Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at San Francisco Towers during CMS and state inspections, most recent first.
Scoops were found stored directly inside jasmine and brown rice bins, with the scoops in contact with the rice. One bin had a scoop holder under the lid, but the scoop was not in it, and the other bin had no scoop holder at all. The KS confirmed the setup, and the RD stated scoops should not touch the rice because contaminants could be transferred to the food. Facility policy and the FDA Food Code both addressed proper in-use utensil storage and prevention of contamination.
Advance Directive Documentation Not Accurate: The facility failed to properly inform and document a resident’s right to formulate an advance directive. A resident’s AAD form was reviewed and found to contain another resident’s name, and both an LVN and staff member acknowledged the EHR and hard chart forms were not correctly under the resident’s name. Staff stated the resident refused an advance directive and signed the form, but the documentation was inaccurate.
A resident with COPD exacerbation, acute kidney failure, and CKD stage 3 was transferred to the hospital after becoming lethargic with abnormal renal values and low K+. The MD spoke with the resident’s wife, who agreed to the transfer and said she did not want to hold the bed, but surveyors found no written transfer/discharge notice in the record. Staff stated the notice was given verbally, even though the facility policy called for written bed-hold and transfer information.
A resident’s MDS was coded incorrectly for hospice status. The resident had diagnoses including Alzheimer’s disease, dementia, type 2 DM, and major depressive disorder, and the record showed hospice services were started, but the LVN and DON both confirmed the MDS did not reflect the resident was on hospice.
Pain Medication Orders Not Followed as Written: Two residents received Tramadol in ways that did not match the documented order indications. One resident was given PRN Tramadol for mild pain even though the order was for moderate to severe pain, and another resident received scheduled Tramadol during most shifts for mild or absent pain despite the order stating moderate to severe pain. The DON and an LVN confirmed the mismatches between the MAR documentation, pain scores, and the medication orders.
The facility failed to meet food safety standards, with issues including wet-stacked baking pans, a broken blender, and undated food items. Kitchen staff were observed handling clean plates unsafely and not following proper hand hygiene protocols.
A facility failed to ensure a resident was free from unnecessary psychotropic medication due to inadequate monitoring of specific target behaviors for Lorazepam use. The resident, with diagnoses including mesothelioma and anxiety disorder, received Lorazepam without documented specific behavior monitoring. Staff interviews confirmed the lack of specificity in clinical records, and the facility's policy did not address monitoring guidelines.
A facility failed to properly store and label an unopened Basaglar KwikPen Insulin for a resident, leaving it in a medication cart instead of a refrigerator as required by policy. Interviews with staff revealed a misunderstanding of storage procedures, potentially affecting the medication's potency and safety.
Scoops Stored Directly in Rice Bins
Penalty
Summary
Food was stored in a manner that did not follow professional food service standards when scoops were found inside the jasmine rice and brown rice bins with the scoops in direct contact with the rice. During a concurrent observation and interview in the kitchen dry storage area, the bin containing jasmine rice had a scoop holder under its lid, but the scoop was not in the holder and was placed directly inside the bin in contact with the rice. The brown rice bin did not have a scoop holder, and its scoop was also placed directly in contact with the rice. Kitchen Staff 1 confirmed the observation and stated that the brown rice bin did not have a holder for the scoop and that the bin should be changed. During an interview, the RD stated scoops should not be touching the rice and explained that staff hands could be contaminated and contaminants could get into the scoop and add bacteria or other contaminants to the rice. Review of the facility policy titled Production, Purchasing, Storage stated that all food and supplies used in food preparation shall be stored to prevent contamination, that opened foods must be stored in NSF-approved containers with tight-fitting lids, and that scoops may be stored in bins on a scoop holder with the food level at least one inch below the handle of the scoop. The FDA Food Code 2022 was also reviewed and stated that in-use utensils in food that is not TCS may be stored with handles above the top of the food within closed containers such as bins of sugar, flour, or cinnamon.
Advance Directive Documentation Not Accurate
Penalty
Summary
The facility failed to inform and provide written information to residents about the right to formulate an advance directive, and it failed to maintain accurate documentation showing that this information had been offered and explained to Resident 10. Review of Resident 10’s Acknowledgement for Advance Directive form dated 11/12/25 showed that a different resident’s name was written on the signed form. During interview and record review on 12/2/25, LVN 1 acknowledged that the scanned Acknowledgement for Advance Directive form in the EHR was not under Resident 10’s name. Staff 1 reviewed the hard chart form and stated that Resident 10 refused to have an advance directive and signed the form, but also acknowledged that the form contained a different resident’s name. Staff 1 stated, “They could have given the wrong code or different from the patient's wishes.” The facility policy stated that upon admission, social services staff or designee will inform and provide written information to the resident concerning the right to formulate an advance directive, and an Acknowledgement for Advance Directive form will be completed, signed, and placed in the resident’s medical record.
Missing Written Transfer Notice and Bed-Hold Information
Penalty
Summary
The facility failed to provide a written notice of transfer that included the reason for transfer, the bed-hold policy, and other discharge rights as soon as practicably possible for one of three sampled residents, Resident 25. The report states that Resident 25 was admitted in August 2025 with COPD exacerbation, acute kidney failure, and chronic kidney disease stage 3, and on 09/09/25 the resident was seen by the MD, was responsive but complaining of pain, then became lethargic with abnormal renal values and low potassium. The MD spoke with the resident’s wife, who agreed to transfer the resident to the hospital and stated she did not want to hold the bed. During review of the resident’s scanned documents, surveyors found no written discharge notice for the September 2025 hospital transfer. The progress note documented that the wife agreed to the transfer and did not want to hold the bed, but the facility’s staff stated that verbal notice was sufficient in emergency cases and that the notice was verbal because the wife was at bedside. The facility policy stated that before an emergency transfer or discharge, the facility would provide written information specifying the duration of the state bed-hold policy, the reserve bed payment policy, and the facility’s bed-hold and notice requirements.
