Other·February 10, 2020

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. Complaint no. 616499 Facility reported incident no. 616191 Representing the California Department of Public Health: ID# 28225, Health Facilities Evaluator Nurse The inspection was limited to the specific complaint and facility reported incident investigated and does not represent the findings of a full inspection of the facility. One deficiency was written as a result of complaint 616499 and facility reported incident 616191. The following medical terms were used: According to www.healthline.com, Accessed 3/19/19: 1. Ethmoid sinus: "(one of six sets of sinuses) is part of the paranasal sinus system and is located between the nose and eyes. In addition to creating mucus, the sinuses - including the ethmoid sinus - reduce the skull's overall weight and make one's voice more resonant as they grow in size during puberty." 2. Sinuses: "air-filled sacs (empty spaces) on either side of the nasal cavity that filter and clean the air breathed through the nose and lighten the bones of the skull." 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: 0C2V11 Facility ID: CA220000518 If continuation sheet 1 of 11 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: _______________ 055169 (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JEWISH HOME & REHAB CENTER D/P SNF 302 Silver Ave San Francisco, CA 94112 (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 3. sphenoid sinus: "The most posterior (farthest toward the back of the head)" According to www.mayoclinic.org, Accessed 12/28/18, "Osteoarthritis is the most common form of arthritis, affecting millions of people worldwide. It occurs when the protective cartilage that cushions the ends of your bones wears down over time." According to www.alz.org/alzheimers, Accessed 12/28/18: 1. Dementia: "not a specific disease. It's an overall term that describes a group of symptoms associated with a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities. " 2. Alzheimer's Dementia: a type of dementia that causes problems with memory, thinking and behavior. Symptoms usually develop slowly and get worse over time, becoming severe enough to interfere with daily tasks." According to spine-health.com Accessed 3/19/19: 1. Cervical spine (C): "also called the neck, is a well engineered structure of bones nerves, muscles and tendons. 2. Flexion: "when the cervical spine bends directly forward with the chin tilting down." 3. Extension: is when the cervical spine straightens or moves directly backward with the chin tilting up." 4. Vertebrae: "the 33 individual, interlocking bones that form the spinal column." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0C2V11 Facility ID: CA220000518 If continuation sheet 2 of 11 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: _______________ 055169 (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JEWISH HOME & REHAB CENTER D/P SNF 302 Silver Ave San Francisco, CA 94112 (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 5. C1 vertebra (atlas): shaped more like a ring, connects to the occipital bone above to support the base of the skull and form the base of the atlanto-occipital joint. More of the head's forward/backward occurs at this joint compared to any other spinal joint." 6. C2 (axis): " "The second vertebra, has a large bony protrusion (odontoid process) that points up from its vertebral body and fits into the ring shaped atlas. The atlas is able to rotate around the axis, forming the atlantoaxial joint. More rotational range of motion occurs at this joint compared to any other." 7. lamina: "is the flattened or arched part of the vertebral arch, forming a roof of the spinal canal; the posterior part of the spinal ring that covers the spinal cord or nerves." 8. Coccyx: "a triangular arrangement of bone that makes up the very bottom portion of the spine below the sacrum." According to Medline Plus.gov Accessed 3/19/19, "MRI (Magnetic Resonance Imaging): uses a large magnet and radio waves to look at organs and structures in your body." According to RadiologyInfo.org Accessed 3/19/19, "CT (Computed Tomography) is a diagnostic imaging test used to create detailed images of internal organs bones, soft tissue and blood vessels." According to www.thefreedictionary.com Accessed 3/19/19, "slough (sluf): (medical term) is a layer or mass of dead tissue separated from surrounding living tissue, as in a wound, sore, or inflammation." According to www.spinalcord.com Accessed 5/24/19, "What Is The Difference Between FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0C2V11 Facility ID: CA220000518 If continuation sheet 3 of 11 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: _______________ 055169 (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JEWISH HOME & REHAB CENTER D/P SNF 302 Silver Ave San Francisco, CA 94112 (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 Hemiplegia And Hemiparesis?... Hemiparesis is weakness on half of the body, while hemiplegia refers to paralysis that affects just one side ..." Otolaryngology: study of disease of ear and throat Ophthalmology: branch of medicine or surgery that diagnose and treat eye disorders. Cervical Collar (neck brace): a medical equipment to support the spinal cord and head. Foley: a tube (catheter) placed in the body to drain urine. perineal area: is between the anus (opening at the end of the digestive tract where stool leaves the body) and the posterior part of the external genitalia erythema are patches of red raised skin exudate is pus like or clear fluid leaked out of the blood vessels and into nearby tissues mechanical ventilation (ventilator) machine helps people breathe when they are not able to breathe on their own. intubated (intubation) is when a tube insertion for ventilator assisted breathing. extubation (extubated) is the removal of a tube used during mechanical ventilation FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0C2V11 Facility ID: CA220000518 If continuation sheet 4 of 11 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: _______________ 055169 (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JEWISH HOME & REHAB CENTER D/P SNF 302 Silver Ave San Francisco, CA 94112 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

F689 Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) SS=G ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 02/28/2020 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation. interview and record review, the facility failed to provide supervision for one of three sampled residents (Resident 1) who had mobility impairment and a history of a fall. Resident 1 was left in the dining room unsupervised and had an unwitnessed fall on 12/16/18 . The deficient practice resulted in a fractured bone on the neck (Type II dens fracture), multiple facial fractures and a right eye globe rupture requiring surgery and hospitalization. His functional activities of daily status declined after the 12/16/18 fall. Findings: Review of Resident 1's "Minimum Data Set (MDS- an assessment tool)", dated 11/13/18, indicated he was admitted to the facility on 2/13/17 with diagnosis including heart failure, high blood pressure, arthritis (inflammation of the joints) , Alzheimer's Disease, Dementia, and weakness. (Dementia: an overall term that describes a group of symptoms associated with a decline in memory or other thinking skills severe enough FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0C2V11 Facility ID: CA220000518 If continuation sheet 5 of 11 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: _______________ 055169 (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JEWISH HOME & REHAB CENTER D/P SNF 302 Silver Ave San Francisco, CA 94112 (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 to reduce a person's ability to perform everyday activities. Alzheimer's Dementia: a type of dementia that causes problems with memory, thinking and behavior. Symptoms usually develop slowly and get worse over time, becoming severe enough to interfere with daily tasks). He had moderate difficulty hearing, clear speech, usually was able to express ideas and wants with difficulty communicating some words, sometimes understood/responded adequately to simple direct communication, had impaired vision, one sided upper extremity impairment, impairment on both sides of lower extremity. He needed one staff assistance with dressing, eating, toilet use and personal hygiene; two staff assistance with bed mobility and transfer; and required 100 percent support assistance with locomotion off unit (in areas set aside for dining) when in a wheelchair. Record review of Resident 1's November 2018 Physician Order Sheet indicated diagnoses included hemiplegia and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (stroke) affecting dominant right side. Record review of document, "Fall Risk Assessment", dated 11/06/18, for Resident 1 indicated, "Total Score: 16... Total Score of 10 or greater represents HIGH RISK..." Record review of Resident 1's Comprehensive Care Plan, dated 5/14/18, indicated, "Functional ADL (activities of daily living), Goals... will be assisted as needed..." During an observation on 1/2/19 at 2:06 PM, Resident 1 was in his room, in bed, on his right side, asleep. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0C2V11 Facility ID: CA220000518 If continuation sheet 6 of 11 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: _______________ 055169 (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JEWISH HOME & REHAB CENTER D/P SNF 302 Silver Ave San Francisco, CA 94112 (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 During an interview on 1/2/19 at 2:58 PM, Registered Nurse (RN ) 1 stated that Resident 1 had a history of a fall prior to the 12/16/18 fall incident. Residents are brought into the dining room around 7:30 AM to 8 AM. Breakfast is at 8 AM. During an observation on 1/2/19 at 3:45 PM, Resident 1's family member was at the bedside. Resident 1 was in his bed. During an observation on 1/2/19 at 3:50 PM, Resident 1 had a scab on his right arm, a scab on the right top part of his forehead, his right eye was red, and he had a bruise by his right ear. During a telephone interview on 2/6/19 at 3:02 PM, Licensed Nurse (LN) 2 stated she was the nurse in charge on 12/16/18 when Resident 1 fell. During an interview on 2/6/19 at 3:10 PM, LN 2 stated, "I was passing medications. Breakfast starts at 8 AM in the dining room. If a resident is in the dining room the nurse in charge or a staff should be in the dining room." LN 2 stated that Certified Nurse Assistant (CNA) 2 was the staff assigned to work with Resident 1 on 12/16/18, day shift. "CNA 2 was the one that should have gotten (Resident 1) from his bed to his wheelchair to the dining room for his breakfast. Around 7:50 AM (12/16/18), I was passing medications. As I was heading back to the medication cart from a patient's room, I suddenly heard a falling sound and one resident scream in the dining room. I rushed to the dining room and saw (Resident 1) on the floor, on his right side, his head was resting on the floor. I saw blood on the floor. When I checked on the resident (Resident 1), I saw a laceration on his right upper eyebrow. There was one other resident in the dining room when FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0C2V11 Facility ID: CA220000518 If continuation sheet 7 of 11 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: _______________ 055169 (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JEWISH HOME & REHAB CENTER D/P SNF 302 Silver Ave San Francisco, CA 94112 (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 I found the resident (Resident 1) on the floor." On 2/6/19 at 3:17 PM, LN 2 stated that when she went in the dining room to check what happened there was "no nursing staff " in the dining room with the residents. "Before 8 AM, during that time all staff are with residents preparing them for breakfast." On 2/6/19 at 3:30 PM, LN 2 stated, "I was not informed there were residents in the dining room." LN 2 stated a nursing staff should have been in the dining room with the residents. During a telephone interview on 2/7/19 at 1:29 PM, CNA 2 stated, she brought Resident 1 from his room to the dining room for breakfast. "I put him in front of the table and I locked the wheelchair. Then I left to get to the other resident to bring them to the dining room". On 2/7/19 at 1:42 PM, CNA 2 stated, "I know for a fact that the nurse was there when I left the resident in the dining room. We don't necessarily tell the nurse everytime we bring the resident to the dining room." During an interview on 5/23/19 at 4:15 PM, LN 2 stated, that on 12/16/18, she saw CNA 2 bring Resident 1 from his room to the dining room by wheelchair as they passed her while she was passing medications at the hallway. LN 2 stated she could not see Resident 1 when he was in the dining room, and did not see CNA 2 leave Resident 1 in the dining room. Record review of LN 2's "Clinical Notes Report", dated 12/16/18 at 10:43 AM, for Resident 1, indicated, "At around 07:40 AM, LN (licensed nurse) noted assign CNA (certified nurse assistant) propelling resident and getting ready for breakfast. Around 07:50 AM, LN heard sound from dining room and immediately FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0C2V11 Facility ID: CA220000518 If continuation sheet 8 of 11 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: _______________ 055169 (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JEWISH HOME & REHAB CENTER D/P SNF 302 Silver Ave San Francisco, CA 94112 (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 checked the situation. Noted resident had an unwitnessed fall inside the dining room. LN found resident R (right) side lying on the floor with injury/laceration on his R upper eyebrow... Noted 4 cm (centimeter) x (by) 2 cm x 1 cm laceration (a deep cut or tear in skin or flesh) on R upper eyebrow... alert oriented x (times) 2... with history of dementia and fluctuating cognition... When asked what happened before the incident, resident answers, "I am not well situated"...On