Inspection·August 1, 2024

F 0622 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure appropriate discharge for one of 3 sampled residents (Resident 1) when there was no evidence of discharge basis and discharge summary for Resident 1 regarding his discharge on [DATE]. This failure could result in an inappropriate discharge that may disrupt the provision of care for Resident 1. Findings: Review of Resident 1's clinical record indicated, Resident 1 was admitted to the facility on [DATE], with diagnoses including cachexia (a condition that causes significant weight loss and muscle loss), severe protein-calorie malnutrition (the state of severely inadequate intake of food), iron deficiency (a condition that your body does not have enough iron), and unsteadiness (inability to stand firmly) on feet. Review of Resident 1's Minimum Data Set (MDS, resident assessment tool), dated 4/19/24, indicated, his memory was moderately impaired. Review of Resident 1's doctor's order, dated 7/16/24, indicated, May discharge to home on 7/17/2024 with HH (Home health, a nursing specialty in which nurses provide multidimensional home care to patients of all ages) (PT [physical therapy, a branch of rehabilitative health that uses specially designed exercises and equipment to help patients regain or improve their physical abilities]/OT [occupational therapist, a healthcare provider who helps patients improve their ability to perform daily tasks]/RN [registered nurse]) and incontinent supplies (products designed to help manage urine or stool) Review of Resident 1's Licensed Nurse's Notes, dated 7/17/24 indicated, . Patient is discharged , left the facility at around 1400 (2 PM) with social worker on a wheelchair . During an interview on 8/1/24 at 11:11 AM with Director of Social Worker (DoSW), DoSW stated, . Of course! The doctor should have a discharge note for him . I don't see it here (in Resident 1's medical record) . when asked about the basis of discharge of Resident 1. DoSW stated, . I cannot see . when asked about Resident 1's basis of discharge again. She stated, there should be a reason for discharge to be documented by the doctor when asked. She stated, Definitely! when asked if there should be the basis of discharge. (continued on next page) 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 2 Event ID: 056272 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 08/01/2024 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)