Health inspection·October 17, 2023

F 0552 Ensure that residents are fully informed and understand their health status, care and treatments. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure result of the Covid-19 test (nasal swab test to detect the current infection with the virus called SARS-CoV-2) was accurately communicated in the language and manner the resident fully understand for one of three sampled residents (Resident 1) when the preliminary positive Covid result was not communicated in the resident ' s native language and with no explanation that a re-run of the test was needed to confirm the validity of the result. This deficient practice caused Resident 1 to get upset about the result and raised concern among the Family Members. Residents Affected - Few The re-run test was done later on the same day (7/20/23), as per facility policy, and indicated a false positive result (False positive, means that a person was told a positive result, but are not actually infected with the SARS-CoV-2 virus (covid virus). Findings: Record review of the Face sheet indicated Resident 1 was admitted to the facility on [DATE]. The admission H & P dated 7/14/23 indicated, the resident came for rehabilitation therapy following surgery of a fracture (broken) left tibia (define) and fibula (define). Record review of the Minimum Data Set (MDS, an assessment tool) dated 7/31/23 indicated, the resident ' s preferred language was Spanish and the Brief Interview for Mental Status (BIMS) had the score of 15 (15/15 means the person is awake, alert and oriented to person, time, and place). Interview on 10/17/23 at 11:32 AM, with the Nurse Manage (NM) and Director of Nursing (DON) in the presence of the Regulatory Affair Nurse (RAN 1) and the Regulatory Affair Coordinator (RAC), DON stated, the Physicians and License Nurses can disclose results of covid test to the residents and Covid test was done two times per week in the facility, Mondays and Thursdays, each week. When asked, what was her expectations from the staff when covid test were disclosed, the DON stated, staff would informed the residents in a manner that would avoid potentially alarming situation since there was small percentage of small positive results, to take infection control measures while the resident was still in active phase of the infection, and to educate and respond to any questions the residents may have. The NM stated, the resident tested positive for Covid test on 7/20/23, it was initial (or preliminary), and the re-run test was done later on the same day, and it was negative. The NM stated, the staff would disclose the covid-19 test result after the test has been confirmed. Record review of the Covid-19 test (preliminary) result dated 7/20/23 at 7:59 indicated, Detected (means positive). The re-run Covid-9 test result dated 7/20/23 at 4:40 pm indicated, Not detected (means negative) and the re-run Covid-19 test result dated 7/20/23 at 6:21 pm indicated, Not detected. (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: 555660 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 555660 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/17/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Zuckerberg San Francisco General Hosp & Trauma Snf 1001 Potrero Avenue San Francisco, CA 94110 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)