San Francisco Health Care
Inspection History Overview
Detailed Inspection Reports
Notice: These are official CMS inspection narratives containing detailed regulatory findings. This information is not available in searchable format anywhere else online.
Fines and Penalties by Year
2025 1 penalties totaling $43,890
Fine
2022 1 penalties totaling $663
Fine
2020 1 penalties totaling $9,750
Fine
2019 1 penalties totaling $113,360
Fine
Health Violations by Year
2025 12 violations
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide enough food/fluids to maintain a resident's health.
Ensure medication error rates are not 5 percent or greater.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Dispose of garbage and refuse properly.
Provide or get specialized rehabilitative services as required for a resident.
Provide and implement an infection prevention and control program.
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
2024 13 violations
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Keep residents' personal and medical records private and confidential.
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
PASARR screening for Mental disorders or Intellectual Disabilities
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Ensure medication error rates are not 5 percent or greater.
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Provide and implement an infection prevention and control program.
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
2023 5 violations
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
2021 7 violations
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Ensure medication error rates are not 5 percent or greater.
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide and implement an infection prevention and control program.
Provide and implement an infection prevention and control program.
2020 5 violations
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide and implement an infection prevention and control program.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Ensure each resident receives an accurate assessment.
2019 10 violations
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide and implement an infection prevention and control program.
Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Ensure that residents are free from significant medication errors.
2018 12 violations
Keep residents' personal and medical records private and confidential.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Provide and implement an infection prevention and control program.
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Provide necessary care and services to maintain or improve the highest well being of each resident .
2017 18 violations
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents.
Keep clinical record information safe.
Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality.
Honor a residents' rights as a residents of the nursing home, free of coercion and reprisal, and as citizens or residents of the United States.
Develop a post-discharge plan with the resident and family for the resident's care after leaving the nursing home.
Give residents a notice of rights, rules, services and charges.
Ensure each resident receives an accurate assessment by a qualified health professional.
Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients.
Provide necessary care and services to maintain or improve the highest well being of each resident .
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being.
Store, cook, and serve food in a safe and clean way.
Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse.
At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor.
Have a program that investigates, controls and keeps infection from spreading.
Keep accurate, complete and organized clinical records on each resident that meet professional standards.
Train all employees on what to do in an emergency, and carry out unannounced staff drills.
Permit residents to remain in the facility and not be transferred or discharged without adequate reason.
Have a program that investigates, controls and keeps infection from spreading.