Deficiencies (last 6 years)
Deficiencies (over 6 years)
2.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
30% better than California average
California average: 4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
100% occupied
Based on a February 2026 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 350
Capacity: 350
Deficiencies: 0
Date: Feb 4, 2026
Visit Reason
The visit was conducted in response to a report of suspected abuse dated 2026-01-26 involving client #1. The licensing program analyst met with facility staff and the client to gather information regarding the allegation.
Complaint Details
The visit was triggered by a report of suspected abuse of client #1. The licensing program analyst interviewed the client and staff. No deficiencies or substantiated violations were found.
Findings
No deficiencies were cited during this investigation. The facility was advised to provide written documentation of a new directive requiring home care agencies to notify the facility in advance when sending new caregivers.
Report Facts
Capacity: 350
Census: 350
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mark Nitsche | Administrator/Director | Facility administrator present during inspection |
| Lucy Ascalon | Met with licensing analyst during inspection, provided information on new caregiver notification directive | |
| Audrey Jeung | Licensing Program Analyst | Conducted investigation and interviews related to suspected abuse |
| April Cowan | Licensing Program Manager | Named as licensing program manager on report |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Dec 4, 2025
Visit Reason
The inspection was conducted as a regulatory annual survey to assess compliance with healthcare regulations and standards at San Francisco Towers nursing home.
Findings
The facility was found deficient in multiple areas including failure to provide accurate advance directive documentation, failure to provide written discharge notices including bed-hold policies, inaccurate resident assessments, improper documentation and administration of pain medications, and unsafe food storage practices.
Deficiencies (5)
F 0578: The facility failed to inform and provide written information to residents to formulate an advance directive, with inaccurate documentation found for one resident's advance directive form.
F 0628: The facility failed to provide a written notice of transfer including reason for transfer and bed-hold policy for one resident discharged to hospital, providing only verbal notice.
F 0641: The facility failed to ensure accurate assessments for one resident when the Minimum Data Set (MDS) did not reflect the resident's hospice status.
F 0757: The facility failed to ensure pain medication orders were accurately documented and administered, with two residents receiving Tramadol for mild pain contrary to prescribed indications.
F 0812: The facility failed to ensure food was stored safely when scoops were placed directly inside rice bins in contact with the rice, risking contamination.
Report Facts
Residents sampled: 16
Residents sampled: 3
Residents sampled: 16
Residents sampled: 6
Pain medication dose: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse (LVN) 1 | Interviewed regarding advance directive documentation and MDS assessment | |
| Staff 1 | Interviewed regarding advance directive form signed by resident | |
| Licensed Vocational Nurse (LVN) 2 | Interviewed regarding discharge notice documentation | |
| Medical Records (MR) | Interviewed regarding bed hold notice requirements | |
| Director of Nursing (DON) | Interviewed regarding discharge notices, MDS assessment, and medication orders | |
| Licensed Vocational Nurse 3 (LVN 3) | Interviewed regarding pain medication administration | |
| Kitchen Staff (KS) 1 | Interviewed regarding food storage practices | |
| Registered Dietitian (RD) | Interviewed regarding food safety and scoop storage |
Inspection Report
Annual Inspection
Census: 319
Capacity: 350
Deficiencies: 0
Date: Oct 20, 2025
Visit Reason
The inspection was conducted as the required annual 1-year unannounced inspection of the facility.
Findings
The facility was found to be in compliance with no deficiencies cited. All safety measures, medication storage, resident and staff files, and facility conditions met licensing requirements.
Report Facts
Units in building: 264
Hot water temperature range: 105
Hot water temperature range: 120
Resident files reviewed: 5
Staff files reviewed: 5
Non-perishable food supply: 7
Perishable food supply: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Calandra | Licensing Program Analyst | Conducted the annual inspection |
| Lucy Ascalon | Director of Resident Health Services | Met with Licensing Program Analyst during inspection |
| Mark Nitsche | Executive Director/Administrator | Facility Administrator present during inspection |
| Akindele Omole | Healthcare Administrator | Met with Licensing Program Analyst during inspection |
| Brenda Chan | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 319
Capacity: 350
Deficiencies: 0
Date: Oct 20, 2025
Visit Reason
The inspection was conducted as the Annual 1-year required inspection to evaluate compliance with licensing requirements at the facility.
