Inspection Reports for
San Francisco Health Care and Rehab Inc.
1477 Grove St, San Francisco, CA 94117, United States, CA, 94117
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
9.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
138% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 3
Date: Feb 28, 2025
Visit Reason
The inspection was conducted to evaluate medication administration practices and ensure medication error rates are not 5 percent or greater.
Findings
The facility had a medication error rate of 25.9%, with seven medication errors occurring out of 27 opportunities during medication administration for four residents. Errors included crushing medications improperly, unavailable medications, and documentation issues.
Deficiencies (3)
Medication error rate of 25.9% with seven errors out of 27 medication administration opportunities.
Medication not available for Resident 72 leading to missed doses of cardiac medication.
Medication administration without use of medication administration record (MAR) due to electronic system downtime.
Report Facts
Medication error rate: 25.9
Medication errors: 7
Medication administration opportunities: 27
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 3 | Registered Nurse | Observed preparing and administering medications; involved in medication errors and interviews |
Inspection Report
Routine
Deficiencies: 12
Date: Feb 28, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, infection control, medication administration, nutrition, rehabilitation services, and facility maintenance.
Findings
The facility was found deficient in multiple areas including failure to ensure privacy for urinary catheter drainage bags, incomplete and delayed care plans, inadequate coordination with hospice services, environmental hazards contributing to resident falls and injuries, insufficient nutritional support and monitoring, medication administration errors, unsanitary kitchen conditions, improper refuse disposal, lack of specialized rehabilitative services, failure to implement infection control precautions for residents with indwelling devices, and ineffective pest control program.
Deficiencies (12)
Urinary catheter drainage bag was uncovered, unlabeled, and undated, lacking privacy cover for Resident 25.
Baseline care plan was not developed within 48 hours of admission for Resident 204.
Failed to develop a complete care plan for Resident 25 who fell and fractured his hip, resulting in lack of necessary therapy and miscommunication.
Failed to coordinate care plan and communication with Hospice agency for Resident 61.
Environmental hazards and lack of maintenance contributed to falls and injuries for Residents 25 and 73.
Failed to provide adequate nutritional support and monitoring for Resident 3, resulting in 24.4% weight loss.
Medication error rate of 25.9% observed during medication administration for four residents.
Failed to maintain sanitary conditions in kitchen including dripping icemaker spout, unreplaced water filter, and greasy kitchen hood.
Two garbage containers in kitchen lacked lids, risking contamination.
Failed to provide specialized rehabilitative services (PT/OT) for Resident 25 post hip surgery.
Failed to implement infection prevention and control program; enhanced barrier precautions not followed for residents with indwelling devices and no signage or PPE carts present.
Facility failed to maintain effective pest control program; flying insects observed in resident rooms and kitchen.
Report Facts
Medication error rate: 25.9
Weight loss percentage: 24.4
Number of residents sampled: 22
Number of residents with indwelling catheters: 6
Number of medication administration opportunities observed: 27
Number of medication errors observed: 7
Number of residents with medication errors: 4
Number of residents affected by environmental hazards: 2
Number of residents affected by infection control failures: 4
Number of garbage containers without lids: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Stated urinary catheter drainage bag needs privacy cover for Resident 25. |
| CNA 3 | Certified Nursing Assistant | Acknowledged uncovered, undated, unlabeled urinary catheter drainage bag for Resident 25. |
| RNS | Registered Nurse Supervisor | Reviewed Resident 25's orders and care plan; unable to find PT referral or fracture care plan. |
| PT | Physical Therapist | Unaware of Resident 25's recent fall and fracture until 2/26/25. |
| CNA 1 | Certified Nursing Assistant | Reported Resident 73 slid arm on wheelchair metal armrest due to missing padding. |
| RD | Registered Dietitian | Unable to confirm documentation of supplement intake percentages for Resident 3. |
| RN 3 | Registered Nurse | Observed medication administration errors for Residents 17, 256, 63, and 72. |
| IP | Infection Preventionist | Acknowledged lack of signage and PPE carts for residents with indwelling devices. |
| MM | Maintenance Manager | Stated water filters for icemaker changed in December 2024 but no documentation for second filter. |
| DON | Director of Nursing | Acknowledged inadequacies in meal intake monitoring and intervention. |
| NHA | Nursing Home Administrator | Unable to find documentation of broken wheelchair report for Resident 73. |
Inspection Report
Deficiencies: 1
Date: Aug 1, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulations regarding resident discharge procedures, specifically to determine if the facility ensured appropriate discharge documentation and basis for discharge for Resident 1.
