Health inspection·February 26, 2026

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report three allegations of abuse within the mandated time frame to California Department of Public Health (CDPH), the Ombudsman (advocates for residents in nursing homes), and local law enforcement for one of one sampled resident (Resident 34). In addition, the facility failed to report the result of its investigation to CDPH within five working days.This failure to follow mandated reporting timeframes had the potential to delay investigation and implementation of protective measures for all residents of the facility.Review of three facility documents, titled Report of Suspected Dependent Adult/Elder Abuse (Reports 1, 2, and 3), dated 12/21/24 indicated on Report 1 and Report 2 that on 12/20/24 (time not specified), Resident 34 reported to Social Services Manager (SSM) that Registered Nurse (RN) 3 physically and verbally abused him by intimidating him, dragging him from bed, giving his medications late, shoving laxatives in his mouth, and along with Hospital Aide (HA) 4, hosing him down in the shower and putting soap in his eyes. Report 3 dated 12/21/24 indicated Resident 34 reported to SSM that Licensed Vocational Nurse (LVN) 2 withheld his medications and made him suffer. Report 3 did not indicate the date and time the allegation was reported. Further review of Report 3 indicated LVN 2 was placed on leave effective 12/20/24 until further notice. Review of Resident 34's face sheet indicated Resident 34 was admitted on [DATE] with diagnoses that included Parkinsonism (refers to brain conditions that cause slowed movements, rigidity (stiffness) and tremors) and dementia (a progressive state of decline in mental abilities). Resident 34 was discharged on 5/23/25. During an interview on 2/26/26 at 11:33 AM with the Director of Quality, Patient Safety and Risk (DQSR) and SSM, SSM stated that on 12/20/25 before 5:00 PM, Resident 34 alleged he was being abused physically and mentally by RN 3, HA 4, and LVN 2. SSM stated she reported Resident 34's allegation of abuse to CDPH, the Ombudsman, and local police on 12/21/24. Review of the fax transmittal report for Reports 1, 2, and 3 indicated the facility notified CDPH, the Ombudsman, and local law enforcement on 12/21/24 at 3:00 PM (22 hours after the allegation was made). The DSQR stated that when staff are involved in an abuse allegation, it is the Human Resources Office (HRO - a department of a company in charge of issues related to employees) who conducts the investigation. During an interview on 2/26/26 at 1:08 PM the Director of Staff Development (DSD) stated the facility reports to 911 or non-emergency number immediately but not later than two hours if the abuse allegation includes physical harm or serious bodily injury. The DSD stated further, Other forms of abuse (financial, etcetera) are reported to CDPH and other appropriate agencies within 24 hours. During a telephone interview on 2/26/26 at 1:39 PM with the Chief Human Resources Officer (CHRO) Page 1 of 2 555933 555933 02/26/2026 Chinese Hospital D/P Snf 845 Jackson Street San Francisco, CA 94133

F 0609 Level of Harm - Minimal harm or potential for actual harm and in-person interview with the Chief Nursing Officer (CNO), the CHRO stated that on 12/20/24, the HRO received a report that a resident made an allegation of harassment or abuse through SSM. The CHRO stated investigation started the following day and concluded on 1/10/25. When asked if the result of the investigation was reported to CDPH, the CHRO stated, Our department does not report to external agencies. The CNO stated that reporting to CDPH is not an HR function. Residents Affected - Few During an interview on 2/26/26 at 2:12 PM, the CNO confirmed the result of investigation was not report to CDPH. Review of the facility's policy and procedures (P&P), titled D/P (distinct part) SNF (skilled nursing facility) Free of Elderly Abuse Policy, last revised and approved on 2/20205, indicated Purpose: The facility will develop and operationalize policies and procedures for screening and training employees, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, and misappropriation of property. The purpose is to assure that the facility is doing all that is within its control to prevent occurrences. Further review of the P&P indicated Policy: The D/P SNF policies and procedures in accordance to federal and state regulations.I. Abuse Prohibited.D/P SNF shall abide by all abuse reporting laws that apply to skilled nursing facilities (SNFs) .VIII. Reporting Under Various Laws - All employees and certain contractors must follow the standards of conduct in this Policy to comply with the reporting requirements contained in various State and federal laws.A. Various Laws Requiring Reporting. D/P SNF is subject to certain basic reporting duties under . 2. The Federal Medicare/Medicaid (government-provided health insurance programs) laws .C. Reporting Duties Specific to Skilled Nursing.2. Under Federal laws, Medicare-participating SNFs must report immediately to DHS (referring to Department of Health and Human Services) all alleged resident mistreatment, neglect, or abuse. Review of the Appendix H of the P&P indicated Elder Abuse Reporting/Response Quick Guide.Timeframes to Report - Abuse and instances of 'serious bodily injury' must be reported immediately, but not later than two (2) hours. Parties to notify.California Department of Public Health.San Francisco Police Department.Ombudsman. The P&P did not include reporting of the results of all investigations of abuse allegation to the State Survey Agency (CDPH), within 5 (five) working days of the incident. 555933 Page 2 of 2