Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 San Francisco Health Care during CMS and state inspections, most recent first.
The facility failed to properly inventory and safeguard residents’ belongings and money, leading to missing items and inaccurate or absent inventory records. One hospice resident arrived with personal items documented by ambulance staff, but the facility’s admission inventory listed no belongings, and her representative later reported missing identification, a cell phone, and a debit card, along with unusual financial transactions and phone use after the resident’s death. The Administrator acknowledged a $1,200 monetary transaction between this resident and a CNA for an airline ticket but did not formally document or broaden the investigation. Another cognitively impaired resident was documented by the hospital as being discharged with $3,600 and jewelry, with instructions to facility admission staff to secure these valuables, yet the social worker later concluded the facility was not responsible when the items were reported missing and the admission staff did not recall the valuables. Additional audits found clothing labeled for another person among one resident’s belongings and a resident with multiple clothing items but no inventory sheet, despite a policy requiring admission inventories and safeguarding of valuables.
The facility failed to report allegations of misappropriation of personal property for two residents to appropriate agencies within the required 24-hour timeframe. One resident’s responsible party notified the Administrator by phone and text about missing items, including a cell phone, driver’s license, and debit card, and the Administrator later acknowledged not reporting the allegation within 24 hours. Another resident reported missing a large sum of money and jewelry, and the SW was informed by the resident’s family, but a review of CDPH electronic data showed no record that this allegation was reported. These actions were inconsistent with the facility’s policy requiring the Administrator or designee to notify appropriate persons or agencies within 24 hours of reported theft or misappropriation.
Two residents’ allegations of missing money and personal property were not thoroughly investigated. One hospice resident arrived with documented belongings, including a cell phone, but the admission inventory listed no items, and her representative later reported missing identification, a debit card, and unusual financial activity involving a CNA and post‑death phone and debit card use; the Administrator acknowledged the unusual monetary transaction but did not suspend the CNA, report the allegation, expand the review to other residents, or formally document the investigation. Another cognitively impaired resident was documented by the hospital as being discharged with cash and jewelry to be secured by admission staff, yet she was considered to have arrived without belongings, and the facility’s conclusion relied heavily on her inconsistent statement about giving valuables to a man not employed there, without contacting the transport company or expanding the investigation to other residents linked to the involved admission staff, despite a written policy outlining broader investigative steps for suspected theft or misappropriation.
Two residents in a facility suffered injuries due to inadequate safety measures and supervision. One resident tripped over a fall mat placed between beds, resulting in a hip fracture, while another resident was injured due to a missing armrest padding on her wheelchair, leading to a head injury. The facility failed to document and address these hazards, as well as update care plans and communicate maintenance needs, highlighting deficiencies in safety protocols.
A resident experienced a 24.4% weight loss over six months due to inadequate nutritional support and monitoring. The facility failed to provide 1:1 meal assistance as ordered, did not offer alternatives during poor intake, and had an inadequate meal monitoring system. The resident's food preferences were not assessed, and there was no documentation of supplement intake, hindering effective nutritional intervention evaluation.
The facility failed to maintain sanitary conditions in the kitchen, with issues including a dripping icemaker spout, an unreplaced water filter, and a greasy kitchen hood. The Maintenance Manager's claim of filter replacement lacked documentation, and the facility had no policies for icemaker maintenance. These deficiencies risked foodborne illnesses.
The facility failed to properly dispose of kitchen refuse as two garbage containers in the kitchen were found without lids. This was confirmed by a Dietary Aide and acknowledged by the Registered Dietitian, who agreed that all garbage containers should have lids. The facility's policy requires food waste to be placed in sealed, leak-proof, non-absorbent, and tightly closed containers. The absence of lids could lead to contamination by flying insects.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices, leading to potential cross-contamination risks. A resident with a feeding tube had an unlabeled syringe, another with a urinary catheter had an uncovered drainage bag, and a third with a central venous catheter had no special precautions. Additionally, a resident with a gastrostomy tube was observed disconnecting his feeding tube without proper precautions, and there was no signage for EBP in his room.
The facility failed to maintain an effective pest control program, as flying insects were observed in a resident's room and during an interview with another resident. Despite having a subcontracted pest control company, the presence of insects indicated a lapse in the program's effectiveness. The facility's policy required the building to be free of insects, which was not achieved.
A facility was found to have a medication error rate of 25.9% due to several issues, including a nurse administering eye drops without consulting the MAR, a resident not receiving a critical cardiac medication due to unavailability, and inadequate documentation of medication issues. These errors involved multiple residents and contributed to the high error rate observed.
A facility failed to cover a resident's urinary catheter drainage bag with a privacy bag, compromising the resident's dignity and privacy. The bag was observed hanging exposed, with a reddish-brown discoloration and was unlabeled and undated. A CNA confirmed the absence of a dignity bag, and an RN acknowledged the need for privacy coverage.
A facility failed to develop a baseline care plan within 48 hours for a resident with heart failure, kidney disease, and dependence on dialysis. The resident missed a dialysis session due to unarranged transportation, and no care plan addressed his dialysis needs or CVC care. Staff interviews revealed the baseline care plan was incomplete, with no specific deadline for completion, potentially leading to inadequate care.
A facility failed to develop a comprehensive care plan for a resident who fell and fractured his hip, leading to the resident not receiving necessary physical and occupational therapy. The resident, who was on non-weight bearing status, was not evaluated by therapists upon readmission, and the facility's records lacked orders for weight-bearing as tolerated and therapy referrals. Miscommunication and lack of documentation resulted in inadequate care and treatment.
