Other·February 7, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an Abbreviated Standard Survey. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. For Complaint no. CA00511870 regarding Admission, Transfer & Discharge Rights, the Department substantiated a violation of Federal regulations and a Class B citation was issued. Representing the California Department of Public Health: Surveyor 31983, Health Facilities Evaluator Nurse

F206 SS=D POLICY TO PERMIT READMISSION BEYOND BED-HOLD CFR(s): 483.15(e)(1)(2)

F206 03/07/2018 (e)(1) Permitting residents to return to facility. A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following. (i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0UWJ11 Facility ID: CA220000039 If continuation sheet 1 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056272 (X3) DATE SURVEY COMPLETED 02/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN FRANCISCO HEALTH CARE 1477 Grove St San Francisco, CA 94117 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE their previous room if available or immediately upon the first availability of a bed in a semiprivate room if the resident(A) Requires the services provided by the facility; and (B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services. (ii) If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges. (e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to readmit one resident (Resident 1) after he was transferred to a General Acute Care Hospital (GACH) on 8/27/16. This refusal to readmit Resident 1 violated his right to return to the facility. Findings: Resident 1 was admitted with diagnoses FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0UWJ11 Facility ID: CA220000039 If continuation sheet 2 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056272 (X3) DATE SURVEY COMPLETED 02/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN FRANCISCO HEALTH CARE 1477 Grove St San Francisco, CA 94117 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE including dementia (degenerative cognitive impairment affecting memory, judgment, behavior, and physical function) and schizophrenia (mental disorder characterized by disordered thinking and faulty understanding or perception of reality). Record review on 12/9/16 and 12/19/16 of Resident 1's Care Plans at the facility indicated he had multiple behaviors of verbal and physical aggression toward other residents and staff, with actions noted to redirect and manage these behaviors. Document review on 12/16/16 of, "Management of Complex Psychiatric and Mental-Health [sic] Needs of Residents in All Health Care Settings", at http://www.hcanj.org/files/2013/10/seminarsconvention2011-3.pdf noted wandering, agitation, and catastrophic reactions (person with dementia has severe emotional reaction not appropriate for situations) are common behaviors in those with dementia. During an interview with concurrent record review on 12/9/16 at 11 am with the Administrator and Director of Nursing (DON), they stated that Resident 1 had verbal and physical incidents of aggression towards others. The latest incident that occurred on 8/27/16, Resident 1 attacked another frail, postoperative cardiac surgery resident by hitting the other resident on the chest/midsection with the walker. The Administrator stated the facility was not taking him back so no 30 day notice was provided. Record review of the Licensed Nurse's Notes dated 8/27/16 at 3:23 PM indicated staff notified the Physician on Call and the Medical Director for transfer to the General Acute care FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0UWJ11 Facility ID: CA220000039 If continuation sheet 3 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056272 (X3) DATE SURVEY COMPLETED 02/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN FRANCISCO HEALTH CARE 1477 Grove St San Francisco, CA 94117 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Hospital (GACH) Emergency Room for psychiatric evaluation and treatment via Welfare and Institution Code Section 5150. Section 5150 is a section of the California Welfare and Institutions Code the (LantermanPetris-Short Act or "LPS") which authorizes a qualified officer or clinician to involuntarily confine a person suspected to have a mental disorder that makes them a danger to themselves, a danger to others, or gravely disabled. Record review of the facility policy and procedure titled, Notice of a Transfer and/or Discharge dated April 2011 indicated in the policy statement, "Our facility shall provide a resident and /or the resident's representative (sponsor) with a thirty (30) day written notice of an impending transfer or discharge." Record review of the GACH's Transfer Summary electronically signed by MD 1 on 9/16/16 for Resident 1 indicated, "He (Resident 1) has been stable and only intermittently agitated (but not physically violent) since he was admitted..." The section under "Brief History Leading to this Hospitalization" indicated Resident 1 had psychotic features (unclear psychiatric history) was presented to the ED with concerns about aggressive behavior at the SNF (Skilled Nursing Facility). The Transfer Summary stated, "The patient (Resident 1) was initially placed on 5150 for intent to harm another person and transported via EMS (Emergency Medical System) to the ED (Emergency Dept.) He was seen in the ED by psychiatry, and the 5150 was cleared. According to his SNF, the patient had no recent illness and no recent changes to his medications. When his 5150 was cleared, the SNF ( the facility) deferred accepting this patient (Resident 1) again and requested FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0UWJ11 Facility ID: CA220000039 If continuation sheet 4 of 5 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056272 (X3) DATE SURVEY COMPLETED 02/07/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE SAN FRANCISCO HEALTH CARE 1477 Grove St San Francisco, CA 94117 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE placement at an institution that was better equipped to care for the aggressive behaviors associated with the patient's dementia." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0UWJ11 Facility ID: CA220000039 If continuation sheet 5 of 5