San Francisco Towers

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. The scoop was not in its holder and was placed directly inside the bin, in contact with the rice. The bin containing brown rice did not have a scoop holder, and the scoop was placed directly in contact with the rice. KS 1 confirmed the observation and stated, This one (referring to the brown rice bin) does not have a holder for the scoop. We should change the bin.During an interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. Review of Resident 10's Acknowledgement for Advance Directive form dated 11/12/25 indicated, a different resident's name was written on the signed form.During a concurrent interview and record review on 12/2/25 at 1:02 PM with Licensed Vocational Nurse (LVN) 1, Resident 10's scanned Acknowledgement for Advanced Directive (AAD) form dated 11/12/25 was reviewed. LVN 1 acknowledged that the scanned form on the electronic health record (EHR) was not under Resident 10's name.During a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 therapeutic leave, the facility will provide written information to the resident or resident representative that specifies: the duration of the state bed-hold policy.the reserve bed payment policy in the state plan. the facility's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 use insulin well and can't keep blood sugar at normal levels), and major depressive disorder.Review of Resident 1's medical record titled Hospice Certification and Plan of Care indicated, Resident 1 was admitted for hospice…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure that the indications for pain medication orders were accurately documented for two out of six residents (Resident 19 and Resident 20). This failure had the potential to result in a serious adverse consequence (a bad or harmful effect that can happen when someone takes a medicine).During a review of the Medication Administration Record (MAR) for Resident 19, dated November 2025, the MAR indicated a pain medication order for Tramadol 25 mg with an indication to, give 1 tablet by mouth every 8 hours as needed for moderate to severe pain. The pain medication order was started on 11/19/2025. Tramadol 25 mg was given at 7:49 AM on 11/21/2025 for a pain level of 3 and was also given at 4:50 AM on 11/24/2025 for a pain level of 2, both of which are considered mild pain according to the facility's pain scale, which did not align with the prescribed indication for moderate to severe pain. Pain levels are a way to describe how much pain someone is feeling and is usually rated on a pain scale from 0 to 10.During an interview on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. A kitchen staff did not perform hand washing between tasks. The failure to store cooking and serving utensils and blender; store opened and undated foods; handling eating utensils in a sanitary manner; and practicing proper hand hygiene has the potential of putting residents at risk for foodborne illnesses leading to severe negative health outcomes and even death for 21 residents who consumed food by mouth during mealtimes. Findings: 1. During a concurrent observation and interview on 6/4/24 at around 10 AM in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 69) was free from unnecessary psychotropic medication (drug that affect brain activities associated with mental processes and behavior) when there was no specific target behavior monitoring for the use of Lorazepam (medication used to treat anxiety). This failure had the potential for Resident 69 to receive unnecessary psychotropic medication, be exposed to adverse health consequences from the medication, which could negatively impact the resident's mental, physical, and psychosocial well-being. Findings: Resident 69 was admitted on [DATE] with diagnoses including mesothelioma of pleura (a rare cancer that grows in the membrane that lines the walls of your chest and lungs), major depressive disorder, and anxiety disorder (a mental health disorder characterized by feelings of worry, or fear that are strong enough to interfere with one's daily activities). During a review of Resident 69's clinical record,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure medications were properly stored and appropriately labeled when one unopened and undated Basaglar KwikPen Insulin (hormone medication that helps control blood sugar levels in people with diabetes) for Resident 3 was stored in the medication cart. This failure had the potential for Resident 3 to receive medication with unsafe and reduced potency from improper storage. Findings: During an observation on 6/5/24 at 10:20 AM, one unopened and sealed Basaglar KwikPen Solution Pen Injector 100 Unit/ml Insulin was stored in the medication cart. Review of Resident 3's Medication Administration Record (MAR) dated 6/2/24 indicated, Basaglar Kwikpen Solution per injector 100 Unit/ml (Insulin Glargine) was last administered on 6/2/24 at 7:00PM. During an interview on 6/5/24 at 11:42 AM, with Licensed Vocational Nurse (LVN) 1, LVN 1 stated, Resident 3 always refused to take insulin, that's why the insulin is not yet opened, it is still full. All I know that once taken out from the refrigerator and it's in the cart…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure food was stored, prepared, and served in a sanitary manner when: 1. Three kitchen staff and a maintenance staff failed to wear hair net or head/hair covering when working inside the kitchen. 2. Two flies were found inside the kitchen. 3. The top rack of the wire drying racks had fuzzy, dust like coating on the racks. 4. Two oven mittens had damaged outer covering. 5. A food service staff did not wash his hands when he changed his gloves. 6. A scoop was left inside the thickener container during and after lunch service. These failures had the potential for food contamination and the potential for spread of food borne illnesses. Findings: During kitchen observation on 3/14/23 at 10:12 AM, with the Director of Dining Services A (DDS), the Executive Chef and a Maintenance Worker were observed without hair nets or head covering. On the same day at 11:52 AM, a Kitchen Staff A (KS) was observed without hair net or head covering. These additional observations were made on 3/14/23 from 10:12 AM to 11:52 AM with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure garbage containers in the kitchen and the dining area had lids and/or undamaged lids. This failure had the potential for an unsanitary environment and for pests to spread diseases within the facility. Findings: During kitchen observation on 3/14/23 at 10:12 AM, with the Director of Dining Services A (DDS), four garbage containers did not have lids. One garbage container had a lid that was cracked, and one garbage container had a non-functional foot operated lid. During dining service observation on 3/14/23 at 12:34 PM, the garbage container in the skilled nursing facility dining room had spring operate lids that was half opened and could not be closed properly. On 3/16/23, at 10:13 AM, DDS A was interviewed about the garbage containers. DDS A stated he expected all garbage containers to have undamaged and functional lids. Review of the facility's policy titled SOLID WASTE DISPOSAL, revised on 1/23, indicated .Food waste and rubbish in the Food and Nutrition Services Department/Dining Services will be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program when a certified nursing assistant (CNA 1) did not perform hand hygiene (hand washing with soap and water, or cleaning hands with alcohol-based hand sanitizers) before serving food to Resident 16 in the dining room for lunch. This failure had the potential to promote development and spread of communicable diseases and infections in the facility. Findings: During an observation on 3/14/23, at 12:20 PM, in the dining room, CNA 1 did not perform hand hygiene before serving lunch to Resident 16. During an interview on 3/14/23, at 12:24 PM, with CNA 1, CNA 1 stated, Not yet . I have to wash . when asked if he washed his hands before serving the food to Resident 16. After admitting not performing hand hygiene, CNA 1 washed his hand in the sink in the dining room, then approached this surveyor, and stated, I forgot to wash. During an interview on 3/14/23, at 12:28 PM, with CNA 1, CNA 1 stated, Before and after the food . when asked about hand hygiene when serving…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.