Above 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 Post Acute during CMS and state inspections, most recent first.
A facility failed to follow disinfection protocols for reusable medical equipment, specifically blood pressure cuffs, for three residents. An RN was observed taking blood pressures without disinfecting the cuff between uses, contrary to the facility's policy. The RN was unclear about the disinfection policy, and a review confirmed that equipment should be disinfected between residents.
A resident with multiple diagnoses, including a fractured femur and Parkinson's disease, indicated abdominal pain but did not receive a documented pain assessment as required by the facility's policy. Despite being cognitively intact, the resident's pain care plan was not followed, leading to a deficiency in meeting the resident's nursing needs.
A resident with COPD was administered oxygen at 3.5 LPM, contrary to the doctor's order of 1-2 LPM as needed. Despite having adequate oxygen saturation levels, the facility staff did not adhere to the prescribed oxygen flow, and the discrepancy was acknowledged by the RN and DON. The facility's policies on care plans and oxygen administration were not followed.
A resident with limited English proficiency experienced a lack of interpreter services on a Sunday, leading to communication barriers during a health concern. The facility relied on Chinese-speaking staff or a translated book, but these resources were unavailable, and the RN was unaware of the communication binder's location. The BOM, who assists with translation, was not available on weekends, and there was no clear protocol for interpreter services during these times.
A resident was prescribed multiple psychotropic medications without evidence of non-pharmacological interventions being attempted first. There was no targeted behavior identified for Lorazepam, nor specific behavioral monitoring for its use. Additionally, no specific indication for Mirtazapine was documented, despite the resident's diagnoses of depression and PTSD.
The facility failed to provide a 7-Day Bed-hold written notice to the representative of a resident who was transferred to a hospital due to a change of condition. This oversight resulted in the resident being discharged from the facility seven days after the emergency transfer, without proper notification to the representative.
Failure to Disinfect Reusable Medical Equipment
Penalty
Summary
The facility failed to adhere to disinfection protocols for reusable medical equipment, specifically blood pressure cuffs, for three residents. During an observation, a registered nurse (RN1) was seen taking the blood pressure of three residents consecutively without disinfecting the blood pressure cuff between uses. This action was contrary to the facility's policy and procedure, which mandates that reusable items be cleaned and disinfected between residents. In an interview, RN1 was unclear about the facility's disinfection policy and could not provide an explanation for the oversight. A review of the facility's policy confirmed that durable medical equipment, including blood pressure cuffs, should be disinfected between uses to prevent cross-contamination and infection spread among residents.
Failure to Implement Pain Care Plan for Resident
Penalty
Summary
The facility failed to implement a pain care plan for one resident, identified as Resident 38, who was admitted with multiple diagnoses including a displaced intertrochanteric fracture of the left femur, Parkinson's disease, and hyperlipidemia. Despite being cognitively intact, Resident 38 indicated abdominal pain during an observation and interview. However, there was no evidence of a pain assessment conducted by the nursing staff, as required by the resident's care plan and the facility's policy. The deficiency was further highlighted during interviews and record reviews with the nursing staff, including a Registered Nurse and a Licensed Vocational Nurse, who confirmed the absence of documented pain assessments for Resident 38 until the night shift on a specific date. The facility's policy mandates pain assessments every shift and as needed, using a standardized instrument appropriate to the resident's cognitive level. The lack of adherence to this policy resulted in the potential for not meeting the resident's nursing needs and goals for achieving the highest practicable well-being.
