San Francisco Towers

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Jun 7, 2024

  Based on observation, interview and record review, the facility failed to ensure food safety requirements in accordance with professional standards for food service when: 1. Cleaned baking pans and metal trays were stacked moist and wet. 2. One blender had broken and jagged rim. 3. Opened and undated apricot jelly, mustard, and muffin butter were found in the refrigerator, on the shelf, and the walk-in refrigerator. 4. A kitchen staff was observed carrying clean plates in an unsanitary manner. 5. […]

• No harm, potential for more than minimal, patternF812Dec 4, 2025

  Based on observation, interview, and record review, the facility failed to ensure food was stored in accordance with professional standards for food service safety when scoops were stored inside the jasmine and brown rice bins with the scoops in direct contact with the rice.This deficient practice may put the residents who receive food from the facility kitchen at risk for food borne illness (an illness caused by the food you eat).During a concurrent observation and interview on 12/1/25 at 10:06 AM with Kitchen Staff (KS) 1, Dry Storage 2 (an area where food items that are safe at room temperature are stored) in the kitchen was inspected. The bin containing jasmine rice had a scoop holder under its lid. […]

• No harm, potential for more than minimal, isolatedF578Dec 4, 2025

  Based on interview and record review, the facility failed to inform and provide written information to residents to formulate an advanced directive (a legal document indicating resident preference on end-of-life treatment decision) when there was no accurate documentation to demonstrate offering and educating the advance directive to one of 16 sampled residents (Resident 10).This failure was likely to result in not following the residents' desired health care decisions when residents become unable to make decisions for themselves. […]

• No harm, potential for more than minimal, isolatedF628Dec 4, 2025

  Based on interview and record review, the facility failed to provide a written notice of transfer that included the reason for transfer, bed-hold policy, and other discharge rights as soon as practicably possible for one out of three sampled residents (Resident 25).This failure has the potential for residents to be inappropriately discharged without understanding the reason for their discharge or their rights regarding that discharge.A review of the facility's policy and procedure titled, Transfer, Evacuation, Relocation, or Discharge, last revised 08/202, indicated, Emergency Transfer/Discharges.The facility shall make an emergency transfer or discharge when it is in the best interest of the resident.Before the facility transfers a resident to a hospital or the resident goes on a… […]

• No harm, potential for more than minimal, isolatedF641Dec 4, 2025

  Based on interview and record review, the facility failed to ensure assessments for one of sixteen sampled residents (Resident 1) was accurate when the Minimum Data Set (MDS-an assessment tool) for Resident 1's hospice status was coded inaccurately.Failure to complete accurate assessments could potentially harm the residents by not providing needed care and services to maintain their highest level of functioning.Resident 1's most recent admission was on 9/16/25 with diagnosis including Alzheimer's disease (a type of dementia that affects memory, thinking and behavior), dementia (general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), type 2 diabetes mellitus (a disease that occurs when your body doesn't… […]