A facility failed to develop a coordinated care plan with a Hospice agency for a resident with end-stage dementia. The resident's care plan did not specify Hospice services or communication protocols, leading to potential gaps in care. Interviews revealed that while Hospice plans were in binders, the facility's care plan lacked documentation of Hospice's role. Staff described communication processes, but the facility's policy on collaboration with Hospice was not fully implemented.
A resident who underwent hip surgery was not provided with necessary physical and occupational therapy upon readmission to the facility. Despite hospital discharge instructions for rehabilitation, there were no therapy orders or interdisciplinary team meetings to address the resident's fall and care plan. The facility's failure to adhere to its fall management protocol and lack of communication led to this deficiency.
A resident was discharged from the facility without a documented discharge basis or summary, despite having multiple health issues. The Director of Social Worker confirmed the absence of necessary documentation, which is required by facility policy and the State Operations Manual.
A facility failed to prevent a resident from having unsupervised access to smoking materials, leading to multiple incidents of the resident smoking inside the facility and in non-designated areas. Despite multiple educations and reminders, the resident continued to violate the smoking policy, and staff were inconsistent in monitoring and enforcing the policy.
The facility failed to maintain clean and homelike shower rooms, with observations revealing peeling paint, rust, water damage, and visible stains. A resident expressed dissatisfaction with the cleanliness, and staff confirmed the deteriorating conditions. Despite attempts to address the issues, the shower rooms remained in poor condition.
The facility failed to complete a facility-specific risk assessment to identify areas where Legionella and other waterborne pathogens could grow and spread. Despite having policies for Legionella surveillance, no risk assessment or water-flow diagram was completed. Multiple staff members, including the ADON, Maintenance Manager, previous DON, and CEO, confirmed the lack of a risk assessment and water testing.
The facility failed to ensure comprehensive care plans reflected all care needs for several residents, including accurate hospice provider information, clothing preferences, documented behaviors, and the use of an indwelling urinary catheter. Staff acknowledged these deficiencies during interviews.
The facility failed to ensure that residents' EHRs and physical medical charts accurately reflected their treatment wishes, including CPR decisions. This deficiency was identified for three residents, with discrepancies between POLST forms, EHRs, and physical charts, leading to potential confusion about the residents' code status and treatment preferences.
The facility failed to ensure personal privacy for two residents during showers. One resident was left fully unclothed with the privacy curtain and door open, while another resident's backside was exposed during transport to and from the shower room. Staff interviews confirmed that privacy protocols were not followed.
The facility failed to include a diagnosis of schizophrenia on the PASRR Level I screening for a resident admitted with schizophrenia, epilepsy, and Parkinson's disease. The omission was identified during a review of the resident's records, and staff interviews confirmed the oversight.
A facility failed to meet professional standards when an RN reused a needle to administer an intramuscular injection to a resident, contrary to facility policy and CDC guidelines. The resident had a history of acute pyelonephritis and other medical conditions.
A resident with a feeding tube did not receive appropriate treatment as staff failed to check tube placement before administering water flushes and medications, and used a syringe plunger instead of gravity flow, contrary to facility policy and physician's orders.
The facility failed to maintain a medication error rate below 5%, resulting in a 5.8% error rate. A resident with a history of diabetes, heart failure, and dysphagia received incorrect medications due to RN misreading orders and failing to locate the correct medication. The DON confirmed the expectation for correct medication administration.
A facility failed to ensure all drugs and biologicals were secured and accessible only by licensed personnel. An RN left a medication cart unlocked and out of sight with medications on top, violating facility policy. Interviews with the ADON and DON confirmed the expectation for nurses to lock the cart and keep keys with them at all times.
The facility failed to maintain an effective pest control program, resulting in a cockroach infestation in a resident's room. Despite efforts to address the issue, including deep cleaning and sealing entry points, the presence of food in the room exacerbated the problem, leading to ongoing pest sightings and resident complaints.
Failure to Inventory and Safeguard Residents’ Belongings and Money
Penalty
Summary
The deficiency involves the facility’s failure to properly inventory and safeguard residents’ personal belongings and money, resulting in missing property and inaccurate or absent inventory documentation. For one resident admitted under hospice care, ambulance transport records showed she arrived with a bag of supplies, a cell phone, a wheelchair, and a backpack, while the facility’s admission inventory form documented “No Belongings upon arrival” and noted that donated clothes were provided. The resident’s responsible party later reported missing items including a cell phone, driver’s license, and debit card, and described abnormal financial activity and long-distance calls from the resident’s phone and withdrawals from her debit card after the resident’s death. The responsible party stated she had shared this information with the Administrator and requested help in investigating and retrieving the missing items, but reported that the facility had not taken responsibility for safeguarding the resident’s belongings. The Administrator acknowledged awareness of the responsible party’s concerns and confirmed that the resident had transferred $1,200 to a CNA to purchase an airline ticket to Zimbabwe, which he characterized as a highly unusual interaction between a resident and staff member. He stated that he determined the money was refunded when the resident was unable to take the trip and took no further action because there was nothing in the facility’s handbook or policy specifically prohibiting this type of transaction. The Administrator did not comment when presented with ambulance documentation indicating the resident arrived with belongings that were not reflected on the admission inventory, and he stated he did not expand his review to other residents under the CNA’s care and did not formally document the allegations or his investigation beyond some emails. For another resident with a BIMs score indicating severe cognitive impairment, the hospital discharge record documented that she was to be discharged with $3,600 in U.S. currency, a yellow necklace and bracelet, and two pendants, and that hospital staff had discussed these valuables with facility admission staff, who reportedly would document and secure them for safekeeping. The social worker reported that the resident’s family later raised concerns about missing money and jewelry and that, based on the resident arriving without belongings, she concluded the facility was not responsible. She stated she was aware of the hospital documentation and had interviewed the admission staff, who did not recall the conversation or valuables, and that the resident reported giving her money and jewelry to a Vietnamese man, although no such staff member worked at the facility at that time. Additional issues were identified during an inventory audit: one resident’s belongings included a housedress labeled with another woman’s name and room number, and another resident had multiple clothing items in his room but no inventory sheet in either the electronic or physical chart. These findings occurred despite a facility policy stating that residents have the right to be free from theft or misappropriation of personal property and that resident belongings are to be inventoried upon admission and safeguarded from easy public access.
