titled, Off-Premise Activities, revision dated 6/2018, the P&P indicated, .Residents are considered appropriate for off-premise activities based on interdisciplinary team and physician approval and resident ' s request to participate in the outing . Resident safety is a priority when conducting off-premise activities . In case of resident outings with family, friend(s) or by self, the licensed nurse shall be responsible for checking resident upon his/her return if any adverse incident is reported that happened during the planned outing . 3. During a concurrent interview and record review of Resident A ' s medical records on 3/6/23 at 3:33 PM, with the ADON, ADON stated Resident A had no care plan developed for Out-on-Pass ordered by the physician on 11/30/22. ADON said, I don ' t see it. ADON stated there should be a care plan on Resident A ' s OOP order. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056272 If continuation sheet Page 10 of 23 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 04/10/2023 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 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Review of the facility ' s Policy and Procedures (P&P), titled, Care Plans, Comprehensive Person-Centered, revision dated 3/2022, the P&P indicated, .A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident ' s physical, psychosocial and functional needs is developed and implemented for each resident . The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident . The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident ' s highest practicable physical, mental, and psychosocial well-being . Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident ' s problem areas and their causes, and relevant clinical decision making . interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers . Assessments of residents are ongoing and care plans are revised as information about the residents and the residents ' conditions change . The interdisciplinary team reviews and updates the care plan . 4. During a review of the social services note, dated 11/30/22 at 10:47 AM, the note indicated, Resident A was informed that the order for her out-on-pass will be once a week and within 4 hrs only. During a review of the facility ' s clinician note, dated 1/25/23, the note indicated, Resident A ' s history included, .Many falls, she sometimes falls asleep in wheelchair. Numerous episodes of going out on pass and returning late, resulting in restriction on her ability to leave facility . During a concurrent interview and record review of the OOP Log on 3/6/23 at 12:04 PM, with the Director of Nursing (DON), and the Assistant Director of Nursing (ADON) present, DON stated the OOP log was in place to ensure the resident ' s safety as per the physician ' s order. DON stated Resident A ' s OOP was not followed and monitored as ordered by the physician. DON confirmed the lack of monitoring by staff on Resident A ' s departure and return to and from the facility while OOP. ADON acknowledged the findings and stated improvement was needed on the facility ' s OOP process. During a concurrent interview and record review of Resident A ' s medical records on 3/6/23 at 2:15 PM, with the Social Services Director (SSD), SSD stated Resident A ' s last Interdisciplinary team (IDT) meeting was held on 9/30/22. The IDT meeting on 9/30/22 was prior to the physician ' s OOP order for Resident A on 11/30/22. SSD acknowledged there was no IDT meeting held for Resident A after 9/30/22. When asked, SSD said that she cannot tell why. SSD stated she was responsible to organize IDT meetings. SSD explained it was a facility practice for the IDT to meet quarterly and discuss the resident ' s progress or change of condition. During an interview on 3/6/23 at 3:20 PM, with the ADON, ADON acknowledged there was no IDT meeting held to discuss Resident A ' s OOP. ADON stated IDT should be the same as care conference meetings. Review of the facility ' s Policy and Procedures (P&P), titled, Care Planning – Interdisciplinary Team, revision dated 3/2022, the P&P indicated, .The interdisciplinary team is responsible for the development of resident care plans . Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT) . The IDT includes but is not limited to: a. the resident ' s attending physician; b. a registered nurse with responsibility for the resident; c. a nursing assistant with responsibility for the resident; d. a member of the food and nutrition services staff; e. to the extent practicable, the resident and/or the resident ' s representative; and f. other staff as appropriate or necessary to meet the needs of the resident, or as requested by the resident . Care plan meetings are scheduled at the best time of the day for the resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056272 If continuation sheet Page 11 of 23 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 04/10/2023 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 0684 and family when possible . Level of Harm - Minimal harm or potential for actual harm Review of the facility ' s Policy and Procedures (P&P), titled, Charting and Documentation, revision dated 3/2017, the P&P indicated, .All services provided to the resident, progress toward the care plan goals, or any changes in the resident ' s