Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lawton Skilled Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Missing PASRR Level II Evaluation for Resident with Schizophrenia: A resident with schizophrenia and DM2 had a PASRR Level I screen that was positive for suspected MI and required a Level II MH evaluation, but the record contained no Level II PASRR documentation. During review, the DOA acknowledged the required evaluation had not been completed, and the SW stated PASRR was handled by admissions.
Insufficient Bedroom Square Footage in Multiple Occupancy Rooms: The facility failed to provide the required 80 square feet per resident in 17 of 28 bedrooms. Review of the waiver request showed multiple 2-bed rooms at 78.75 square feet per resident and multiple 3-bed rooms at 75 square feet per resident. During observations and resident interviews, occupants reported no concerns about quality of life, quality of care, or safety related to the room space.
The facility failed to maintain sanitary conditions in the kitchen, as observed during a survey. An undated and sticky Thousand Island dressing container was found in the refrigerator, contrary to the facility's policy requiring all foods to be labeled and dated. Additionally, a drawer with kitchen utensils contained bread crumbs, indicating a lack of adherence to the facility's cleaning schedule. The Dietary Manager and Registered Dietitian confirmed these deficiencies and took immediate action to address them.
A facility failed to properly document the administration of controlled medications for three residents, leading to unaccounted doses. Norco, tramadol, and oxycodone were signed out but not recorded on the MAR, as confirmed by the DON and ADON. Staff cited system errors and forgetfulness for the lack of documentation. Additionally, an oxycodone tablet was destroyed without a witness's signature, violating facility policy.
The facility did not meet the required square footage per resident in 17 out of 28 rooms, with space ranging from 75 to 78.75 square feet per resident instead of the mandated 80 square feet. Despite this, residents expressed no concerns about their quality of life or safety related to room space during interviews.
A survey identified a 7.69% medication error rate in an LTC facility. Errors included improper administration of eye drops and metformin to a resident. RN1 did not follow procedures for eye drop instillation, and metformin was given before a meal, contrary to guidelines. These actions deviated from the facility's policies and medication instructions.
An LTC facility failed to maintain a sanitary environment by leaving an unlabeled basin with personal care items on an overbed table between two residents' beds. The items, including toothpaste and toothbrushes, were not stored properly, posing a risk of cross-contamination. A CNA acknowledged the oversight, and the Infection Preventionist confirmed the breach of protocol, highlighting a lapse in adherence to the facility's infection prevention and control policies.
Missing PASRR Level II Evaluation for Resident with Schizophrenia
Penalty
Summary
The facility failed to obtain the required PASRR Level II evaluation for a resident with schizophrenia. Resident 47 was admitted with diagnoses including type 2 diabetes and schizophrenia, and the medical record showed an active diagnosis of schizophrenia in the quarterly MDS and physician progress notes. The resident’s PASRR Level I Screening Document, DHCS Form 6170, dated 12/21/22, identified the resident as Positive for suspected MI and indicated that a Level II Mental Health Evaluation Referral was required. During interview and record review, the Director of Admissions reviewed Resident 47’s PASRR and found no Level II evaluation in the record. The medical record did not contain documentation showing that the required Level II PASRR evaluation had been completed, despite the Level I screening indicating that it was needed. The Director of Admissions acknowledged that the Level II evaluation was required and had not been completed. The Social Worker stated that PASRR was not part of their role and that admissions handled it.
Insufficient Bedroom Square Footage in Multiple Occupancy Rooms
Penalty
Summary
The facility failed to provide the required square footage per resident in multiple bedrooms for 17 of 28 rooms, including Rooms 101, 102, 103, 104, 105, 106, 107, 108, 111, 115, 126, 127, 131, 132, 134, 136, and 139. Review of the facility’s waiver request dated 4/3/26 showed that these bedrooms did not meet the 80 square feet per resident requirement for multiple-occupancy rooms, with room sizes listed at either 78.75 square feet per resident in 2-bed rooms or 75 square feet per resident in 3-bed rooms. During random observations and interviews with residents occupying these rooms, the residents expressed no concerns about quality of life, quality of care, or safety related to the room space.
Unsanitary Food Storage and Kitchen Utensil Maintenance
Penalty
Summary
The facility failed to store foods and maintain kitchen utensils in a sanitary manner, as observed during a survey. An opened container of Thousand Island dressing was found undated on the top shelf of the produce refrigerator, with dried and sticky dressing spill on the lid and neck of the container. The Dietary Manager (DM) and Registered Dietitian (RD) confirmed the absence of a date label and discarded the container. The facility's policy requires all foods to be covered, labeled, and dated, which was not adhered to in this instance. Additionally, during the same kitchen tour, a drawer containing kitchen utensils was found to have bread crumbs on its floor. The DM identified the crumbs as originating from a bread toaster placed on top of the serving station. The DM instructed the cook to wash all the utensils and clean the drawer. The facility's policy mandates maintaining kitchen sanitation through a comprehensive cleaning schedule, which was not followed, leading to unsanitary conditions.