Failure to Follow Oxygen Administration Orders
Penalty
Summary
The facility failed to meet professional standards of quality by not adhering to a doctor's order regarding oxygen administration for a resident. The resident, who was admitted with conditions including spinal stenosis, acute respiratory failure with hypoxia, COPD, and hypertension, was observed receiving oxygen at 3.5 liters per minute via nasal cannula, despite the doctor's order specifying 1-2 liters per minute as needed to maintain oxygen saturation levels above 90%. During an observation, a registered nurse acknowledged the discrepancy and adjusted the oxygen flow to 3 liters per minute, but this still did not comply with the prescribed order. Further interviews and record reviews revealed that the resident's oxygen saturation levels were 95% on room air and 96% at 3 liters per minute, indicating that the higher oxygen flow was unnecessary. The Director of Nursing and a Licensed Vocational Nurse were unable to provide a rationale for the increased oxygen flow, and the Director of Nursing acknowledged that the oxygen level administered was too high for a resident with COPD. The facility's policies on care plans and oxygen administration were not followed, as the physician's order was not verified or adhered to, leading to this deficiency.
Failure to Provide Adequate Interpreter Services for Non-English Speaking Resident
Penalty
Summary
The facility failed to provide adequate communication services for a resident who primarily spoke Cantonese, Mandarin, and Chinese, and had limited proficiency in English. This deficiency was observed when the resident experienced abdominal discomfort on a Sunday, and there were no interpreter services available. The resident's son confirmed the language barrier, and the Registered Nurse (RN) on duty admitted to relying on Chinese-speaking staff or a translated book for communication. However, on the day in question, the Chinese-speaking staff was off, and the RN was unaware of the location of the communication binder. Further interviews revealed that the Business Office Manager (BOM), who usually assists with translation, was not available on Sundays, and there was no clear protocol for using interpreter services during weekends or nights. The Director of Nursing (DON) acknowledged the importance of communication in the resident's native language and suggested alternative methods, such as using another Chinese-speaking CNA or Google interpreter services. The facility's policy on accommodating residents' needs was not effectively implemented, as evidenced by the RN's unfamiliarity with the communication binder and the resident's dissatisfaction with the new binder format.
Failure to Implement Non-Pharmacological Interventions Before Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications. The resident was prescribed Aripiprazole, Bupropion, Lorazepam, and Mirtazapine without evidence of non-pharmacological interventions being attempted first. Additionally, there was no targeted behavior identified for the use of Lorazepam, nor was there specific behavioral monitoring in place for its administration. Furthermore, there was no specific indication documented for the use of Mirtazapine for this resident. The resident, who was admitted with diagnoses including low back pain, depression, and PTSD, was found to be cognitively moderately impaired. Despite these conditions, the facility did not provide evidence of efforts to determine the underlying causes of the resident's behavioral symptoms or to utilize appropriate non-pharmacological interventions. The facility's policy on psychotropic medications emphasizes the importance of using these medications appropriately and in compliance with state and federal regulations, which was not adhered to in this case.
Failure to Provide 7-Day Bed-Hold Notice
Penalty
Summary
The facility failed to provide a 7-Day Bed-hold written notice to the representative of a resident who was transferred to a hospital due to a change of condition. The resident was admitted to the facility and later had an emergency transfer to the hospital. The facility did not provide the required written notice at the time of transfer or within 24 hours, as confirmed by the Executive Assistant and the Director of Nursing during interviews and record reviews. This oversight resulted in the resident being discharged from the facility seven days after the emergency transfer. The facility's policy and procedure titled 'Bed-Holds and Returns' mandates that residents or their representatives be given written information about bed-hold policies at least twice: once in advance of any transfer and again at the time of transfer or within 24 hours in case of an emergency. The policy also requires documentation of multiple attempts to notify the representative if initial attempts are unsuccessful. In this case, the facility did not adhere to its policy, leading to a facility-initiated discharge of the resident without proper notification to the representative.
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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) |
|---|---|---|---|---|
| Jewish Home & Rehab Center D/p Snf | 1.7 mi | ★★★★★ | 16 | 0 |
| Ahmc Seton Medical Center | 2.2 mi | ★★★★★ | 34 | 0 |
| Laguna Honda Hospital & Rehabilitation Ctr D/p Snf | 2.6 mi | ★★★★★ | 5 | 0 |
| Golden Heights Healthcare | 2.9 mi | ★★★★★ | 0 | 0 |
| Golden Pavilion Healthcare | 2.9 mi | ★★★★★ | 2 | 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.