San Francisco Post Acute

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF801Oct 6, 2023

  Based on observation, interview, and facility document review, the facility failed to have a full-time, qualified, and competent person to supervise food and nutrition services when: 1. The registered dietitian (RD) and the qualified dietary supervisor were at the facility less than full-time defined as 35 hours per week; 2. Food and Nutrition Services (FNS) supervisory staff did not ensure: a resident received food preferences; FNS staff were competent to carry out job duties and tasks they performed; the planned menu was followed; a resident received the appropriate texture food according to the diet order; there was an effective system to maintain food and nutrition services in a safe and sanitary manner; and the kitchen was pest free; and 3. […]

• No harm, potential for more than minimal, widespreadF802Oct 6, 2023

  Based on observation, interview, and facility document review, the facility failed to ensure the competency of Food and Nutrition Staff when: 1. A cook did not know the steps for cooling Time Temperature Control for Safety (TCS, foods more likely to grow harmful bacteria and/or microorganisms if not stored appropriately) food; 2. A cook did not follow recipes when preparing food for the planned menu; 3. A diet aide did not know how long to submerge items in the sanitizer solution when washing manually using the 2-compartment sink; 4. […]

• No harm, potential for more than minimal, widespreadF803Oct 6, 2023

  Based on observation, interview and record review, the facility failed to follow the planned menu when: 1) The incorrect serving size of the main entree was served according to the menu for a lunch meal; 2) Pureed melon was not served according to the menu for a lunch meal. 3) Pureed salad was not served according to the menu for a lunch meal. 4 ) Fresh strawberry and ice cream were not served according to the menu for a lunch meal. This failure to follow the planned menu had the potential to result in residents not receiving the nutrients the menu was intended to provide leading to decreased nutrient intake and further compromising residents' medical status for 51 residents who received food from the kitchen. […]

• No harm, potential for more than minimal, widespreadF812Oct 6, 2023

  Based on observation, interview and record review, the facility failed to ensure food safety requirements in accordance with professional standards for food service safety when: 1. Staff did not ensure food was cooled safely. 2. Pans and bowls were not dried appropriately. 3. Frying pans were in poor condition. 4. A large mixer was not clean and in poor condition. 5. An industrial can opener was not clean and in poor condition. 6. Refrigerator and Freezer door rubber gaskets (a rubber strip surrounding the perimeter of the inside of the cooler door to seal the door when it is closed so air cannot go in or out) were not clean. 7. Staff did not handle clean dishes appropriately to prevent contamination of the dishes. 8. […]

• No harm, potential for more than minimal, widespreadF814Oct 6, 2023

  Based on observation, interview, and facility document review, the facility failed to maintain the outside compost bin in a clean manner. This failure had the potential to attract pests resulting in pest related illness for 51 residents out of a census of 51. Findings: An observation and interview with Dietary Supervisor 2 (DS2) on 10/3/23 at 12:51 p.m., showed a compost bin stored outside with other waste receptacles directly next to the facility's outside side wall. The compost bin had a significant amount of thick dark brown and black residue on the outside surface and sides of the inside surface of the bin also covered with a thick black and brown residue. DS2 stated the black and brown residue was food residue. […]