medical, physical, functional or psychosocial condition, shall be documented in the resident ' s medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident ' s condition and response to care . Residents Affected - Few 5. During a review of the Physician ' s Active Orders, printed 3/6/23 at 11:41 AM, the verbal order indicated, Resident A May OOP [Out-on-Pass] up to 4 hrs every week. The OOP was ordered on 11/30/22. During a review of a facility note, created by the Social Services Director (SSD) on 3/3/23 [no time indicated], the note indicated, .per our MD [medical doctor], her [Resident A] out-on-pass order is temporarily cancelled until further determination of her safety issues. She had 2 falls in a week and always violating the 4 hrs. maximum hours to be in the community. During an interview on 3/6/23 at 3:44 PM, with the Assistant Director of Nursing (ADON), ADON stated he had discontinued Resident A ' s OOP order in the system today [3/6/23]. The OOP order was discontinued 3 days after the initial order was received by SSD from the physician on 3/3/23. Review of the facility ' s Policy and Procedures (P&P), titled, Medication and Treatment Orders, revision dated 7/2016, the P&P indicated, .Orders for medication and treatments will be consistent with principles of safe and effective order writing . Verbal orders must be recorded immediately in the resident ' s chart by the person receiving the order and must include prescriber ' s last name, credentials, the date and the time of the order . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056272 If continuation sheet Page 12 of 23 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 04/10/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 6 out of 8 residents who were allowed to go Out-on-Pass (OOP, off-premise activities) were provided adequate supervision and monitoring to prevent avoidable accidents when: 1. Resident A ' s Out-on- Pass (OOP, off-premise activities) was not followed and monitored by staff 2. OOP log records for 5 residents (Resident B, Resident C, Resident D, Resident E, and Resident F) were not monitored by staff This failure resulted in an incident wherein Resident A received treatment for a skin tear and moderate bleeding on her right hand while out-on-pass on 2/26/23. This failure had the potential to put other residents at risk for avoidable harm and injury. Findings: 1.During a concurrent observation and interview on 3/6/23 at 10:20 AM, Resident A was in her room and sat in a wheelchair. Resident A was awake and alert. Resident A had a small dressing applied on the front of her right hand. When asked, Resident A explained the red color noted on the dressing was dry blood from an abrasion sustained when she visited a friend in the city. Resident A explained she was in a hurry to get back to the facility after the visit. Resident A stated it was 6 PM at the time, and it started to get dark. Resident A explained she did not notice a pole along the sidewalk and stated that she could have brushed or scraped her hand with something on the pole. Resident A stated this incident occurred a few days ago. During a review of the Out-on-Pass Log, dated 2/26/23, the log on Resident A indicated the following: Date: 2/26/23 Time Out: 10:30 AM Expected Return: 2/26/23 – no time indicated Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank During a review of the nurse ' s note, dated 2/26/23, at 10:52 PM, the note indicated, Resident A was on OOP this AM and came back at 1915 [7:15 PM] with a skin tear on the right dorsal hand which was bleeding moderately . The site was cleansed . MD [medical doctor] was informed . During a review of the facility ' s Out-on-Pass Binder, the log from 1/10/23 through 3/6/23 was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056272 If continuation sheet Page 13 of 23 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 04/10/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some reviewed. The log indicated, Nurses on duty must ensure each resident OUT on PASS is reported in the Nurses 24 Hours Report, PCC and COMPLETE ALL COLUMNS in this LOG, ACTUAL RETURN Date and Time must be filled in immediately on return. Do NOT forget to sign on Leave and Return. During a review of the social services note, dated 11/30/22 at 10:47 AM, the note indicated, Resident A was informed that the order for her out-on-pass will be once a week and within 4 hrs only. For the week of 1/8/23 to 1/14/23, the log indicated Resident A was OOP two times, on 1/10/23 and 1/12/23. The following were missing from the log. Date: 1/10/23 Time Out: 9:40 AM Expected Return: Date/Time – Blank Location of Event: Blank Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank Date:1/12/23 Time Out: 11 AM Expected Return: Date – Blank, Time – unclear Phone Number: Blank Location of Event: Blank Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank For the week of 1/15/23 to 1/21/23, the log indicated Resident A was OOP two times, on 1/18/23 and 1/19/23. The following were missing from the log. Date:1/18/23 Time Out: 11 AM Expected Return: Date/Time - Blank (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056272 If continuation sheet Page 14 of 23 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 04/10/2023 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 