Findings
The facility was found to be in compliance with no deficiencies cited. All safety measures, medication storage, resident and staff files, and required documentation were observed to be complete and satisfactory.
Report Facts
Units in building: 264
Hot water temperature range: 105
Hot water temperature range: 120
Resident files reviewed: 5
Staff files reviewed: 5
Non-perishable food supply: 7
Perishable food supply: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Calandra | Licensing Program Analyst | Conducted the annual inspection visit |
| Lucy Ascalon | Director of Resident Health Services | Met with Licensing Program Analyst during inspection |
| Mark Nitsche | Executive Director/Administrator | Facility Administrator present during inspection |
| Akindele Omole | Healthcare Administrator | Met with Licensing Program Analyst during inspection |
Inspection Report
Complaint Investigation
Census: 319
Capacity: 350
Deficiencies: 0
Date: Sep 2, 2025
Visit Reason
An unannounced complaint investigation was conducted due to an allegation that the licensee was not appropriately addressing a change in a resident's condition.
Complaint Details
The complaint alleged that the licensee was not appropriately addressing a resident's decline in condition over 9 months, including hospitalization for infection and a fall. The investigation found the allegations to be unfounded.
Findings
The investigation found that the resident was capable of making decisions, was not confused or disoriented, and the facility had addressed the infection with appropriate care. The allegations were determined to be unfounded.
Report Facts
Capacity: 350
Census: 319
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Grace Donato | Licensing Program Analyst (LPA) | Conducted the complaint investigation visit |
| Mark Nitsche | Executive Director | Met with LPA during investigation |
| Lucy Ascalon | Director of Resident Health Services (DRHS) | Met with LPA during investigation |
| Akendel Omoli | Health Care Administrator (HCA) | Met with LPA during investigation |
Inspection Report
Complaint Investigation
Capacity: 350
Deficiencies: 0
Date: Jan 22, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit conducted in response to a complaint alleging that facility staff interfered with residents' visits.
Complaint Details
The complaint alleged that staff interfered with resident (R1) visits with an individual (I1). Interviews with staff, residents, and outside parties revealed that the visitor was granted access but was observed or reported to be disruptive. The facility's visitation protocols allow limiting or restricting visits to protect residents. Resident R1 did not report concerns. Due to conflicting information and lack of evidence, the allegation was unsubstantiated.
Findings
The investigation found conflicting statements and a lack of corroborating evidence regarding the allegation that staff interfered with resident visits. The allegation was determined to be unsubstantiated.
Report Facts
Capacity: 350
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mark Nitsche | Executive Director | Met with Licensing Program Analyst during the investigation |
| Dominic Tobola | Licensing Program Analyst | Conducted the complaint investigation |
| Andrea Medlin | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Capacity: 350
Deficiencies: 0
Date: Dec 10, 2024
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that the facility did not provide resident records upon legal request.
Complaint Details
The complaint alleged that the facility did not provide resident records upon legal request. The allegation was found to be unfounded after review of records and interviews with facility staff.
Findings
The investigation found that the facility complied with the legal record request and provided all requested documents within a timely manner. The complaint was determined to be unfounded with no deficiencies cited.
Report Facts
Capacity: 350
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dominic Tobola | Licensing Program Analyst | Conducted the complaint investigation |
| Ryan Banner | Healthcare Director | Met with Licensing Program Analyst during investigation |
| Mark Nitsche | Administrator | Facility administrator named in report |
Inspection Report
Complaint Investigation
Capacity: 350
Deficiencies: 0
Date: Dec 10, 2024
Visit Reason
The inspection visit was conducted as an unannounced complaint investigation regarding an allegation that the facility did not provide resident records upon legal request.
Complaint Details
Complaint alleged the facility did not provide resident records upon legal request. The allegation was found to be unfounded after investigation.
Findings
The investigation found that the facility complied with the legal record request in a timely manner, providing all requested documents between 10/2/2024 and 10/8/2024. The complaint was determined to be unfounded with no deficiencies cited.