Findings
The facility failed to ensure appropriate discharge documentation and basis for discharge for Resident 1, as there was no discharge summary or documented reason for discharge in the medical record, which could result in an inappropriate discharge disrupting care.
Deficiencies (1)
Failure to ensure appropriate discharge documentation and basis for discharge for Resident 1.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Social Worker | Interviewed regarding lack of discharge documentation for Resident 1 |
Inspection Report
Deficiencies: 12
Date: Jan 22, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including resident privacy, environmental conditions, care planning, medication administration, infection control, safety, and other aspects of facility operations.
Findings
The facility was found deficient in multiple areas including failure to ensure resident privacy during showers, unclean and poorly maintained shower rooms, incomplete PASARR screenings, incomplete and inaccurate care plans, improper medication administration techniques, inconsistent advance directive documentation, unsafe smoking practices leading to immediate jeopardy, improper feeding tube care, medication errors, unsecured medication carts, lack of Legionella risk assessment, and ineffective pest control program.
Deficiencies (12)
Failure to ensure residents were provided personal privacy during showers, with observations of residents exposed to passers-by and staff not fully closing privacy curtains or doors.
Failure to maintain 4 of 4 resident shower rooms in a clean and homelike condition, with peeling paint, rust, water damage, and presence of soiled items.
Failure to include a diagnosis of major mental illness on a PASARR Level I screening for Resident #26 with schizophrenia.
Failure to develop and implement comprehensive care plans that meet all resident needs, including hospice services, clothing preferences, behavioral needs, and indwelling urinary catheter care.
Failure to provide services meeting professional standards for intramuscular injection administration, including reuse of the same needle for medication preparation and administration.
Failure to ensure residents' electronic health records, physical medical charts, and visual indicators consistently reflected accurate and current advance directives and code status orders.
Failure to prevent Resident #76 from having unsupervised access to smoking materials despite multiple education and restrictions, resulting in immediate jeopardy to resident health and safety.
Failure to ensure feeding tube placement was checked prior to administration of water flushes and medications, and failure to administer medications by gravity flow as per facility policy.
Failure to ensure medication error rate was not greater than 5%, with errors including administration of wrong aspirin and calcium medications.
Failure to ensure all drugs and biologicals were secured and accessible only by licensed personnel, with medication cart left unlocked and medications unsecured.
Failure to complete a facility-specific risk assessment for Legionella and other waterborne pathogens in the facility's water system.
Failure to maintain an effective pest control program, with presence of cockroaches in Resident #76's room and other areas despite ongoing pest control efforts.
Report Facts
Medication errors: 2
Medication error rate: 5.8
Smoking frequency: 4
Smoking assessment date: May 30, 2023
Discharge notice date: Jan 21, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Named in medication administration errors and medication cart security finding |
| ADON #6 | Assistant Director of Nursing | Provided statements on medication administration, smoking safety, and feeding tube care |
| DON | Director of Nursing | Provided statements on medication administration, advance directives, smoking safety, and pest control |
| RN #27 | Registered Nurse | Provided statements on advance directives and smoking assessments |
| Administrator | Provided statements on smoking policy enforcement and advance directives | |
| Maintenance Manager | Provided statements on shower room maintenance and pest control | |
| SSD | Social Services Director | Provided statements and documentation on smoking policy education and advance directives |
| Visitor #28 | Named in smoking policy noncompliance with Resident #76 |
Inspection Report
Deficiencies: 1
Date: Jun 1, 2023
Visit Reason
The inspection was conducted to assess compliance with medication storage regulations, specifically ensuring drugs and biologicals are stored in locked compartments according to professional standards.
Findings
The facility failed to keep valproic acid medication in a locked compartment for one of three residents reviewed, posing a potential risk for drug diversion. Observations showed medication left unlocked and unsupervised outside the Director of Nursing's office.
Deficiencies (1)
Failure to keep drugs (valproic acid) in a locked compartment as required.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in observation and interview regarding medication storage deficiency |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Apr 10, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to develop and implement a comprehensive, person-centered care plan for Resident A, and inadequate treatment and monitoring of Resident A's Out-on-Pass (OOP) activities.
