Health inspection·July 19, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop a comprehensive care plan (CP) for each resident that included measurable objectives and specific interventions for two of eight sampled residents (Residents 14 and 7) when: 1. No individualized person-centered CP was developed for the use of Citalopram (Celexa - brand name of drug used to treat depression) for Resident 14. 2. For Resident 7, the CP did not have specific interventions for end stage renal disease [ESRD - when the kidneys are no longer able to work at a level needed for day-to-day life that requires a regular course of dialysis (a type of treatment that helps your body remove extra fluid and waste products from your blood when the kidneys are not able to)]. This failure had the potential for not meeting the residents' nursing needs and goals, as well as the quality of care and services they receive to attain their highest practicable well-being. Findings: 1. Resident 14 was admitted on [DATE] with diagnoses including seizure disorder and depression. Review of Resident 14's Physician's Orders indicated, .citalopram (Celexa) tablet 40 milligram (mg) daily . During a concurrent interview and record review on 7/17/24 at 11:45 AM, with Registered Nurse (RN) 4, Resident 14's care plans were reviewed. RN 4 confirmed that there was no CP for the use of Celexa, and stated, It's not here. RN 4 said that CP is important, so the team knows the resident's goal of care. 2. Resident 7 was admitted on [DATE] with diagnoses including diabetes (a group of diseases that result in too much sugar in the blood) and ESRD. During an interview on 7/15/24 at 11:45 AM, Resident 7 said he goes to dialysis three times a week, on Monday, Wednesday, and Friday (M-W-F). Resident 7 further said that he has a left upper arm fistula (a connection that's made between an artery and a vein for dialysis access). During a concurrent interview and record review on 7/17/24 at 2:13 PM, with Licensed Vocational Nurse (LVN) 1, Resident 7's ESRD CP was reviewed. LVN 1 confirmed Resident 7 goes to dialysis in the Page 1 of 8 555660 555660 07/19/2024 Zuckerberg San Francisco General Hosp & Trauma Snf 1001 Potrero Avenue San Francisco, CA 94110

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some afternoon on M-W-F. LVN 1 acknowledged that Resident 7's ESRD CP did not have specific interventions, and stated, None. Review of facility policy titled, 4A-SNF Interdisciplinary Resident Care Planning last reviewed on 11/23, indicated, .3. During Interdisciplinary team meetings, all clinical issues on the Interdisciplinary Care Plan list as well as triggered CARE ASSESSMENT AREAS (CAA'S) on MDS will be reviewed, and the Interdisciplinary Team (IDT) will determine which problems warrant a care plan, and if any care plans warrant revisions or closure. The RN will document the rationale if a care plan is not initiated for a triggered CARE ASSESSMENT AREAS (CAA'S) .11. Documentation: .c. Approaches/interventions to be utilized by specific disciplines to meet the goal(s) . 555660 Page 2 of 8 555660 07/19/2024 Zuckerberg San Francisco General Hosp & Trauma Snf 1001 Potrero Avenue San Francisco, CA 94110

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to provide pharmaceutical services to meet the needs of one sampled resident (Resident 79) when Registered Nurse (RN) did not rotate injection sites of insulin glargine (injection that can treat diabetes). This failure had the potential risk of Resident 79 developing thickened skin and localized skin with lumps. Findings: During a medication administration observation on 7/17/24 at 8:51 AM, RN 4 administered insulin glargine injection at the back of Resident 79's left upper arm. Review of Resident 79's Physician Orders indicated, .insulin glargine (LANTUS - brand name) injection 20 units subcutaneous (SQ - injection inserted under the skin) every morning . Review of Resident 79's Medication Administration Record (MAR), dated 7/3/24 to 7/17/24, indicated, insulin glargine was administered on the following dates: On 7/3/24 at 8:30 AM, given in the right lower abdomen; On 7/4/24 at 8:02 AM, given in the right lower abdomen; On 7/5/24 at 8:23 AM, given in the right lower abdomen; On 7/16/24 at 8:00 AM, given in the left upper arm (back); On 7/17/24 at 8:51 AM, given in the left upper arm (back). During a concurrent interview and record review on 7/17/24 at 11:36 AM, with RN 4, Resident 79's MAR for insulin glargine was reviewed. RN 4 said that insulin injection sites should be rotated in the abdomen, back of the arm, and thigh to prevent skin and fatty tissue irritation. RN 4 acknowledged that the injection was administered on the back of Resident 79's left upper arm for two consecutive days, 7/16/24 and 7/17/24, and stated, It should have been rotated. Review of facility policy titled, Pharmaceutical Services: Guidelines for Administration of Medications last revised on 1/23, indicated, .F. Route Specific .2. Intramuscular (IM), subcutaneous (SQ), or Intradermal (ID) medications .b. Do not give IM or SQ medications in the same site for consecutive drug administration unless specified to do so in the provider order . Review of manufacturer's prescribing information for LANTUS injection for subcutaneous use, revised 6/2022, indicated, .Dosage and Administration .Rotate injection sites to reduce risk of lipodystrophy (a disorder of fatty tissue) and localized cutaneous amyloidosis (condition in which clumps of abnormal proteins build up in the skin .Warning and Precautions .Repeated insulin injections into areas of lipodystrophy or localized cutaneous amyloidosis have been reported to result in hyperglycemia . 555660 Page 3 of 8 555660 07/19/2024 Zuckerberg San Francisco General Hosp & Trauma Snf 1001 Potrero Avenue San Francisco, CA 94110