0689 Location of Event: Blank Level of Harm - Minimal harm or potential for actual harm Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Residents Affected - Some Nurse Signature for Actual Leave and Return: Blank Date:1/19/23 Time Out: 10:15 AM Expected Return: Date/Time – 1/19/23 at 1 PM Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank For the week of 1/29/23 to 2/4/23, the log indicated Resident A was OOP three times, on 1/29/23, 2/1/23, and 2/3/23. Resident A also had one entry logged for this period that had no date. The following were missing from the log. Date:1/29/23 Time Out: 11:10 AM Expected Return: Date/Time – 1/29/23 at 3:30 PM Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank Date:2/1/23 Time Out: Blank Expected Return: Date/Time – 2/1/23 at 4 PM Location of Event: Blank Actual Leave Date/Time: 2/1/23 – no time indicated Actual Return Date/Time: 4 PM - no date indicated Nurse Signature for Actual Leave and Return: Blank (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056272 If continuation sheet Page 15 of 23 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 04/10/2023 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 0689 Date: Blank Level of Harm - Minimal harm or potential for actual harm Time Out: Blank Expected Return: Date/Time – Blank Residents Affected - Some Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank Date:2/3/23 Time Out: 10:28 AM Expected Return: Date/Time – Blank Location of Event: Blank Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank For the week of 2/5/23 to 2/11/23, the log indicated Resident A was OOP three times, on 2/5/23, 2/9/23, and 2/10/23. The following were missing from the log. Date:2/5/23 Time Out: 11:45 AM Expected Return: Date/Time – Blank Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank Date:2/9/23 Time Out: 10:40 AM Expected Return: Date/Time – Blank Phone Number: Blank (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056272 If continuation sheet Page 16 of 23 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 04/10/2023 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 0689 Location of Event: Blank Level of Harm - Minimal harm or potential for actual harm Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Residents Affected - Some Nurse Signature for Actual Leave and Return: Blank Date:2/10/23 Time Out: 11:30 AM Expected Return: Date/Time – Blank Phone Number: Blank Location of Event: Blank Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank For the week of 2/12/23 to 2/18/23, the log indicated Resident A was OOP three times on 2/12/23, 2/16/23, and 2/17/23. The following were missing from the log. Date:2/12/23 Time Out: 11 AM Expected Return: Date/Time – Blank Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank Date:2/16/23 Time Out: 8:30 AM Expected Return: Date/Time – Blank Location of Event: Blank Actual Leave Date/Time: Blank (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056272 If continuation sheet Page 17 of 23 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 04/10/2023 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 0689 Actual Return Date/Time: Blank Level of Harm - Minimal harm or potential for actual harm Nurse Signature for Actual Leave and Return: Blank Date:2/17/23 Residents Affected - Some Time Out: Blank Expected Return: 2/17/23 at 3 PM Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank For the week of 2/19/23 to 2/25/23, the log indicated Resident A was OOP two times, on 2/19/23 and 2/24/23. Resident A also had one entry logged for this period that had no date. The following were missing from the log. Date:2/19/23 Time Out: Blank Expected Return: 2/19/23 at 4 PM Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank Date: Blank Time Out: Blank Expected Return: Date/Time – Blank Location of Event: Blank Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank Date: Blank Time Out: Blank (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056272 If continuation sheet Page 18 of 23 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 04/10/2023 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 0689 Expected Return: Date/Time – Blank Level of Harm - Minimal harm or potential for actual harm Location of Event: Blank Actual Leave Date/Time: 2/24/23 at 1:30 PM Residents Affected - Some Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank For the week of 2/26/23 to 3/4/23, the log indicated Resident A was OOP two times, on 2/26/23 and 3/2/23. The following were missing from the log. Date: 2/26/23 Time Out: 10:30 AM Expected Return: 2/26/23 – no time indicated Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank Date: 3/2/23 Time Out: 10:05 AM Expected Return: Date/Time - Blank Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank During an interview on 3/6/23 at 11:42 AM, with the Assistant Director of Nursing (ADON), ADON explained the nurses were responsible for the OOP log including monitoring of residents when OOP. During a concurrent interview and record review of the OOP Log on 3/6/23 at 12:04 PM, with the Director of Nursing (DON), and the Assistant Director of Nursing (ADON) present, DON stated the OOP log was in place to ensure the resident ' s safety as per the physician ' s order. DON stated Resident A ' s OOP was not followed and monitored