Report Facts
Facility capacity: 350
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dominic Tobola | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Ryan Banner | Healthcare Director | Met with Licensing Program Analyst during investigation |
| Mark Nitsche | Administrator | Facility administrator mentioned in the report |
| Andrea Medlin | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Census: 298
Capacity: 350
Deficiencies: 3
Date: Oct 17, 2024
Visit Reason
An unannounced annual required 1-year inspection was conducted to evaluate the facility's compliance with regulations and overall care environment.
Findings
The facility was found to be clean, well-maintained, and compliant with safety and dietary regulations. However, technical violations were issued for outdated resident physician reports, staff first aid certifications, and medication reconciliation issues in the memory care unit.
Deficiencies (3)
Resident (R1) physician's report is in need of updating.
2 out of 5 staff reviewed are in need of updated 1st aid certification.
Several medications in the memory care unit need reconciled start dates and input.
Report Facts
Residents reviewed: 5
Staff files reviewed: 5
Staff needing updated 1st aid certification: 2
Fire extinguisher last charged date: Jan 25, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mark Nitsche | Executive Director | Greeted inspectors and mentioned in findings |
| Ryan Banner | Healthcare Administrator | Greeted inspectors and mentioned in findings; holds active Administrator Certificate |
| Dominic Tobola | Licensing Program Analyst | Conducted inspection and signed report |
| Andrea Medlin | Licensing Program Manager | Named in report header and signature section |
Inspection Report
Annual Inspection
Census: 298
Capacity: 350
Deficiencies: 3
Date: Oct 17, 2024
Visit Reason
An unannounced Annual Required – 1 year inspection was conducted to evaluate the facility's compliance with regulations and overall care standards.
Findings
The facility was found to be clean, well-maintained, and compliant with fire safety and food storage regulations. Staff and resident engagement was positive, but technical violations were noted related to an outdated resident physician's report, two staff members needing updated first aid certification, and medication reconciliation issues in the memory care unit.
Deficiencies (3)
Resident (R1) physician's report is in need of updating.
Two out of five staff reviewed are in need of updated first aid certification.
Several medications in the memory care unit need reconciled start dates and input.
Report Facts
Residents reviewed: 5
Staff files reviewed: 5
Staff needing updated certification: 2
Residents in care: 298
Facility capacity: 350
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mark Nitsche | Executive Director | Greeted inspectors and mentioned in report |
| Ryan Banner | Healthcare Administrator | Greeted inspectors and mentioned in report; Administrator Certificate active |
| Dominic Tobola | Licensing Evaluator | Conducted inspection |
| Andrea Medlin | Supervisor | Supervised inspection |
Inspection Report
Routine
Deficiencies: 3
Date: Jun 7, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to psychotropic medication use, medication storage, and food safety standards in the facility.
Findings
The facility failed to ensure one resident was free from unnecessary psychotropic medication due to lack of specific behavior monitoring. Medications were improperly stored, including an unopened insulin pen stored outside refrigeration. Food safety violations included wet stacking of pans, broken equipment, undated opened food items, unsanitary handling of clean plates, and inadequate hand hygiene by kitchen staff.
Deficiencies (3)
F 0758: The facility failed to ensure one resident was free from unnecessary psychotropic medication due to lack of specific target behavior monitoring for Lorazepam use.
F 0761: The facility failed to ensure medications were properly stored and labeled when an unopened and undated Basaglar KwikPen insulin was stored in the medication cart.
F 0812: The facility failed to ensure food safety by storing wet baking pans, using a blender with a broken rim, storing opened and undated food items, unsanitary handling of clean plates, and inadequate handwashing by kitchen staff.
Report Facts
Medication administrations: 3
Date of survey completion: Jun 7, 2024
Residents affected: 1
Residents affected: Few
Residents affected: Many
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) 1 | Interviewed regarding Resident 69's anxious behavior | |
| Registered Nurse (RN) 1 | Interviewed and reviewed Resident 69's clinical records | |
| Licensed Vocational Nurse (LVN) 1 | Interviewed regarding insulin storage and Resident 3's medication | |
| Director of Nursing (DON) | Interviewed regarding insulin storage policy and Resident 3's medication | |
| Director of Dining Services (DDS) | Interviewed during food safety observations | |
| Corporate Chef (CC) | Interviewed and observed during food safety deficiencies and staff handwashing | |
| Executive Sous Chef (ESC) | Interviewed and observed during food safety deficiencies |
Inspection Report
Deficiencies: 3
Date: Mar 16, 2023
Visit Reason
The inspection was conducted to evaluate compliance with food safety, sanitation, infection prevention, and control standards in the facility's kitchen and dining areas.