Controlled Medication Documentation and Disposal Deficiencies
Penalty
Summary
The facility failed to ensure that controlled medications were fully accounted for, as evidenced by discrepancies in the documentation of medication administration for three residents. For Resident 12, Norco was signed out of the Controlled Drug Record (CDR) but not documented on the Medication Administration Record (MAR) on six occasions. Similarly, for Resident 19, tramadol was signed out but not documented on the MAR on four occasions. Resident 202's record showed that oxycodone was signed out but not documented on the MAR, leaving two tablets unaccounted for. These discrepancies were confirmed by the Director of Nursing (DON) and Assistant Director of Nursing (ADON) during interviews and record reviews. The facility's policy requires that controlled medications be documented on the MAR to ensure proper administration and reassessment. However, interviews with nursing staff revealed that documentation was not completed due to system errors or forgetfulness. RN1 admitted to not documenting the administration of medications for Residents 12 and 19, citing system issues and forgetfulness. LVN1 also acknowledged forgetting to document the administration of pain medication for Resident 12. The lack of documentation prevented the computer system from triggering necessary reassessments, increasing the risk of medication errors. Additionally, the facility failed to adhere to its policy regarding the destruction of controlled medications. For Resident 204, an oxycodone tablet was wasted without a witness's signature, contrary to the facility's policy requiring two sets of initials for the disposal of controlled substances. The DON acknowledged this oversight and signed the document in the surveyor's presence, confirming that the waste should have been double-signed at the time of disposal.
Non-Compliance with Room Size Requirements
Penalty
Summary
The facility failed to provide the required square footage per resident in multiple bedrooms for 17 out of 28 rooms. Specifically, rooms 101, 102, 103, 104, 105, 106, 107, 108, 111, 115, 126, 127, 131, 132, 134, 136, and 139 did not meet the requirement of 80 square feet per resident. The square footage per resident in these rooms ranged from 75 to 78.75 square feet, which is below the mandated standard. This deficiency was identified through observation, interviews, and record reviews during a survey. Despite the non-compliance with space requirements, residents occupying these rooms expressed no concerns about their quality of life, quality of care, or safety related to the room space during interviews conducted as part of the survey.
Medication Administration Errors Identified
Penalty
Summary
The facility was found to have a medication error rate of 7.69% during a survey, with two errors occurring out of 26 opportunities. The first error involved the improper administration of brimonidine ophthalmic solution to a resident with glaucoma. Registered Nurse 1 (RN1) did not follow the facility's policy and procedures for eye drop instillation, as he failed to tilt the resident's head back and did not pull the lower eyelid down to create a conjunctival sac for the drops. Instead, the drops were placed directly onto the eye, which was not in accordance with the prescribed method. The second error involved the administration of metformin, a medication for diabetes, to the same resident. RN1 administered the metformin tablet before the resident's meal, contrary to the instructions in the medication's package insert, which specifies that metformin should be taken with meals to reduce the risk of an upset stomach. The resident's dinner was served 33 minutes after the medication was given, which was confirmed by RN1 and the Director of Nursing. This deviation from the recommended administration time could potentially affect the medication's efficacy and the resident's comfort.
Inadequate Storage of Personal Care Items
Penalty
Summary
The facility failed to maintain a safe and sanitary environment by leaving an unlabeled basin containing personal care items on an overbed table between the beds of two residents. During observations, the basin was found to contain a tube of toothpaste, an exposed toothbrush, a packaged toothbrush, and a deodorant. These items were left unattended and unlabeled, which could lead to cross-contamination and the spread of infection. A Certified Nursing Assistant (CNA) acknowledged the presence of the items and admitted that they were not supposed to be there, indicating a lapse in following proper storage procedures. The facility's Infection Preventionist confirmed that staff are not supposed to leave personal care items in such a manner, as it poses a risk of confusion and potential misuse by other residents. The facility's policy on infection prevention and control emphasizes the importance of educating staff and ensuring adherence to proper techniques and procedures. However, in this instance, the staff failed to follow the established protocol, which requires personal care items to be stored in the resident's drawer after use, thereby compromising the infection prevention and control program.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near San Francisco
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Laguna Honda Hospital & Rehabilitation Ctr D/p Snf | 0.8 mi | ★★★★★ | 5 | 0 |
| The Avenues Transitional Care Center | 1.3 mi | ★★★★★ | 1 | 0 |
| Hayes Convalescent Hospital | 1.6 mi | ★★★★★ | 2 | 0 |
| San Francisco Health Care | 1.6 mi | ★★★★★ | 5 | 0 |
| California Pacific Medical Ctr- Davies Campus Hosp | 1.8 mi | ★★★★★ | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.