Failure to Timely Report Allegations of Misappropriation of Resident Property
Penalty
Summary
The facility failed to report allegations of misappropriation of personal property for two residents to the appropriate agencies within 24 hours, as required by its policy. Resident 1’s responsible party reported missing items, including a cell phone, driver’s license, and debit card, and provided evidence of having texted the Administrator about these concerns on March 17, 2026. In an interview, the Administrator acknowledged being aware of the responsible party’s concerns through phone calls and text messages and agreed that March 17, 2026, sounded like the date he was first made aware of the allegations. When asked if he reported the allegation within 24 hours of learning about it, the Administrator stated that he did not. A second allegation involved Resident 2, who reported missing approximately $3,000 and some jewelry. The Complainant stated that Resident 2 made this allegation, and the SW reported being informed of the missing money and jewelry by Resident 2’s family member on March 17, 2026. A review of CDPH electronic data for facility-reported incidents between March 17 and April 21 showed no evidence that the facility reported Resident 2’s allegation to CDPH. The facility’s policy on investigating incidents of theft and/or misappropriation of resident property, revised April 2017, states that the Administrator or designee will notify appropriate persons or agencies within 24 hours of such incidents, but this was not done for either resident’s allegation.
Failure to Investigate Alleged Misappropriation of Resident Property
Penalty
Summary
The deficiency involves the facility’s failure to investigate and respond appropriately to allegations of misappropriation of personal property for two residents. For the first resident, who was admitted under hospice for comfort-focused treatment, ambulance transport documentation showed she arrived with a bag of supplies, a cell phone, a wheelchair, and a backpack, while the facility’s admission inventory documented no belongings and indicated she was given donated clothes. The resident’s responsible party reported to the Administrator that the resident’s cell phone, driver’s license, and debit card were missing, and also reported abnormal financial activity, including the resident withdrawing $1,200 to give to a CNA to purchase an airline ticket to Zimbabwe, long-distance calls made from the resident’s cell phone after her death, and withdrawals from her debit card after death. The responsible party stated she shared all this information with the Administrator and requested help in investigating and retrieving the missing items, but the facility had not taken responsibility for safeguarding the resident’s belongings. During interview, the Administrator acknowledged awareness of the responsible party’s concerns and confirmed he looked into the issue of the resident transferring money to a CNA for an airline ticket, which he recognized as a highly unusual interaction between staff and resident. He stated he determined the money was refunded when the resident did not take the trip and took no further action because there was nothing in the facility’s handbook or policy specifically prohibiting this type of interaction. The Administrator did not comment when presented with ambulance documentation showing the resident arrived with belongings that were not reflected on the admission inventory. He also stated he did not suspend the CNA, did not report the allegation to appropriate agencies, did not expand the investigation to other residents under the CNA’s care, and did not formally document the allegations or his investigation beyond some emails, despite facility policy requiring investigation of incidents of theft or misappropriation. For the second resident, who had a BIMs score of 5/15 indicating severe memory and thinking problems, the hospital discharge record documented that she was to be discharged with $3,600 in U.S. currency, a yellow necklace and bracelet, and two pendants, and that the hospital social worker had discussed these valuables with facility admission staff, who agreed to document and secure them. The facility social worker reported she became aware of missing money and jewelry when informed by the resident’s family member and concluded the facility was not responsible because the resident allegedly arrived without belongings. She interviewed the admission staff, who did not recall the phone conversation or discussion of valuables, and relied heavily on the resident’s statement, translated by the ombudsman, that she gave her money and jewelry to a Vietnamese man on arrival, despite the facility having no Vietnamese male staff at that time and the resident’s documented severe cognitive impairment. There was no evidence the facility contacted the transport company to verify what items accompanied the resident, no documented follow-up when the resident arrived without the valuables the hospital had reported, and no expansion of the investigation to review other residents’ belongings associated with the admission staff involved, contrary to the facility’s written policy on investigating theft and misappropriation.
Failure to Prevent Accidents and Maintain Safe Environment
Penalty
Summary
The facility failed to maintain a safe environment and provide adequate supervision to prevent accidents for two residents. Resident 25 experienced a fall due to a fall mat placed between his bed and his roommate's bed, obstructing safe passage. This resulted in Resident 25 tripping, falling, and sustaining a right hip fracture that required surgical repair. Despite being at high risk for falls, as indicated by his care plan and assessments, there was no documentation of an interdisciplinary team meeting to assess the cause of the fall or update his care plan. Additionally, there was no order for weight-bearing as tolerated or a physical therapy referral upon his readmission to the facility. Resident 73 suffered an injury due to a missing armrest padding on her wheelchair, which was not reported or replaced. This led to her sliding her right arm on the metal part of the wheelchair, hitting her head on the window, and sustaining a large hematoma on her forehead. Despite the incident, there was no documentation of a fall in her clinical record, and the missing padding was not reported to maintenance for repair or replacement. The facility's maintenance log did not contain any reports regarding the broken wheelchair, indicating a lack of communication and follow-up on safety hazards. The facility's policies and procedures for fall prevention and maintenance were not adequately followed. The interdisciplinary team and staff failed to identify and address environmental hazards and did not document or communicate necessary interventions to prevent further accidents. The lack of proper assessment, documentation, and maintenance contributed to the injuries sustained by both residents, highlighting deficiencies in the facility's safety protocols and supervision.