Findings
The facility failed to ensure sanitary food storage, preparation, and serving practices, including staff not wearing hair coverings, presence of flies, unclean drying racks, damaged oven mittens, improper hand hygiene, and leaving scoops inside containers. Additionally, garbage containers lacked proper lids, and a certified nursing assistant failed to perform hand hygiene before serving food.
Deficiencies (3)
F 0812: The facility failed to ensure food was stored, prepared, and served in a sanitary manner including staff not wearing hair nets, presence of flies in the kitchen, dusty drying racks, damaged oven mittens, improper hand hygiene when changing gloves, and leaving a scoop inside the thickener container.
F 0814: The facility failed to ensure garbage containers in the kitchen and dining area had lids or undamaged lids, posing a risk for unsanitary conditions and pest spread.
F 0880: The facility failed to maintain an infection prevention program when a certified nursing assistant did not perform hand hygiene before serving food to a resident.
Report Facts
Residents Affected: Few residents affected as stated in deficiencies
Number of flies observed: 2
Number of kitchen staff without hair nets: 3
Number of oven mittens damaged: 2
Number of garbage containers without lids: 4
Inspection Report
Annual Inspection
Census: 297
Capacity: 350
Deficiencies: 0
Date: Oct 11, 2022
Visit Reason
An unannounced annual inspection was conducted to evaluate compliance with health and safety regulations, including infection control practices and facility conditions.
Findings
No deficiencies were cited during the inspection. The facility demonstrated adequate infection control measures, proper storage of medications and supplies, and compliance with safety requirements.
Report Facts
Residents in memory care unit: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Murial Han | Licensing Program Analyst | Conducted the unannounced annual inspection |
| Ryan Banner | Health Services Administrator | Met with Licensing Program Analyst and provided facility tour |
| Cara Smith | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 297
Capacity: 350
Deficiencies: 0
Date: Oct 11, 2022
Visit Reason
An unannounced annual inspection was conducted to evaluate compliance with licensing requirements, including infection control practices and facility safety.
Findings
The inspection found no deficiencies. COVID-19 signage and infection control measures were observed throughout the facility. Safety features such as emergency call systems and delayed egress exits were functioning as required. Kitchen, medication storage, and first-aid supplies were inspected and found compliant.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Murial Han | Licensing Program Analyst | Conducted the inspection and authored the report. |
| Ryan Banner | Health Services Administrator | Met with the Licensing Program Analyst and provided the facility tour. |
| Cara Smith | Supervisor | Named as supervisor overseeing the inspection. |
Inspection Report
Census: 306
Capacity: 350
Deficiencies: 0
Date: Jul 19, 2022
Visit Reason
The visit was an unannounced walk-through/inspection of the facility's Memory Care Unit as part of Case Management - Other.
Findings
The inspection found that fire clearance was granted recently, egress doors functioned properly, water temperatures were within safe ranges, grab bars were installed, and emergency exits and corridors latched properly. No deficiencies were cited.
Report Facts
Memory Care Unit Capacity: 15
Water Temperature Range: 105.4
Water Temperature Range: 109.2
Egress Door Delay: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Spence | Administrator | Met with Licensing Program Analyst during the inspection and discussed the report |
| Murial Han | Licensing Program Analyst | Conducted the unannounced walk-through/inspection |
| Julio Montes | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Follow-Up
Census: 306
Capacity: 350
Deficiencies: 0
Date: Jul 19, 2022
Visit Reason
The visit was a follow-up to deliver findings of an investigation initiated after a serious incident involving resident #1 who was found unresponsive with a head injury after falling from a balcony.
Complaint Details
The investigation was initiated following a serious incident report concerning resident #1. The incident was deemed unfounded with no substantiation of neglect or lack of supervision.
