Jewish Home & Rehab Center D/p Snf
JEWISH HOME & REHAB CENTER D/P SNF in SAN FRANCISCO, CA — inspection on October 3, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
meeting note indicated The family and the resident.also report that she (Resident 1) is unable to stand up due to foot ulcer and the resident reports that her left leg pain and pain on (her) coccyx due to pressure ulcer prevent her from standing up and spending more than five minutes in the w/c (wheelchair).During a concurrent interview and record review on 9/30/2025 at 12:57 PM with the Nursing Supervisor (NSP) 1, Resident 1's Care Plan Report- Risk for impaired skin integrity. initiated on 11/26/2024 revised on 4/18/2025 was reviewed. NSP 1 verified, Resident 1's Coccyx pressure injury was reopened on 4/18/2025 and stated This wound (pressure injury) was on and off.
When asked if there were any updates to the interventions for the focus/goals, NSP 1 stated, No.
There were no updated interventions for this reported wound (pressure injury), but the old interventions were resumed.During a concurrent interview and record review on 9/30/2025 at 1:10 PM with the Director of Long Term Care/Quality Assurance (DLTC/QA), Resident 1's Care Plan Report- Risk for impaired skin integrity. initiated on 11/26/2024 revised on 4/18/2025 was reviewed. DLTC/QA verified interventions were resumed from 11/26/24, with no additional revisions made for the pressure injury on Resident 1's Coccyx. DLTC/QA agreed interventions should have been revised. A review of Resident 1's care plan titled SKIN ISSUES initiated on 04/18/2025 last revised on 8/17/2025 AND Resident 1's care plan titled Care Plan Report- Risk for impaired skin integrity. initiated on 11/26/2024 revised on 4/18/2025, DLTC/QA and NSP 1 agreed the Risk and Skin Issue care plans are two separate documents and have two different focus and goal outcomes. DLTC/QA agreed the goals identified in the Risk care plan focused on addressing risk factors with interventions to reduce risk of future ongoing pressure injuries, while the Skin Issue care plan and interventions focus on healing/treating the identified skin issues. DLTC/QA agreed that interventions for risk care plan should have been updated at least with every new inhouse pressure injury and more frequently throughout resident's stay.During a review of Resident 1's IDT meeting note(s) throughout her stay, dated 12/8/2024, 5/30/2025, 6/10/2025, 7/29/2025, 7/31/2025, 8/17/2025, and 8/19/2025, no indication of updated treatment orders, review of impact of current wound treatment orders, or collaboration with Resident 1 and/or family for new interventions to reduce risk for continued impaired skin integrity were discussed.
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