Inadequate Nutritional Support and Monitoring for Resident
Penalty
Summary
The facility failed to provide adequate nutritional support and monitoring for Resident 3, who experienced a significant weight loss of 24.4% over six months. The resident, who had memory problems and sometimes understood others, was not provided with the 1:1 assistance during meals as ordered by the physician. Observations revealed that staff only set up the meal tray and did not assist the resident with eating, despite the resident's poor appetite and usual intake of only 20% of meals. Additionally, the facility did not offer alternatives or other interventions during poor meal intake, as required by their policy. The facility's meal monitoring system was inadequate, as it could not distinguish between 0-25% intake, which is critical for determining when to intervene. The Director of Nursing acknowledged this shortcoming and the importance of intervening even if a resident was on comfort measures. Furthermore, the facility did not document the percentage of nutritional supplements consumed by the resident, making it difficult to evaluate the effectiveness of nutritional interventions. Despite requests for this information, it was not provided by the time of the survey exit. The facility also failed to assess Resident 3's food preferences, which could have informed better meal planning and interventions. There was no evidence that the facility reached out to the resident's responsible parties or family members to assist with this assessment. The resident's records showed that she ate 51-100% of her food for only 24% of meals, with no analysis of whether higher intakes were related to specific food preferences. For 47.1% of meals, the resident ate between 0-25%, with no assessment of whether these low intakes were related to controllable factors such as menu items or meal timing.
Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which was observed during an inspection. Specifically, one of the icemaker's dispensing spouts was dripping water, and the icemaker had two water filters, one of which was not replaced. The Maintenance Manager claimed both filters were changed in December 2024, but there was no documentation to support this, as only one filter was purchased according to facility records. Additionally, the bottom of the kitchen hood was covered in a greasy film, with at least 30 spots where the substance was lumped into droplets, indicating a lack of regular cleaning. During interviews, it was revealed that the facility did not have policies regarding the replacement of icemaker water filters or maintenance to address drips. The facility's existing policy on hoods, filters, and vents required cleaning every two weeks to be free of dust and grease, which was not adhered to. These deficiencies in food storage, preparation, and service practices had the potential to put residents at risk for foodborne illnesses.
Improper Disposal of Kitchen Refuse
Penalty
Summary
The facility failed to properly dispose of kitchen refuse, as observed during an inspection. Two garbage containers in the kitchen were found without lids, which was confirmed by a Dietary Aide during the initial observation. This deficiency was further corroborated during an interview with the Registered Dietitian, who acknowledged that all garbage containers in the kitchen should have lids. The facility's policy, dated 2023, requires that all food waste be placed in sealed, leak-proof, non-absorbent, and tightly closed containers. The absence of lids on the garbage containers had the potential to result in flying insects contaminating food items, food preparation areas, and utensils.
Failure to Implement Enhanced Barrier Precautions for Residents with Indwelling Devices
Penalty
Summary
The facility failed to implement its infection control program by not adhering to Enhanced Barrier Precautions (EBP) for residents with indwelling medical devices. Resident 62, who was admitted with multiple diagnoses including stroke and diabetes, was observed with an unlabeled and undated irrigation syringe hanging on the feeding pump pole. The registered nurse confirmed that the syringe should have been labeled and dated, and acknowledged that Resident 62 was not on any precautions. The care plan for Resident 62 did not address infection control precautions. Resident 25, who was readmitted with a fracture and neuromuscular dysfunction of the bladder, was observed with an uncovered and unlabeled urinary catheter drainage bag. The certified nursing assistant acknowledged the lack of labeling and covering, and the registered nurse stated that contact precautions were followed during dressing changes. However, the care plan did not address infection control precautions for the suprapubic catheter. Resident 204, admitted with heart failure and kidney disease, had a central venous catheter for dialysis. The registered nurse supervisor stated that no special precautions were followed for this resident, and the care plan did not address infection control precautions. Additionally, Resident 256, who had a gastrostomy tube, was observed disconnecting his feeding tube without proper precautions, and there was no signage for EBP in his room. The infection preventionist acknowledged the lack of signage and PPE setup for residents with catheters and tube feedings.
Failure in Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by the presence of flying insects within the premises. During an observation and interview in a resident's room, a family member pointed out a flying insect resting on the wall. Additionally, another flying insect was observed in the presence of the Kitchen Supervisor during an interview with another resident. The Maintenance Manager confirmed that the facility had subcontracted a pest control company as part of their pest management program. However, the presence of insects indicated a lapse in the effectiveness of this program. The facility's pest control policy, last revised in May 2008, stated that the building should be kept free of insects and rodents, which was not upheld in this instance.