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Resident 14 was readmitted on [DATE] with diagnoses including seizure disorder and depression. Review of Resident 14's admission MDS dated [DATE] indicated Resident 14 was cognitively intact. Review of Resident 14's Physician's Orders dated 7/11/24 indicated, .citalopram (Celexa) tablet 40 mg daily . Review of Resident 14's Consent for Psychoactive Oral Medication signed 7/11/24 indicated, .Anti-depressant .Citalopram .Behaviors to Monitor .Monitor s/s (signs and symptoms) of depression . Review of Resident 14's Nursing Note from 7/12/24 to 7/19, indicated, .on Citalopram for MDD (major depressive disorder), monitoring for signs and symptoms of depression . Review of Resident 14's SNF Nursing Weekly Summary dated 7/16/24, indicated, .Target Symptom Order: 1. On Citalopram, monitored for signs and symptoms of depression . During a concurrent interview and record review on 7/17/24 at 11:41 AM, with RN 4, Resident 14's behavioral monitoring for the use of Celexa was reviewed. RN 4 said that depression could be not socializing or showing no interest in care. When queried what behavior Resident 14 was being monitored for, RN 4 acknowledged that there was no specific target behavior to monitor for depression, and stated, No, it doesn't say. Not specific, it should be specific. Review of facility policy titled, Therapeutic Use of Medications revised in October 2023, indicated, .Informed Consent: The Resident or the resident's legal representative when applicable must be provided (informed of) the following information each psychotropic medication by the attending physician or nurse practitioner .2. For Psychotropic Medications Complete all categories on flowsheet record of all patients on psychoactive medications .Response to the psychotropic medication when ordered will be monitored by the nurse every shift and will include the behavior response per resident . Based on interview, and record review the facility failed to ensure two of 5 sampled residents (Residents 227 and 14) were free from unnecessary psychotropic medications (any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic [a type of psychiatric medication which are available on prescription to treat psychosis]; (ii) Anti-depressant [prescription medicines to treat depression]; (iii) Anti-anxiety [drugs used to treat symptoms of anxiety, such as feelings of fear, dread, uneasiness, and muscle tightness, that may occur as a reaction to stress]; and (iv) Hypnotic [a class of drugs that induce or prolong sleep in people with sleep disorders and are intended to improve the overall quality of sleep]) when: 1. For Resident 227, there was no consent and monitoring of targeted behaviors for Wellbutrin (antidepressant). 2. For Resident 14, there was no specific behavioral monitoring for Celexa (antidepressant). 555660 Page 4 of 8 555660 07/19/2024 Zuckerberg San Francisco General Hosp & Trauma Snf 1001 Potrero Avenue San Francisco, CA 94110