call MD (medical doctor) notified... order to send resident to the hospital for further management and treatment... At 0820 AM, resident left the unit via gurney and was headed to (acute care hospital) ..." Record review of RN 1's "Clinical Notes Report", dated 12/16/18 at 6:43 PM, for Resident 1, indicated, "IDT (interdisciplinary team) Meeting Note, Unwitnessed fall with injury... discussed the issue of the unwitnessed fall with injury. On December 16, 2018 at approximately 07:50 AM, CNA... wheeled the resident (Resident 1) to the dining room area for breakfast and 10 minutes after, he was found lying on his right side on the floor and noted to have skin laceration on his right upper eyebrow... The resident complaint of head pain (8/10)... When the resident was asked how he fell, he stated that, "I am not well situated"... alert oriented x 2 and verbally responsive, with BIMS (Brief Interview for Mental Status) Score of 03 at latest MDS per ARD 8/30/18... The resident has previous medical diagnosis of Alzheimer's Disease, Dementia, Generalized muscle weakness, osteoarthritis... which together, can be contributory to his fall..." Record review of document, CNS (clinical nurse specialist)/RN (Registered Nurse) Note for General Acute Care Hospital, Inpatient", dated 12/17/18, 17:31 (5:31 PM), for Resident 1 indicated, "Admitted s/p (status post) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0C2V11 Facility ID: CA220000518 If continuation sheet 9 of 11 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: _______________ 055169 (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JEWISH HOME & REHAB CENTER D/P SNF 302 Silver Ave San Francisco, CA 94112 (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 mechanical fall out of a wheelchair w/(with) head strike, found to have dens fracture, multiple facial fx (fractures) and C1 bilateral lamina fx. s/p OR w/ ophthalmology for globe rupture repair ... " Record review of LN 1's "Clinical Notes, Readmission", dated 12/24/18 at 4:14 PM, for Resident 1, indicated, "Received from hospital via ambulance... with stage PU (pressure ulcer) on COCCYX( Coccyx: a triangular arrangement of bone that makes up the very bottom portion of the spine below the sacrum.), BRUISING ON RIGHT EYE COMING DOWN TO RIGHT CHEEK. 4cm LACERATION RIGHT EYEBROW with absorbable sutures. Noted eye patch (Fox shield) ON RIGHT EYE. Resident with Aspen collar to remain on resident x 24 hours for life... received with type 2 dens fx (fracture) bilat(eral) C1 laminae non operable fx, s/p repair of right eye globe rupture... on ATB (antibiotic) until 12/28/18..." Record review of Resident 1's MDS, dated 12/31/18, for Significant Change under functional activities of daily status indicated Resident 1 currently required full staff performance with locomotion on unit, and at least 2 person- physical assist with dressing, toilet use, and personal hygiene. During an interview on 1/2/19 at 3:39 PM, LN 1 stated that Resident 1 used to feed himself before his fall (12/16/18). Now he needs to be fed. In addition, LN 1 stated Resident 1 wore his neck brace for one or two days, now refuses to wear his neck brace. Resident 1's family was notified regarding Resident 1's refusing to wear his neck brace. Record review of Policy and Procedure titled, "Fall Prevention Program", revised 5/14, indicated, "Policy... ensures that the resident's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0C2V11 Facility ID: CA220000518 If continuation sheet 10 of 11 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: _______________ 055169 (X3) DATE SURVEY COMPLETED 01/31/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE JEWISH HOME & REHAB CENTER D/P SNF 302 Silver Ave San Francisco, CA 94112 (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 environment remains as free of accident hazards as is possible and that each resident receives adequate supervision and assistive devices to prevent accidents and mitigate injuries from falls while improving mobility and maintaining or enhancing the residents Quality of Life... Purpose... Any Residents identified as "at risk" for falls shall have an individual care plan that includes interventions to prevent falls from occurring... Procedure.... 3. A care plan and approaches for risks for falls will be initiated upon admission and updated as needed... 4. Appropriate interventions will be implemented for residents at high risk as identified by nursing, IDT (InterDisciplinary Team), and other disciplines... 6. A resident who triggers the fall assessment as high risk will be reviewed by the IDT..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0C2V11 Facility ID: CA220000518 If continuation sheet 11 of 11