High Medication Error Rate Due to Documentation and Availability Issues
Penalty
Summary
The facility was found to have a medication error rate of 25.9%, with seven medication errors occurring out of 27 opportunities during medication administration for four residents. One incident involved Resident 17, where a registered nurse (RN) crushed and mixed four oral medications with applesauce for administration, which was in accordance with the pharmacy protocol. However, the report does not specify if the medications were meant to be administered together or if there was an error in the dosage or timing. Another incident involved Resident 256, who has a gastrostomy tube and requires medications to be crushed and administered via the tube. The RN prepared six tablets, crushed them, and mixed them with water for administration through the gastrostomy tube. The RN noted that it takes time to dilute the tablets and sometimes requires additional effort, but the report does not indicate any specific error in this process. For Resident 63, the RN administered eye drops without consulting the medication administration record (MAR) due to a system outage, resulting in a deviation from the prescribed order of two drops in the left eye every four hours. Additionally, Resident 72 did not receive a critical cardiac medication, Vyndaquel, due to unavailability, and there was a lack of documentation regarding the medication's absence and the physician's notification. This oversight in documentation and medication availability contributed to the high medication error rate observed during the survey.
Failure to Cover Urinary Catheter Drainage Bag
Penalty
Summary
The facility failed to ensure the urinary catheter drainage bag of Resident 25 was covered with a privacy bag, which is necessary to maintain the resident's dignity and privacy. During an initial tour, the drainage bag was observed hanging on the side rail of the bed, partially filled and exposed, with a reddish-brown discoloration on the front of the bag and in the attached tube. The bag was also unlabeled and undated. A Certified Nursing Assistant (CNA) confirmed the absence of a dignity bag and acknowledged the lack of labeling and dating. A Registered Nurse (RN) later stated that the drainage bag should have been covered for privacy, indicating a lapse in maintaining the resident's right to a dignified existence and self-determination.
Failure to Develop Timely Baseline Care Plan for Resident
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident, identified as Resident 204, who was admitted with multiple diagnoses including heart failure, acquired absence of the left leg below the knee, kidney disease, and dependence on renal dialysis. Upon review, it was found that Resident 204's care plan did not address his dialysis needs or the care of his central venous catheter (CVC), which is crucial for his dialysis treatment. Interviews with the resident and staff revealed that the resident missed a dialysis session due to a lack of arranged transportation, and no special precautions were being followed for his CVC care. Further investigation showed that the baseline care plan for Resident 204 had not been completed, contrary to the facility's practice of completing it within three days of admission. The Registered Nurse Supervisor confirmed that there was no dialysis care plan in place and that the nursing section of the care plan was incomplete. The supervisor also mentioned that there was no specific deadline for completing the baseline care plan, indicating a lack of urgency in addressing the resident's immediate care needs. This oversight had the potential to result in inadequate care and services for the resident.
Failure to Develop Comprehensive Care Plan for Resident with Hip Fracture
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident who fell and fractured his hip, resulting in the resident not receiving necessary care and treatment such as physical and occupational therapy. The resident, who had a history of falls and was readmitted to the facility after hip surgery, was not evaluated by a physical therapist or occupational therapist upon his return. The resident reported being on non-weight bearing status and had not been out of bed since readmission. The facility's records did not include an order for weight-bearing as tolerated (WBAT) or a referral for physical therapy, and there was no documentation of an interdisciplinary team meeting to discuss the fall and update the care plan. The resident's care plan was outdated and did not reflect the recent fall and fracture. The facility's staff, including the Registered Nurse Supervisor and the Physical Therapist, were unaware of the resident's recent fall and fracture until several days after the incident. The lack of communication and documentation led to miscommunication between the staff and the resident regarding aftercare and weight-bearing activities. The resident's post-fall assessment and hospital discharge summary indicated the need for skilled nursing facility rehabilitation, but these were not incorporated into the resident's care plan, resulting in inadequate care and treatment.
Lack of Coordinated Care Plan with Hospice Agency
Penalty
Summary
The facility failed to develop a coordinated plan of care and communication process with the Hospice agency for a resident admitted under Hospice Services. The resident, who was admitted with an end-stage diagnosis of dementia, did not have a care plan that addressed the specific services Hospice would provide or when the facility should notify Hospice. This lack of coordination and documentation was identified during a review of the resident's records and interviews with facility staff, including the MDS Coordinator and the Director of Social Services. Interviews with facility staff revealed that while Hospice residents have binders containing the Hospice agency's plan of care, there was no mention of Hospice in the facility's care plan for the resident. The Director of Social Services acknowledged the absence of documentation regarding Hospice's role and the coordination process between the facility and Hospice. Additionally, the Director of Nursing and a Registered Nurse described the communication process with Hospice, but the facility's policy on collaboration with Hospice providers was not being fully implemented, as evidenced by the lack of documented collaboration efforts and care plan updates.
Failure to Provide Rehabilitative Services Post-Surgery
Penalty
Summary
The facility failed to provide specialized rehabilitative services for a resident who required physical and occupational therapy following a right hip hemiarthroplasty. The resident, who had been readmitted to the facility after a fall that resulted in a hip fracture, was not evaluated by a physical therapist or occupational therapist upon return. Despite the resident's discharge summary from the hospital indicating the need for rehabilitation services, there was no documentation of orders for weight-bearing as tolerated or a referral for physical therapy. The resident, who had a history of falls, reported not being out of bed since readmission and stated that the therapy team was unaware of his recent fall and subsequent surgery. The facility's registered nurse supervisor confirmed the absence of documentation for therapy orders and noted that no interdisciplinary team meeting had occurred to address the resident's fall and update his care plan. The facility's policy on falls required assessment and intervention within 24 to 48 hours of a fall, which was not adhered to in this case. The physical therapist confirmed being unaware of the resident's recent fall and fracture until several days after the readmission. The facility's failure to follow its protocol for fall assessment and management, as well as the lack of communication and documentation regarding the resident's need for rehabilitative services, contributed to the deficiency in care provided to the resident.