as ordered by the physician. DON confirmed the lack of monitoring by staff on Resident A ' s departure and return to and from the facility while OOP. ADON acknowledged the findings and stated improvement was needed on the facility ' s OOP process. Review of the facility ' s Policy and Procedures (P&P), titled, Off-Premise Activities, revision dated 6/2018, the P&P indicated, .Residents are considered appropriate for off-premise activities (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056272 If continuation sheet Page 19 of 23 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 04/10/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some based on interdisciplinary team and physician approval and resident ' s request to participate in the outing . Resident safety is a priority when conducting off-premise activities . In case of resident outings with family, friend(s) or by self, the licensed nurse shall be responsible for checking resident upon his/her return if any adverse incident is reported that happened during the planned outing . 2.During a review of the facility ' s Out-on-Pass Binder, the log from 1/10/23 through 3/6/23 was reviewed. The log indicated, Nurses on duty must ensure each resident OUT on PASS is reported in the Nurses 24 Hours Report, PCC and COMPLETE ALL COLUMNS in this LOG, ACTUAL RETURN Date and Time must be filled in immediately on return. Do NOT forget to sign on Leave and Return. For the week of 1/8/23 to 1/14/23, the following were missing from the log for Resident B. Date: 1/11/23 Time Out: Blank Expected Return: Date/Time – Blank Location of Event: Blank Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank For the week of 1/22/23 to 1/28/23, the following were missing from the log for Resident C. Date: 1/22/23 Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank Date: 1/26/23 Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank For the week of 1/29/23 to 2/4/23, the following were missing from the log for Resident C. Date: Blank (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056272 If continuation sheet Page 20 of 23 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 04/10/2023 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 0689 Time Out: Blank Level of Harm - Minimal harm or potential for actual harm Expected Return: Date/Time – Blank Location of Event: Blank Residents Affected - Some Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank Date: 2/3/23 Time Out: 6:10 AM Expected Return: Time - Blank Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank For the week of 2/5/23 to 2/11/23, the following were missing from the log for Resident C. Date: 2/5/23 Time Out: Unclear Expected Return: Date/Time – Unclear Location of Event: Blank Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank For the week of 2/12/23 to 2/18/23, the following were missing from the log for Resident C. Date: 2/14/23 Location of Event: Blank Actual Leave Date/Time: Blank Actual Return Date/Time: Blank (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056272 If continuation sheet Page 21 of 23 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 04/10/2023 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 0689 Nurse Signature for Actual Leave and Return: Blank Level of Harm - Minimal harm or potential for actual harm For the week of 2/19/23 to 2/25/23, the following were missing from the log for Resident C. Date: 2/19/23 Residents Affected - Some Expected Return: Time – Blank Location of Event: Blank Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank For the week of 2/19/23 to 2/25/23, the following were missing from the log for Resident D. Date: 2/19/23 Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank For the week of 2/26/23 to 3/4/23, the following were missing from the log for Resident E. Date: 2/5/23 Expected Return: Time – Blank Location of Event: Unknown Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank For the week of 2/26/23 to 3/4/23, the following were missing from the log for Resident F. Date: 3/1/23 Actual Leave Date/Time: Blank Actual Return Date/Time: Blank Nurse Signature for Actual Leave and Return: Blank (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056272 If continuation sheet Page 22 of 23 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 04/10/2023 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete During a concurrent interview and record review of the OOP Log on 3/6/23 at 12:04 PM, with the Director of Nursing (DON), and the Assistant Director of Nursing (ADON) present, ADON acknowledged the findings and stated improvement was needed on the facility ' s OOP process. Review of the facility ' s Policy and Procedures (P&P), titled, Off-Premise Activities, revision dated 6/2018, the P&P indicated, .Residents are considered appropriate for off-premise activities based on interdisciplinary team and physician approval and resident ' s request to participate in the outing . Resident safety is a priority when conducting off-premise activities . In case of resident outings with family, friend(s) or by self, the licensed nurse shall be responsible for checking resident upon his/her return if any adverse incident is reported that happened during the planned outing . Event ID: Facility ID: 056272 If continuation sheet Page 23 of 23