Complaint Details
The complaint investigation focused on Resident A's care plan deficiencies and inadequate monitoring and supervision of Out-on-Pass activities, which resulted in injury and safety risks. The investigation found substantiated failures in care planning, treatment, monitoring, and documentation.
Findings
The facility failed to develop a comprehensive care plan for Resident A addressing activities of daily living and Out-on-Pass orders. Resident A's OOP orders were unclear, not monitored, and not followed by staff, resulting in a skin tear injury. The facility also failed to hold interdisciplinary team meetings to discuss Resident A's OOP and did not maintain accurate OOP logs for multiple residents.
Deficiencies (3)
Failure to develop and implement a complete, person-centered care plan for Resident A addressing activities of daily living and Out-on-Pass.
Failure to provide appropriate treatment and care according to orders and resident preferences, including unclear and unmonitored Out-on-Pass orders for Resident A.
Failure to ensure nursing home area is free from accident hazards and provide adequate supervision to prevent accidents, including inadequate monitoring of Out-on-Pass for Resident A and five other residents.
Report Facts
Out-on-Pass occurrences: 2
OOP log missing entries: 30
Falls: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Resident A | Resident | Subject of care plan and Out-on-Pass deficiencies. |
| Assistant Director of Nursing | ADON | Acknowledged care plan and OOP monitoring deficiencies; involved in interviews and record reviews. |
| Director of Nursing | DON | Acknowledged unclear OOP orders and lack of monitoring; involved in interviews and record reviews. |
| Social Services Director | SSD | Responsible for organizing IDT meetings; acknowledged no IDT meeting after OOP order. |
| Certified Nursing Assistant 1 | CNA | Provided information on shower schedules and care preferences of Resident A. |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: May 18, 2021
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements and to identify deficiencies in care, medication management, infection control, food safety, and medication storage at San Francisco Health Care.
Findings
The facility was found deficient in multiple areas including incomplete care plans lacking measurable objectives, medication errors with a 20.69% error rate, unsafe medication storage practices, improper food handling with unlabeled and improperly stored food items, and failures in infection prevention and control such as inadequate disinfection of equipment and presence of staff food in resident areas.
Deficiencies (6)
Failed to develop a comprehensive care plan with measurable objectives and timetables for one resident regarding use of Seroquel.
Did not provide correct Vitamin D dose to Resident 36 according to physician's orders.
Medication error rate of 20.69% with six errors out of 29 opportunities during medication pass.
Failed to ensure safe storage of medications; insulin stored with rectal suppositories and nystatin powder left unsecured.
Food safety violations including unlabeled milk and yogurt left at room temperature beyond safe time limits.
Failed to implement infection prevention and control program; glucometer not disinfected between uses, inappropriate disinfectant wipes used, unlabeled suction canisters and catheters, and staff food found in resident rooms.
Report Facts
Medication error rate: 20.69
Medication errors: 6
Medication opportunities: 29
Residents sampled: 21
Medication dose: 75
Medication dose: 500
Medication dose: 17
Medication dose: 1
Temperature: 48
Temperature: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Interviewed regarding vague care plan for verbal aggression. |
| RN 3 | Registered Nurse | Observed administering wrong medication dose and not disinfecting glucometer. |
| RN 2 | Registered Nurse | Acknowledged medication errors and planned to notify physician. |
| Consultant Pharmacist | Pharmacist | Interviewed regarding medication monitoring and errors. |
| LVN 2 | Licensed Vocational Nurse | Observed preparing medications incorrectly and acknowledged errors. |
| LVN 1 | Licensed Vocational Nurse | Interviewed about labeling and disposal of suction equipment. |
| CNA 1 | Certified Nurse Assistant | Interviewed about cleaning practices using disinfectant wipes. |
| CNA 6 | Certified Nurse Assistant | Interviewed about cleaning practices using disinfectant wipes. |
| CNA 2 | Certified Nurse Assistant | Interviewed about cleaning practices and knowledge of disinfectant contact time. |
| DON | Director of Nursing | Interviewed regarding infection control practices and equipment labeling. |
| DSD | Director of Staff Development | Interviewed regarding infection control and staff food policies. |
| Dietary Supervisor | Dietary Supervisor | Interviewed regarding food temperature and safety practices. |
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