Inadequate Discharge Documentation for a Resident
Penalty
Summary
The facility failed to ensure an appropriate discharge for a resident, identified as Resident 1, due to the absence of a documented discharge basis and discharge summary. Resident 1 was admitted with multiple health issues, including cachexia, severe protein-calorie malnutrition, iron deficiency, and unsteadiness on feet. Despite a doctor's order indicating a discharge to home with home health services, there was no evidence in the medical record of the basis for the discharge or a discharge summary from the doctor. Interviews with the Director of Social Worker (DoSW) confirmed the lack of documentation regarding the discharge. The DoSW acknowledged that there should have been a discharge note and a documented reason for the discharge, but these were missing from Resident 1's medical record. The facility's policy on discharging residents, as well as the State Operations Manual, require that the basis for discharge be documented, which was not adhered to in this case.
Failure to Prevent Unsupervised Access to Smoking Materials
Penalty
Summary
The facility failed to implement measures to prevent a resident from having unsupervised access to smoking materials, including lighters, cigarettes, and marijuana. This deficiency was observed when the resident was found in possession of smoking materials in the hallway and later smoking outside without supervision. Despite multiple educations and reminders to both the resident and a visitor, the non-compliance continued, leading to the resident smoking inside the facility and in non-designated areas, posing a significant safety risk. The resident had a history of tobacco use, senile degeneration of the brain, delirium, and muscle wasting. The resident's care plan required supervision while smoking and mandated that smoking materials be stored by the facility. However, the resident repeatedly violated the smoking policy, and the facility failed to enforce the necessary supervision and storage of smoking materials. The resident's smoking assessments were not updated regularly, and staff were inconsistent in monitoring and enforcing the smoking policy. Interviews with staff revealed a lack of clarity and consistency in the enforcement of the smoking policy. Some staff members were unaware of the resident's smoking restrictions, and others admitted to leaving the resident unsupervised while smoking. The facility's failure to reassess the resident's smoking safety and enforce the smoking policy led to multiple incidents of the resident smoking inside the facility and possessing smoking materials, creating a hazardous environment for all residents and staff.
Facility Fails to Maintain Clean and Homelike Shower Rooms
Penalty
Summary
The facility failed to maintain 4 of 4 resident shower rooms in a clean and homelike condition. Observations revealed that the shower rooms had peeling paint, rust, water damage, and visible stains. The third-floor shower room had worn tiles, rust stains, and a musty smell. The second-floor women's shower room had a hole in the wall, peeling paint, rusted fixtures, and visible water damage. The second-floor men's shower room had peeling paint, dirty tiles, and water stains. These conditions were confirmed by multiple staff members, including CNAs and the Maintenance Manager, who acknowledged the deteriorating state of the shower rooms and the challenges in maintaining them. Resident #79, who was cognitively intact and required moderate assistance with showering, expressed dissatisfaction with the cleanliness of the shower rooms, describing them as filthy and unclean. The resident mentioned that the shower rooms had feces in one of the stalls and appeared run down. Despite the resident's concerns, they had not complained to the facility, believing that the staff should be aware of the conditions without being told. Interviews with facility staff, including CNAs, the Maintenance Manager, the VP, the ADON/Infection Preventionist, and the DON, revealed that the shower rooms had been in poor condition for an extended period. The Maintenance Manager had attempted various methods to address the peeling paint and rust issues, but these efforts were unsuccessful. The VP and CEO acknowledged the repeated attempts to repaint the shower rooms, which only provided temporary improvements. Housekeeping staff confirmed that the shower rooms were cleaned daily, but the persistent issues with peeling paint and rust made it difficult to maintain a clean and homelike environment.
Failure to Conduct Legionella Risk Assessment
Penalty
Summary
The facility failed to complete a facility-specific risk assessment to identify areas where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water system. Despite having policies in place for Legionella surveillance and a water management program, the facility did not have a completed risk assessment or a water-flow diagram indicating areas at risk. This oversight was confirmed through multiple interviews with the Assistant Director of Nursing (ADON)/Infection Preventionist (IP), the Maintenance Manager, the previous Director of Nursing (DON), and the Chief Operating Officer (CEO), all of whom acknowledged that no risk assessment had been conducted. Additionally, the facility had not conducted any testing of standing water for Legionella detection, relying only on annual pH testing. The Maintenance Manager admitted to not knowing the layout of the water flow in the facility. The lack of a risk assessment and water testing was further corroborated by the ADON, the previous DON, and the CEO, who all stated that the facility staff were unaware of the requirement to complete a risk assessment of the water system. No previous positive cases of Legionella were reported, but the absence of a risk assessment and water testing posed a potential risk to all residents in the facility.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to ensure comprehensive care plans reflected all care needs for several residents. Resident #400's care plan did not accurately reflect the current hospice provider and contact information, despite the resident receiving hospice services from a different provider than listed. This discrepancy was confirmed through observations and interviews with facility staff, including the RN/MDS coordinator, the Administrator, and the DON, all of whom acknowledged the care plan should have been updated to reflect the correct hospice provider information. Resident #15's care plan did not reflect the resident's preference to wear a hospital gown instead of personal clothing. Despite multiple observations of the resident in a hospital gown and interviews with CNAs and RNs who confirmed the resident's consistent refusal to wear personal clothing, the care plan was not updated to reflect this preference. The DON and other staff members acknowledged that the care plan should have included the resident's clothing preference and refusals. Resident #86's care plan failed to identify and address the resident's documented behaviors, such as flooding the bathroom, taking excessively long showers, and being combative with staff. Despite multiple progress notes documenting these behaviors and interviews with various staff members who were aware of these issues, the care plan did not include specific interventions to manage these behaviors. The Administrator, ADON, and other staff members confirmed that these behaviors should have been included in the care plan. Resident #49's care plan did not address the use of an indwelling urinary catheter or the specific care needs associated with it. Despite the resident having an active order for an indwelling urinary catheter and observations confirming its use, the care plan only mentioned a toileting deficit and incontinence. Interviews with the ADON, DON, and CEO confirmed that the care plan should have included details on the care of the indwelling urinary catheter.