F 0758 Level of Harm - Minimal harm or potential for actual harm These failures could result in unnecessary use of, ineffective and/or lack of monitoring for psychotropic medications that could negatively affect the residents' highest practicable mental, physical and psychosocial well-being. Findings: Residents Affected - Some 1. Review of Resident 227's clinical record indicated, Resident 227 was admitted to the facility with diagnoses including bacteremia (the presence of bacteria in the blood), alcoholic cirrhosis of liver (a result of liver damage from conditions such as hepatitis B or C, or chronic alcohol use), alcohol use disorder (a chronic disease characterized by uncontrolled drinking and preoccupation with alcohol), and moderate methamphetamine use disorder (stimulant dependence, misuse of methamphetamine that has a high potential for abuse and misuse, which can lead to the development of a substance use disorder, including addiction). Review of Resident 227's Minimum Data Set (MDS, resident assessment tool), dated 7/15/24, indicated, Resident 227 was cognitively intact. Review of Resident 227's doctor's order dated 7/10/24 indicated, . buPROPion XL (WELLBUTRIN XL, Wellbutrin extended release) 24 hr (hour) tablet (pill) 150mg (milligram) . oral . Daily . Indications of Use: amphetamine use disorder . During a concurrent interview and record review on 7/17/24 at 12:02 PM with Registered Nurse (RN) 1, RN 1 could not show the evidence of the consent for Resident 227's Wellbutrin XL when asked. RN 1 stated, they did not have the consent because Wellbutrin XL was given for amphetamine use disorder, not for depression (a common mental disorder) for Resident 227. State Operations Manual titled, Appendix PP, dated 2/3/23 indicated, . Risks associated with psychotropic medications still exist regardless of the indication for their use (e.g., nausea, insomnia, itching), therefore the requirements pertaining to psychotropic medications . apply to the four categories of drugs (anti-psychotic, anti-depressant, anti-anxiety and hypnotic) . without exception . During a concurrent interview and record review on 7/17/24 at 1:58 PM with Clinical Pharmacist (CP), CP stated, The consent will be needed when asked. CP stated, Wellbutrin XL is antidepressant and psychotropic medication. CP acknowledged the need for targeted behavioral monitoring after reviewing Appendix PP together. During a concurrent interview and record review on 7/17/24 at 2:12 PM with RN 1, RN 1 stated, It is not applicable when asked again about the consent for Wellbutrin XL. RN 1 stated, it was because Resident 227 was taking Wellbutrin XL for amphetamine use disorder, not depression. RN 1 confirmed that there was no consent for Resident 227's Wellbutrin XL. RN 1 also verified there was no behavioral monitoring for Resident 227 when asked. 555660 Page 5 of 8 555660 07/19/2024 Zuckerberg San Francisco General Hosp & Trauma Snf 1001 Potrero Avenue San Francisco, CA 94110

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review, the facility failed to ensure removal of expired medications when an opened vial of Tuberculin Purified Protein Derivative (Tubersol - a solution injected into the surface layer of the skin to help diagnose tuberculosis infection) was stored in the medication refrigerator beyond its expiration date. This deficient practice had the potential to compromise the integrity and effectiveness of the drug and inaccurate test results. Findings: During an observation of the medication room on 7/16/24 at 12:49 PM, a vial of Tubersol with an opened date of 6/17/24 was stored in the medication refrigerator. The vial did not indicate a discard date. During concurrent interview, Registered Nurse (RN) 1 stated, It's good for 28 days once opened. RN 3 said the medication expired on 7/15/24. RN 2 read the date opened as, 6/17/24 and stated, It should be discarded. Review of facility policy titled, Pharmaceutical Services: Guidelines for Storage and Delivery of Medications last revised on 12/23, indicated, .3. Expiration dates .D. All Multi-dose injectable vials, including vaccines and insulins, are good for a maximum of 28-days after opening and shall be labeled with discard after date . 555660 Page 6 of 8 555660 07/19/2024 Zuckerberg San Francisco General Hosp & Trauma Snf 1001 Potrero Avenue San Francisco, CA 94110