Findings
The investigation concluded that the incident was due to self-inflicted harm with no evidence of lack of supervision or neglect by the facility. No deficiencies were cited.
Report Facts
Capacity: 350
Census: 306
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Spence | Administrator | Met with during the visit and discussed report findings |
| Murial Han | Licensing Program Analyst | Conducted case management visit and follow-up investigation |
| Julio Montes | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 306
Capacity: 350
Deficiencies: 0
Date: Jul 19, 2022
Visit Reason
An unannounced walk-through inspection of the facility's Memory Care Unit was conducted as part of case management to evaluate compliance and safety conditions.
Findings
The inspection found no deficiencies. Observations included proper functioning of egress doors with key FOB devices, water temperatures within safe ranges, installed grab bars in bathrooms and showers, and properly latched emergency exits and corridors.
Report Facts
Memory Care Unit Capacity: 15
Water Temperature Range: 105.4
Water Temperature Range: 109.2
Egress Door Delay: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Murial Han | Licensing Program Analyst | Conducted the unannounced walk-through inspection |
| Christina Spence | Administrator | Facility administrator who provided the tour during the inspection |
| Julio Montes | Supervisor | Supervisor named in the report |
Inspection Report
Follow-Up
Census: 306
Capacity: 350
Deficiencies: 0
Date: Jul 19, 2022
Visit Reason
The visit was a follow-up conducted on 07/19/2022 to deliver the findings of an investigation initiated after a serious incident involving resident #1 on 05/14/2022.
Findings
The investigation found no preponderance of evidence of lack of supervision or neglect by the facility regarding the incident, which was determined to be self-inflicted harm. No deficiencies were cited.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Murial Han | Licensing Program Analyst | Conducted the case management visit and follow-up investigation. |
| Julio Montes | Supervisor | Named as supervisor in the report. |
| Christina Spence | Administrator | Facility administrator met during the visit and discussed the report. |
Inspection Report
Census: 306
Capacity: 350
Deficiencies: 0
Date: May 20, 2022
Visit Reason
An unannounced Case Management visit was conducted concerning a serious incident reported by the facility that occurred on 2022-05-14 involving resident #1.
Findings
The Licensing Program Analyst requested several documents related to the incident, including physician's report, service plans, and hospital records, which were to be emailed by 2022-05-23. The incident requires further investigation.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Spence | Administrator | Met with Licensing Program Analyst during the visit and discussed the incident. |
| Ryan Banner | Health Services Administrator | Met with Licensing Program Analyst during the visit and discussed the incident. |
| Murial Han | Licensing Program Analyst | Conducted the unannounced Case Management visit. |
| Julio Montes | Supervisor | Supervisor overseeing the licensing evaluation. |
Inspection Report
Complaint Investigation
Census: 306
Capacity: 350
Deficiencies: 0
Date: May 20, 2022
Visit Reason
The visit was an unannounced Case Management inspection concerning a serious incident reported by the facility that occurred on 2022-05-14 involving resident #1.
Complaint Details
The visit was triggered by a serious incident reported by the facility on 2022-05-14 involving resident #1. Further investigation is required.
Findings
The Licensing Program Analyst met with the administrator and health services administrator, requested additional documents related to the incident, and collected staff work schedules. The incident requires further investigation.
Report Facts
Census: 306
Total Capacity: 350
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Spence | Administrator | Met with Licensing Program Analyst during the visit |
| Ryan Banner | Health Services Administrator | Met with Licensing Program Analyst during the visit |
| Murial Han | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| Julio Montes | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 306
Capacity: 350
Deficiencies: 0
Date: May 5, 2022
Visit Reason
An unannounced annual inspection was conducted to evaluate compliance with licensing requirements, including infection control practices and safety measures.
Findings
The inspection found no deficiencies. COVID-19 safety measures were observed throughout the facility, medications and hazardous materials were stored properly, and the environment was safe and adequately supplied.
Report Facts
Capacity: 350
Census: 306
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Banner | Health Services Administrator | Met with Licensing Program Analyst during inspection and discussed report findings |
| Christina Spence | Administrator | Facility administrator who reviewed and discussed the report |
Inspection Report
Annual Inspection
Census: 306
Capacity: 350
Deficiencies: 0
Date: May 5, 2022
Visit Reason
An unannounced annual inspection was conducted to evaluate the facility's compliance with health and safety regulations, including infection control practices and overall environment safety.