Inconsistent Documentation of Advance Directives
Penalty
Summary
The facility failed to ensure that each resident's electronic health record (EHR) and physical medical chart accurately and consistently reflected their treatment wishes, including their decision regarding cardiopulmonary resuscitation (CPR). This deficiency was identified for three residents out of thirteen sampled. The discrepancies involved mismatched information between the residents' Physician Orders for Life-Sustaining Treatment (POLST) forms, EHRs, and physical charts, leading to potential confusion about the residents' code status and treatment preferences. For Resident #39, the facility's records showed conflicting information regarding the resident's code status. The resident's POLST form dated a specific date indicated a Do Not Attempt Resuscitation (DNR) order, while another POLST form dated earlier indicated a full code status. The resident's EHR and physical chart contained inconsistent information, and staff interviews revealed that the discrepancies could result in mistakes, potentially leading to the resident's wishes not being followed. Resident #12's records also showed inconsistencies. The resident's POLST form prepared on one date indicated a DNR order with comfort-focused treatment, while another POLST form prepared later indicated selective treatment with a trial period of artificial nutrition. The EHR and physical chart did not consistently reflect these orders, and the responsible party confirmed that the resident should be listed as DNR. Similarly, Resident #92's records contained conflicting information, with the POLST form indicating an attempt resuscitation order, while the EHR and physical chart listed a DNR order. Staff interviews confirmed that these discrepancies were not always identified and corrected promptly, leading to potential risks of not following the residents' treatment wishes.
Failure to Ensure Resident Privacy During Showers
Penalty
Summary
The facility failed to ensure personal privacy for two residents during the provision of showers. Resident #301, who was admitted with diagnoses including cerebral infarction and essential hypertension, was observed sitting fully unclothed in a shower chair with the privacy curtain and door open. This allowed several people to see the resident as they passed by the shower room. The CNA attending to Resident #301 acknowledged the oversight but failed to completely close the privacy curtain, leaving the resident exposed to passers-by in the hallway. Resident #11, who had diagnoses including senile degeneration of the brain and peripheral vascular disease, was transported to and from the shower room in a shower chair with their backside exposed. Despite being covered with a sheet and bath blanket, gaps in the coverage left the resident's buttocks visible during transport. The CNA responsible for Resident #11 speculated that the resident's movements might have caused the blanket to shift, exposing the resident's backside. Interviews with the facility's staff, including the ADON and DON, confirmed that the expectation was for CNAs to ensure residents' privacy by closing the privacy curtain and door during showers and ensuring residents were fully covered during transport. The observations and interviews revealed that these protocols were not followed, resulting in a failure to maintain the residents' privacy during personal care activities.
Failure to Include Schizophrenia Diagnosis on PASRR Level I Screening
Penalty
Summary
The facility failed to include a diagnosis of schizophrenia on the Preadmission Screening and Resident Review (PASRR) Level I for Resident #26. The resident was admitted to the facility with a diagnosis of schizophrenia, epilepsy, and Parkinson's disease. However, the PASRR Level I screening document dated 07/03/2018 did not indicate the diagnosis of schizophrenia, and Section V-Mental Illness was left blank. This omission was identified during a review of the resident's records, including the Minimum Data Set (MDS) and care plan, which clearly documented the diagnosis of schizophrenia. Interviews with facility staff revealed that the PASRR Level I screenings were completed by the facility staff in 2018, and the Assistant Director of Nursing (ADON) or Registered Nurse (RN)-MDS was responsible for completing these screenings. The Administrator and ADON confirmed that the diagnosis of schizophrenia was not indicated on the PASRR Level I screening for Resident #26. The Director of Nursing (DON) and Chief Executive Officer (CEO) emphasized the importance of accurate and thorough PASRR Level I evaluations, noting that the facility's nurses used to complete these screenings, but now they are completed by hospital staff. The failure to include the diagnosis of schizophrenia on the PASRR Level I screening led to the deficiency identified by the surveyors.
Improper Injection Technique
Penalty
Summary
The facility failed to ensure services provided met professional standards of quality for a resident who required an intramuscular injection. Specifically, a Registered Nurse (RN) prepared the injection by reconstituting the medication and then used the same needle to administer the medication to the resident. The RN also stuck the resident with the needle, removed it prior to administering the medication, and then re-stuck the resident with the same needle to administer the medication. This action was against the facility's policy and CDC guidelines, which state that a needle should never be reused either from one patient to another or to withdraw medication from a vial. The resident involved had a medical history that included acute pyelonephritis, diabetes mellitus, atherosclerotic heart disease, chronic systolic heart failure, and benign prostatic hyperplasia. The resident was cognitively intact and had an active diagnosis of a urinary tract infection. The incident was observed during the administration of an antibiotic injection. Both the Assistant Director of Nursing and the Director of Nursing confirmed that the needle should not have been reused, as it could be unclean and dull, increasing the risk of infection and causing pain during the injection.
