Other·March 14, 2019

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 complaints and incident investigated and does not represent the findings of a full inspection of the facility. For Complaint nos. CA00610468 and CA00610498 regarding Quality of Care / Treatment and Nursing Services, and Facility Reported Incident no. (FRI) CA00608528 regarding Pharmaceutical Services, the Department identified a violation of Federal regulations. Representing the California Department of Public Health: Surveyor ID# 37653, Health Facilities Evaluator Nurse

F760 SS=G Residents are Free of Significant Med Errors CFR(s): 483.45(f)(2)

F760 03/22/2019 The facility must ensure that its§483.45(f)(2) Residents are free of any significant medication errors. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure one of one Residents 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: CLU311 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 02/28/2019 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 (Resident 1) was free of significant medication error when two medications were not administered in accordance with the physician's order when: 1. Morphine Sulfate Solution 10 milligrams (mg) / (in) 5 milliliters (ml) 2.5 ml by mouth every 4 hours was ordered for Resident 1 but was given 7.5 ml (three times more than prescribed dose) on 10/7/18 at 9 am and 10/8/18 at 9 am; 2. An order for MS Contin 15mg ER (Extended Release) was discontinued on 10/8/18 but Resident 1 was given the medication two more times (on 10/8/18 at 9 pm and 10/9/18 at 9 am) after it was discontinued. This failed practice led to a significant medication error that caused Resident 1 to be heavily sedated with decreased food and fluid intake and decreased O2 saturation (amount of oxygen in the blood). Findings: Review of Physician (MD) note titled "Visit Type: Nursing Facility, Initial" dated 9/28/18, at 4:40 pm indicated Resident 1 was admitted to the facility on 9/28/18 for comfort care (end of life care), with a diagnosis including but not limited to heart failure with chest pain and tachypnea (rapid breathing) which required morphine administration for pain management. A review of Lexicomp online undated, indicated Morphine Sulfate is "An opioid analgesic indicated for management of pain severe enough to require daily, around-the-clock, longterm opioid treatment and for which alternative treatment options are inadequate" and has the potential for adverse reactions including serious, life-threatening or fatal respiratory depression (lack of oxygen and decreased FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CLU311 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 02/28/2019 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 breathing). Review of Physician Orders dated 9/28/18, indicated an order for Morphine Sulfate Solution 10 milligrams (mg) / (in) 5 milliliter (ml) to be administered 2 ml by mouth every hours as needed for moderate and severe pain and tachypnea. A new physician order dated 10/8/18, added an order for Morphine Sulfate Solution 10 mg / 5 ml to be administered 2.5 ml by mouth every four hours for pain and tachypnea. Review of Physician Orders dated 9/28/18, indicated an order for MS Contin Tablet ER (Extended Release) 15 mg to be administered by mouth every 12 hours for pain and was discontinued on 10/8/18 at 10:35 am. Review of the document titled "Controlled Substance Accountability Sheet" for Resident 1 indicated Morphine Sulfate 15 mg ER was to be administered by mouth one tablet every 12 hours. It was documented as administered by LVN 1 on 10/8/18 at 9 pm and 10/9/18 at 9 am after being discontinued. Review of the "Controlled Substance Accountability Sheet" for Resident 1 indicated Morphine Sulfate 10 mg / 5 ml was to be administered at 2.5 ml by mouth. Morphine Solution 7.5 ml was documented as administered by LVN 1 on 10/7/18 at 9 am and on 10/8/18 at 9 am. Review of the document titled "Nursing Observation Notes for change of Condition" Resident 1 indicated on 10/10/18 under Chief Complaint, Resident 1 had a change in level of consciousness and lethargy (drowsy / sleepy). Under Oral Assessment, Resident 1 was refusing to eat solids and had decreased fluid intake. Under Chest / Respiratory Assessment, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CLU311 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 02/28/2019 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 Resident 1 was noted to have an episode of low O2 saturation on room air. During an interview on 10/19/18, at 2 pm, the Director of Nursing (DON) stated she identified a medication error on 10/9/18 while reviewing the controlled substance sheet. Resident 1 had an order to receive Morphine Sulfate Solution 10 mg / 5 ml (2.5 ml) every four hours for pain and tachypnea. A Licensed Vocational Nurse (LVN 1) mistakenly administered 7.5 ml Morphine solution on 10/7/18 and 10/8/18 at 9 am. Resident 1 also had a medication order for MS Contin 15 mg extended release tablets to be administered every 12 hours. The physician had an order to discontinue this medication on 10/8/18 at 10:35 am. A Nursing Supervisor (RN 1) failed to input the discontinued MS Contin medication into the Medication Administration Record (MAR) until 10/9/18 at 11:39 am. Unaware of the new medication order, LVN 1 administered the discontinued medication on 10/8/18 at 9 pm and 10/9/18 at 9 am. During an interview on 11/16/18, at 9:43 am, the Medical Doctor (MD) of Resident 1 stated "I found on 10/8/18, from the nurse, that the patient (Resident 1) was receiving the shortacting Morphine instead of long-acting, which is not the way it was ordered. The patient's outcome was highly sedated after med error for about a week and was very distressing for the family." Review of the current Policy and Procedure titled "Administering Medications" dated December 2012 indicated "...Medications shall be administered in a safe and timely manner, and as prescribed. ...5. If a dosage is believe to be inappropriate or excessive for a resident, or a medication has been identified as having potential adverse consequences for the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CLU311 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 02/28/2019 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 resident ... the person ... administering the medication shall contact the resident's Attending Physician or the facilities Medical Director to discuss the concerns." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: CLU311 Facility ID: CA220000039 If continuation sheet 5 of 5