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store food for 15 out of 15 sampled residents in accordance with professional standards for food service safety when: Residents Affected - Many 1. floors in the building 5 kitchen had a build-up of grease, grime, debris, and food crumbs, this had the potential for microorganism growth and to attract pests. 2. an ice machine had rust-colored residue on the bottom ledge of the ice bin, this had the potential to contaminate the ice 3. correct hand washing procedure was not followed by a food and nutrition services (FNS) employee during tray line (the process of plating meals), this had the potential to contaminate food and cause food-borne illness (illness contracted from eating contaminated food or beverages) These failures have the potential to result in a pest infestation or the spread of foodborne illness that could harm medically compromised residents' health and safety. Findings: 1. During a concurrent observation and interview 07/15/24 at 9:54 AM with the Executive Chef (EC) in the building 5 kitchen dry storage area, there was a build-up of crumbs under the shelves of food. In addition, crumbs were observed in the floor grates of an old drain system in the dry storage room. The EC acknowledged that the floors under the shelves had not been mopped the day before. During a concurrent observation and interview 07/15/24 at 10:20 AM with the Executive Chef (EC) in the building 5 kitchen cooking line near the pizza oven, the floors underneath the cooking ranges had a build-up of grease and grime. The EC stated that because the new cooking ranges are stationary and fixed to the wall, it has been difficult to clean under the equipment. During an observation on 07/15/24 at 10:23 AM inside the building 5 kitchen refrigerator stocked with prepared vegetables, the floor had multiple pieces of vegetables that had fallen. During an interview with the EC on 07/18/24 at 9:12 AM, the EC stated that his expected standard for food contact surfaces and the kitchen floor is everything should be clean. A review of the facility policy and procedure, titled REQUIRED CLEANING AND SANITATION STANDARD OPERATING PROCEDURES, last reviewed November 2015, indicated that Nonfood contact surfaces [surfaces that do not come into direct contact with food] shall be cleaned as often as is necessary to keep equipment free of accumulation of dust, dirt, food particles, and other debris. It further indicated that the cleaning procedure is for staff to Sweep area to be mopped, getting under any equipment or counter, move equipment when possible. This cleaning procedure should be done in Food preparation areas and Food storage areas Once per shift, or more frequently, as needed to reach a defined standard of Free From Dust/Debris, Free from Grease. A review of the FDA (Food and Drug Administration) Federal Food Code, dated 2022, 40601.11 indicated, (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. In addition The objective of cleaning focuses on the need to remove 555660 Page 7 of 8 555660 07/19/2024 Zuckerberg San Francisco General Hosp & Trauma Snf 1001 Potrero Avenue San Francisco, CA 94110

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many organic matter from food-contact surfaces so that sanitization can occur and to remove soil from nonfood contact surfaces so that pathogenic microorganisms will not be allowed to accumulate and insects and rodents will not be attracted. 2. During an observation on 07/15/24 at 10:57 AM in the building 5 kitchen, there was rust-colored residue on the bottom ledge of the ice bin when wiped with a clean paper towel. A review of facility policy and procedure, titled Ice Machines, last reviewed June 2023, indicated that ice machines and ice chests are maintained in clean condition to prevent transmission of infections. It further indicated that ice machines should be maintained to be visibly clean. A review of the FDA Federal Food Code, dated 2022, 4-602.11 indicated, cleaning should be done (4) In EQUIPMENT such as ice bins and BEVERAGE dispensing nozzles and enclosed components of EQUIPMENT such as ice makers, cooking oil storage tanks and distribution lines, BEVERAGE and syrup dispensing lines or tubes, coffee bean grinders, and water vending EQUIPMENT: (a) At a frequency specified by the manufacturer, or (b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold. In addition, ice makers, and ice bins must be cleaned on a routine basis to prevent the development of slime, mold, or soil residues that may contribute to an accumulation of microorganisms. 3. During an observation 07/16/24 at 12:25 PM in the building 25 kitchen, a Food and Nutrition Services (FNS) employee was observed during tray line. The FNS employee picked up an item off the floor, removed their gloves, put on new gloves, and continued working on the tray line without washing their hands. During an interview with the EC on 07/18/24 at 9:12 AM, the EC was asked what his expectations are regarding glove use and handwashing. The EC stated, that is the policy . we wash hands between glove changes. A review of facility policy and procedure titled Food Safety, last reviewed December 2022, indicated under the section Employee Guidelines: Infection Control Practices that staff should Always wash hands before putting on or changing gloves. During a review of the FDA Federal Food Code, dated 2020, 2-301.14 indicated, FOOD EMPLOYEES shall clean their hands and exposed portions of their arms as specified under § 2-301.12 immediately before engaging in FOOD preparation including working with exposed FOOD, clean EQUIPMENT and UTENSILS, and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLESP and: (H) Before donning gloves to initiate a task that involves working with FOOD. 555660 Page 8 of 8