Zuckerberg San Francisco General Hosp & Trauma SNF

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: 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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. 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and document reviews the facility failed to ensure full-time Dietetic Services oversight for sufficient hours to effectively carry out the day-to-day functions of safe dietetic operations to meet the nutrition needs of 23 residents according to standards of practice when: 1. A nourishment pantry room had dirty ceiling panels and a vent with gray lint blowing out, 2. Resident's ice cream cups were stored and comingled in the staff lounge freezer, 3. A pink substance found in the nourishment pantry room ice machine chute, 4. A full-time qualified Dietetic Nutrition professional did not work in the skilled nursing unit when the Registered dietitian (RD) worked eight to ten hours a week and the Registered Dietetic Technician (DTR) worked five and half hours a week, on average, in the skilled nursing unit. (Cross reference F 726 and F 812) Findings: 1. On 6/7/23 at 10:50 AM, a concurrent observation and interview in the nourishment pantry room with the Registered Dietitian (RD) 1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure safe and sanitary food service operations were carried out according to standards of practice when: 1. expired foods were found in two walk-in refrigerators located in the main food production kitchen and basement food service kitchen, 2. ceiling panels and an air vent in the nourishment pantry room were dirty with large gray and black stains, and thick gray lint particles were hanging out, 3. resident foods were not stored separately from staff foods, and 4. a pink sticky substance was found inside the rim of the ice machine chute located in the nourishment pantry room. These failures had the potential to expose 23 of 23 residents to harmful contaminants that could cause foodborne illness. (Cross reference F 801) Findings: 1. During an observation and interview, on 6/5/23, at 10:10 AM, in a main kitchen walk-in refrigerator, with Executive Chef (EXC) and Foodservice Director (FSD), expired milk cartons were found with the use by…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record record review, the facility failed to have a full time Infection Preventionist designated for the facility. The facility failure has the potential for the lack of oversight to the infection control prevention and control program. Findings: During an interview on 6/7/23, at 2:34 PM, Infection Preventionist (IP) stated, I am the Infection Preventionist for the whole hospital, both for the Skilled nursing facility and the general acute care part of the hospital. I spend five to ten hours a week in the skilled nursing facility. During an interview on 6/8/23, at 7:42 AM, Registered Nurse (RN) 3 was unable to identify the IP for the SNF. During an interview on 6/8/23, at 7:45 AM, RN 4 was unable to identify the IP for the SNF. During an interview on 6/8/23, the Medical Director and Director of Nursing acknowledged the facility has no full time IP designated for the Skilled Nursing unit. A review of the undated facility document titled, Orders by Department and Patient indicated, Resident 2 was on vancomycin (used to treat infection) for psoas (muscles located…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and document reviews the facility failed to ensure licensed nursing personnel verified the skilled nursing unit residents' meals were appropriate according to their physician's order and matched the resident's meal tray ticket prior to receiving their meal. This failure had the potential to negatively affect the nutrition status of 23 out of 23 residents who have chronic medical conditions such as diabetes (inability to manage blood sugar levels), dysphagia (difficulty swallowing), heart disease, and other conditions by receiving an incorrect therapeutic diet meal, which may further impair medical and nutrition status from weight loss, weight gain, and other complications. (Cross reference F801) Findings: During a test tray observation and interview with Foodservice Worker (FSW) 1, on 6/6/23, at 12 PM, on the skilled nursing unit, FSW 1 was in the hallway delivering meal trays to rooms A14 and A15. FSW 1 stated the normal practice for meal tray delivery was for him to serve the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medical supplies were properly stored when expired blood collection tubes were found in the medication storage room. This deficient practice had the potential to cause unsafe and/or inappropriate use of medical supplies to residents. Findings: During an observation on [DATE], at 1:50 PM, with Registered Nurse (RN) 1, there were eight gray top and one light green top expired blood collection tubes found in a small plastic bin in the medication storage room. During an interview, on [DATE], at 2:14 PM, RN 2 said, the blood collection tubes are used for residents with orders for blood draw. RN 2 read the date on the tubes as [DATE] and stated, All are expired and should be tossed out. The ZSFGH ([NAME] San Francisco General Hospital) Clinical Laboratories Test Directory, under Specimen and Lab Test Procedures, indicated, .Clinical Laboratory: Laboratory Administration Date of Original: [DATE] Collection, Labeling and Delivery of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the failed to implement their infection prevention and control program when the personal protection equipment (PPE, equipment worn to minimize exposure to hazards that cause serious workplace illnesses) cart was in close contact with two linen hampers containing soiled linens. This facility failure has the potential for the spread of infection to residents and staff. Findings: A review of the Physician notes dated 6/6/23, indicated, Resident 1 requires contact isolation for the duration of skilled nursing course due to Extended-Spectrum Beta-Lactamases (ESBL, produced by bacteria's resistant to many of the antibiotics that are use to treat infections). According to the CDC Guidelines for Isolation Precaution, retrieved from https://www.cdc.gov/infectioncontrol/guidelines/isolation/precautions.html, on 8/9/18, .Contact Precautions are intended to prevent transmission of infectious agents, including epidemiologically important microorganisms, which are spread by direct or indirect contact with the patient or the patient ' s…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.