San Francisco Health Care

In the surveyor’s words

From the most serious findings on record at San Francisco Health Care, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 22, 2024

  Based on observations, interviews, record review, and facility policy review, the facility failed to implement measures to prevent Resident #76 from having unsupervised access to smoking materials, including lighters, cigarettes, and marijuana. This failure affected 1 (Resident #76) of 5 total residents identified by the facility as smokers. The facility allowed Resident #76 to have unsupervised visits with Visitor #28, who repeatedly provided the resident with smoking materials despite having been educated on the facility's smoking policies multiple times. After the facility had educated both Resident #76 and Visitor #28 on the facility's smoking policies, the resident and visitor continued to be noncompliant. […]

• Actual harm, isolatedF689Feb 28, 2025

  Based on observation, interview, and record review, the facility failed to identify environmental hazards, implement interventions, and maintain assistive device (refers to any item including wheelchair and walker, that is used by, or in the care of a resident to promote, supplement, or enhance the resident's function and/or safety) in good working condition for two of 22 sampled residents (Resident 25 and Resident 73) when: 1. A fall mat was placed on the floor between Resident 25 in bed A and his roommate in bed B obstructing the path and safe passage. As a result, Resident 25 tripped, fell on to the floor and sustained a right hip fracture requiring surgical repair. […]

• Actual harm, isolatedF692Feb 28, 2025

  Based on observation, interview, and record review, for Residents 3, one of two residents with weight loss out of a total sample of 22 residents, the facility did not: 1. Provide 1:1 assistance/support during meals as ordered by the physician. 2. Monitor percentage of supplement eaten. 3. Offered alternatives/other interventions during poor meal intake. 4. Implement a meal monitoring system that could distinguish between 0-25% intake for residents at risk for poor intake. 5. Use meal intake data to investigate refusals, assess food preferences, and/or identify other issues. 6. Assess for food preferences. This resulted in a 24.4% weight loss for Resident 3 within a six months period. […]

• No harm, potential for more than minimal, widespreadF584Jan 22, 2024

  Based on observations, interviews, and facility policy review, the facility failed to ensure that 4 of 4 resident shower rooms were maintained in a clean and homelike condition. Findings included: A review of a facility policy titled Homelike Environment, revised in February 2021, revealed, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The policy revealed, 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. […]

• No harm, potential for more than minimal, widespreadF880Jan 22, 2024

  Based on interviews, facility document review, and facility policy review, the facility failed to ensure they completed a facility-specific risk assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread in the facility's water system. This failure had the potential to affect all residents residing in the facility. Findings included: A review of a facility policy titled Legionella Surveillance and Detection, revised in September 2022, revealed, Our facility is committed to the prevention, detection and control of water-borne contaminants, including Legionella. […]