Zuckerberg San Francisco General Hosp & Trauma SNF

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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)]. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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)

Inspectors wroteBased 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)

Inspectors wroteBased 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.

Inspectors wroteBased 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)

Inspectors wroteBased 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.

Inspectors wroteBased 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.