Findings
The inspection found no deficiencies. COVID-19 safety measures were observed throughout the facility, infection control practices were adequate, medications and hazardous materials were stored properly, and the environment was safe and comfortable for residents.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ryan Banner | Health Services Administrator | Met with during inspection and discussed report findings |
| Christina Spence | Administrator | Discussed report findings |
| Murial Han | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Complaint Investigation
Census: 298
Capacity: 350
Deficiencies: 0
Date: Jun 11, 2021
Visit Reason
An unannounced complaint investigation was conducted in response to allegations received on 05/20/2021 regarding medication dispensing errors and lack of supervision resulting in resident falls.
Complaint Details
The complaint involved allegations that facility staff were not dispensing medication as prescribed and that lack of supervision resulted in multiple resident falls. Interviews with staff and review of records found no preponderance of evidence to substantiate these allegations, resulting in an unsubstantiated determination.
Findings
The investigation found that the allegation of staff not dispensing medication as prescribed was unsubstantiated, as Resident 1 was initially managing medications with assistance but later required facility administration. The allegation of lack of supervision causing multiple falls was also unsubstantiated, with only one fall reported and no evidence supporting the complaint.
Report Facts
Capacity: 350
Census: 298
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Spence | Executive Director | Met with Licensing Program Analyst during investigation |
| Murial Han | Licensing Program Analyst | Conducted the complaint investigation |
| Brenda Chan | Licensing Program Manager | Reviewed and signed the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 298
Capacity: 350
Deficiencies: 0
Date: Jun 11, 2021
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that the facility was not having residents re-appraised after changes in condition or hospital readmission.
Complaint Details
The complaint alleged that many residents were failing and not properly assessed after a change of condition or readmission from hospital. The complaint was found to be unfounded and dismissed.
Findings
The investigation found that the complaint was unfounded as records showed documentation of Resident Functional Evaluation completed by the Registered Nurse after hospital returns. The allegation was dismissed due to lack of evidence.
Report Facts
Facility capacity: 350
Census: 298
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Murial Han | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Christina Spence | Executive Director | Met with Licensing Program Analyst during the investigation |
Inspection Report
Complaint Investigation
Census: 298
Capacity: 350
Deficiencies: 0
Date: Jun 11, 2021
Visit Reason
An unannounced complaint investigation was conducted in response to allegations that facility staff were not dispensing medication as prescribed and that lack of supervision resulted in multiple residents having falls.
Complaint Details
The complaint involved allegations of improper medication dispensing and lack of supervision causing falls. The allegations were found unsubstantiated after investigation, interviews, and review of incident reports.
Findings
The investigation found that Resident 1 was initially able to manage medications but later required assistance after a medication error. Registered Nurses and staff denied the allegations, and only one fall with injury was reported. Based on interviews and record reviews, the allegations were unsubstantiated due to lack of sufficient evidence.
Report Facts
Capacity: 350
Census: 298
Number of falls reported: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Murial Han | Licensing Program Analyst | Conducted the complaint investigation |
| Christina Spence | Executive Director | Facility administrator met during investigation |
| Brenda Chan | Supervisor | Supervisor overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 298
Capacity: 350
Deficiencies: 0
Date: Jun 11, 2021
Visit Reason
An unannounced complaint investigation was conducted in response to an allegation that the facility was not having residents re-appraised after changes in condition or hospital readmission.
Complaint Details
The complaint alleged that residents were failing and not properly assessed after a change of condition or readmission from hospital. The complaint was found to be unfounded and dismissed.
Findings
The investigation found that the complaint was unfounded as records showed documentation of Resident Functional Evaluation completed by the Registered Nurse after hospital returns. The allegation was dismissed due to lack of evidence.
Report Facts
Facility capacity: 350
Census: 298
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christina Spence | Executive Director | Met with Licensing Program Analyst during complaint investigation |
| Murial Han | Licensing Program Analyst | Conducted the complaint investigation |
| Brenda Chan | Supervisor | Named as supervisor on the report |
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