Failure to Follow Feeding Tube Protocols
Penalty
Summary
The facility failed to ensure that a resident with a feeding tube received appropriate treatment and services to prevent potential complications. Specifically, the staff did not check the placement of the resident's feeding tube before administering water flushes and medications, as required by the physician's order and the facility's policy. Additionally, the staff administered the water flushes and medications by using the plunger of a syringe to push them into the feeding tube, instead of administering them by gravity flow as directed by the facility's policy. The resident involved had a medical history that included dysphagia following a nontraumatic intracranial hemorrhage and required attention to a gastrostomy. The resident's comprehensive care plan indicated the need for tube feedings due to dysphagia, and the physician's orders specified checking the feeding tube placement before each use and flushing the tube with water before and after medication administration. However, during an observation, a registered nurse failed to check the tube placement and used a syringe with a plunger to push water flushes and medications into the feeding tube. Interviews with the registered nurse, the Director of Nursing, and the Assistant Director of Nursing confirmed that the proper procedure was not followed. The registered nurse admitted to not checking the tube placement and using the syringe plunger to ensure the medications entered the tube. Both the Director of Nursing and the Assistant Director of Nursing stated that the correct procedure involved auscultating the feeding tube before administration and using gravity flow to administer water and medications. The failure to follow these procedures could result in complications such as gastroesophageal reflux disease, ulcers, or pressure in the stomach.
Medication Error Rate Exceeds 5 Percent
Penalty
Summary
The facility failed to ensure the medication error rate was not greater than 5 percent, resulting in a medication error rate of 5.8%. This deficiency affected one resident who was observed during medication administration. The resident, who had a medical history including type two diabetes mellitus, congestive heart failure, and dysphagia, was admitted to the facility on 11/08/2023. The resident had active orders for aspirin 81 mg chewable tablet and oyster shell calcium with vitamin D 250 mg-3.125 mcg, both to be administered once daily at 9:00 AM. During an observation, RN #3 administered an 81 mg enteric coated aspirin instead of the prescribed chewable aspirin and gave oyster shell calcium 500 mg instead of the prescribed oyster shell calcium with vitamin D 250 mg-3.125 mcg. RN #3 acknowledged the errors during an interview, stating she misread the order and failed to locate the correct medication. The Director of Nursing confirmed that nursing staff are expected to administer medications correctly using the five rights of administration.
Failure to Secure Medication Cart
Penalty
Summary
The facility failed to ensure all drugs and biologicals were secured and accessible only by licensed personnel. Specifically, a Registered Nurse (RN) left the medication cart unlocked and not within their line of sight, with medications lying on top of the cart unsecured. The incident occurred when the RN parked the medication cart outside a resident's room to administer medications, prepared an intramuscular injection, and entered the room without locking the cart. The RN left a vial of antibiotic medication and a bottle of lidocaine on top of the cart and stepped behind the privacy curtain, leaving the cart unattended and out of sight. The RN then walked to the medication room to retrieve insulin, leaving the cart unlocked and unattended for an extended period. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the facility's policy required nurses to lock the medication cart and keep the keys with them at all times. The policy also stated that no medications should be left on top of the cart if the nurse could not see the cart. Both the ADON and DON reiterated that the expectation was for nurses to lock the medication cart when walking away and to ensure no medications or sharp items were left unsecured on top of the cart. The RN admitted to forgetting to lock the cart and leaving the medications on top of it, which was a clear violation of the facility's policy and professional principles for medication storage and security.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of cockroaches in Resident #76's room. The resident, who was cognitively intact with a BIMS score of 14, reported seeing bugs in their room frequently. Observations confirmed the presence of multiple cockroaches on the walls, floor, and furniture in the resident's room, including near food items left out in the open. The facility's pest control policy, revised in May 2008, mandates an ongoing pest control program, but the implementation was found lacking as evidenced by the recurring pest issue in the resident's room. Interviews with staff, including a CNA, RN, Director of Maintenance, ADON, and DON, revealed that the facility was aware of the cockroach problem. The CNA mentioned seeing cockroaches frequently, especially at night, and the RN had reported seeing a cockroach at the nurses' station months ago. The Director of Maintenance acknowledged the issue and described efforts to move residents, seal entry points, and conduct deep cleaning, but these measures were not consistently effective. The ADON and DON both expressed concerns about the pest problem and the need for regular pest control services and thorough cleaning to prevent recurrence. A review of the pest control vendor's monthly report from December 2023 indicated pest activity but did not specify the rooms treated. The facility's staff admitted that the presence of food in residents' rooms, like in Resident #76's case, exacerbated the problem. Despite efforts to address the issue, including deep cleaning and sealing entry points, the facility's pest control measures were insufficient to eliminate the cockroach infestation, leading to ongoing pest sightings and resident complaints.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 945 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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) |
|---|---|---|---|---|
| Hayes Convalescent Hospital | 0 mi | ★★★★★ | 2 | 0 |
| California Pacific Medical Ctr- Davies Campus Hosp | 0.7 mi | ★★★★★ | 11 | 0 |
| Central Gardens Post Acute | 0.7 mi | ★★★★★ | 0 | 0 |
| Pacific Heights Transitional Care Center | 0.8 mi | ★★★★★ | 6 | 0 |
| Sequoias San Francisco Convalescent Hospital | 0.9 mi | ★★★★★ | 13 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.