Inaccurate MDS Hospice Coding
Penalty
Summary
The facility failed to ensure an accurate assessment for one resident when the MDS hospice status was coded incorrectly. Resident 1 was admitted on 9/16/25 with diagnoses including Alzheimer's disease, dementia, type 2 diabetes mellitus, and major depressive disorder, and the medical record titled Hospice Certification and Plan of Care showed the resident was admitted for hospice services on 10/7/25. During interview and record review, the LVN stated the MDS was completed for a significant change in status related to the resident's admission to hospice care and acknowledged that the hospice coding was incorrect, stating it should have been coded as yes rather than no. The DON also reviewed the MDS and stated that it did not reflect that the resident was on hospice.
Pain Medication Orders Not Followed as Written
Penalty
Summary
The facility failed to ensure that pain medication orders were accurately documented for two residents, resulting in Tramadol being administered in a manner that did not match the documented indications. For one resident, the MAR showed Tramadol 25 mg ordered as needed for moderate to severe pain, yet the medication was given on two occasions when the recorded pain levels were 3 and 2, which the facility’s pain scale defined as mild pain. The DON confirmed those administrations were for mild pain and did not align with the order’s indication. For the second resident, the MAR showed Tramadol 25 mg ordered every 8 hours for moderate to severe pain, but the medication was administered during most shifts in November for pain levels documented as mild or absent. An LVN stated the medication had been treated as a routine medication and confirmed it should be held if the resident was not experiencing moderate to severe pain, while also acknowledging there was no order to hold it based on pain level. The DON confirmed the order was written as a routine pain medication and should not have included an indication for moderate to severe pain, and also confirmed the medication should not have been given for mild pain as it had been during most administrations.
Food Safety and Hygiene Deficiencies
Penalty
Summary
The facility failed to adhere to food safety requirements, as observed during a survey. Cleaned baking pans and metal trays were found stacked while still moist and wet, which is against professional standards that require air-drying before storage to prevent microorganism growth. Additionally, a blender with a broken and jagged rim was found on a shelf, posing a potential risk for contamination and injury. These observations were made in the presence of the Director of Dining Services, the Corporate Chef, and the Executive Sous Chef, who acknowledged the issues but did not take immediate corrective action. Further deficiencies were noted in the storage of food items. Opened and undated containers of apricot jelly, mustard, and muffin butter were found in various storage areas, including the refrigerator and walk-in refrigerator. These items were not labeled with dates, violating the facility's policy that requires all opened food items to be labeled and dated to ensure safety and prevent contamination. The Executive Sous Chef identified these items but did not immediately address the lack of proper labeling and storage. The survey also highlighted unsanitary practices by kitchen staff. One staff member was observed carrying clean plates in an unsanitary manner, hugging them against his chest, which could lead to contamination. Another staff member failed to perform proper hand hygiene, using the same gloves to handle a garbage bin and then attempting to continue food service tasks without washing hands. These actions were observed by the Corporate Chef, who intervened but did not ensure immediate compliance with hand hygiene protocols.
Lack of Specific Behavior Monitoring for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medication due to the lack of specific target behavior monitoring for the use of Lorazepam. The resident, who was admitted with diagnoses including mesothelioma of pleura, major depressive disorder, and anxiety disorder, had an order for Lorazepam to be administered as needed for anxiety manifested by anxious behavior with shortness of breath. However, the clinical records did not specify the target behavior symptoms to be monitored, leading to the potential for unnecessary medication administration. The Medication Administration Record indicated that Lorazepam was administered to the resident on multiple occasions, but the monitoring for specific target behaviors was not documented. Interviews with facility staff, including a CNA and an RN, revealed that the resident's anxious behavior was described as a desire to go home and complaints of pain, but the RN acknowledged that the clinical records were too broad and lacked specificity. The facility's policy on psychotherapeutic medication use did not include guidelines for monitoring specific target behaviors, contributing to the deficiency.
Improper Storage and Labeling of Insulin
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications, specifically involving an unopened and undated Basaglar KwikPen Insulin for a resident. During an observation, it was found that the insulin pen was stored in the medication cart, which is not in accordance with the facility's policy that requires insulin products to be stored in the refrigerator until opened. The Medication Administration Record (MAR) indicated that the insulin was last administered to the resident on a previous date, yet the pen remained unopened and undated in the cart. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) revealed a lack of understanding and adherence to proper storage procedures. The LVN mentioned that the resident often refused insulin, which is why the pen was unopened and stored in the cart. The DON confirmed the pen was sealed and questioned the storage requirements, despite the facility's policy clearly stating that insulin should be refrigerated until opened. This oversight had the potential to compromise the medication's potency and safety for the resident.
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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) |
|---|---|---|---|---|
| City View Post Acute | 0 mi | ★★★★★ | 3 | 0 |
| Victorian Post Acute | 0.6 mi | ★★★★★ | 0 | 0 |
| Sequoias San Francisco Convalescent Hospital | 0.6 mi | ★★★★★ | 13 | 0 |
| Central Gardens Post Acute | 0.7 mi | ★★★★★ | 0 | 0 |
| Chinese Hospital D/p Snf | 0.7 mi | ★★★★★ | 19 | 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 June 2026) and official state health department websites.