San Francisco Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow disinfection protocols for reusable items which includes durable medical equipment (DME - equipment that is used for a medical purpose, is used in the home, and is expected to last at least three years) for three out of three residents (Residents 18, 29, and 41). This failure puts residents at risk for cross contamination and the possible spread of infection among residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement pain care plan for 1 of 14 sampled residents (Resident 38) when there was no evidence of pain assessment. This failure had the potential for not meeting Resident 38's nursing needs and goals to attain the resident's highest practicable well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to meet professional standards of quality when the facility did not follow doctor's order regarding oxygen for one of 2 sampled residents (Resident 8). This failure could potentially result in negative outcomes for Resident 8.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure communication services were provided for one of 6 sampled residents (Resident 38) who spoke in his native language when there were no interpreter services for Resident 38 on Sunday (12/8/24). This failure has the potential for Resident 38 not to understand and carry out activities of daily living (ADL) to attain the resident's highest practicable well-being.

Inspectors wroteBased on interview, and record review, the facility failed to ensure Resident 25 was free from unnecessary psychotropic medications (any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic [a type of psychiatric medication which are available on prescription to treat psychosis]; (ii) Anti-depressant [prescription medicines to treat depression]; (iii) Anti-anxiety [drugs used to treat symptoms of anxiety, such as feelings of fear, dread, uneasiness, and muscle tightness, that may occur as a reaction to stress]; and (iv) Hypnotic [a class of drugs that induce or prolong sleep in people with sleep disorders and are intended to improve the overall quality of sleep]) when: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide, one of three sampled residents (Resident 1), Resident 1's representative with the 7-Day Bed-hold written notice at the time of transfer or within 24 hours of Resident 1's emergency transfer to a higher level of care on [DATE]. This failure resulted in a facility-initiated discharge on [DATE] for Resident 1.

Inspectors wroteBased 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. The dietary supervisor did not ensure chicken potstickers were cooked to an appropriate temperature. [...]

Inspectors wroteBased 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. A diet aide did not follow manufacturer's instructions for a sanitizer test strip when testing the surface sanitizer. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the planned menu when: 1) The incorrect serving size of the main entrée 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.

Inspectors wroteBased 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. There was no airgap (a gap between the sink drains and the drain that leads to sewage drain. [...]

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to maintain the kitchen free of pests. This failure had the potential to result in contamination of food and utensils used by residents leading to pest related disease and/or illness for 51 residents who received food from the kitchen out of a facility census of 51.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan (CP) for each resident that included measurable objectives and specific interventions for four of 13 sampled residents (Residents 18, 19, 43, and 31) when: 1. The CP for Resident 19 did not have specific interventions for the use of Trazodone (medication used to treat depression). 2. No individualized person-centered CP was developed for the management of peripherally inserted central catheter (PICC - a long thin tube that's inserted through a vein in an arm and passed through a larger vein near the heart) line for Residents 18 and 43. 3. No individualized person-centered CP was developed for the management of the urinary catheter (a tube left in the bladder to carry urine from the bladder to outside the body) for Resident 43. 4. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to: 1. Provide food preferences to one resident (Resident 10); and 2. Provide an appealing option of similar nutritive value for milk when 39 residents chose not to drink milk. These failures had the potential for residents to not receive the amount of nutrients provided by the planned menu and/or the Registered Dietitians recommended nutrient needs leading to nutrient deficiency, weight loss, and/or malnutrition out of a census of 51.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and services provided meet professional standards for one of 13 sampled residents (Resident 43) when there was no order for the use of oxygen for Resident 43. This failure could potentially prevent staff from providing Resident 43 with appropriate treatment and care which could jeopardize the resident's health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident's (Resident 10) nutritional status was maintained when poor intake, significant weight loss, and insidious weight loss were not monitored and assessed. This failure had the potential to result in avoidable weight loss from inadequate nutrient intake for one resident out of a facility census of 51.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the manufacturer's recommendations and specifications for installing and maintaining bed rails when the bed of Resident 10, one of 13 sampled residents, had a left sided bed rail that would fall down periodically when used by resident. This failure of the facility had the potential to injure the resident resulting from an accidental fall from the bed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe storage and proper labeling of medication when an unlabeled loose white round tablet and cherry colored liquid were found on Resident 19's over bed table. This deficient practice had the potential for Resident 19 to self-administer or receive incorrect medication that may cause harm or death, and the unattended medication had the potential for drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 13 sampled residents (Resident 19) was free from unnecessary psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) when Resident 19 received Trazodone (an antidepressant) without adequate monitoring. This failure had the potential for Resident 19 to receive unnecessary psychotropic medication and be exposed to adverse health consequences from the medication, which could negatively impact the resident's mental, physical, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure Resident 31 was served the correct food texture according to her physician prescribed therapeutic diet. This failure to serve Resident 31 the prescribed texture of food had the potential to result in one resident not being able to tolerate food texture resulting in decreased nutritional intake and/or choking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store medications according to standard of practice when: 1. Two injection needles with damaged packaging, 12 expired syringes of saline (a mixture of salt and water) and a box containing 100 expired syringes were kept in the medication room. 2. Three opened insulin (medication that allows your body to use sugar) vials and three opened and used insulin vials after 28 days were kept inside the medication cart. These failures had the potential to subject residents to sub-therapeutic medications, non-sterile needles, and use of expired syringes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Physician ordered therapeutic diet was followed for four of four residents on renal diet (Resident 153, 22, 27 and 11). The deficient practice had the potential to compromise the health of the residents on therapeutic diets.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe food practices when: 1. The water heater has build up of grease and dirt. 2. A green bucket placed on top of water heater contained sponges, a scrubber and three unidentifiable tools were kept on top of the water heater. 3. The hair of the kitchen staff was not properly restraint. These deficient practices had the potential to expose residents to food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1:1 assistance during meal was provided as per physician's order and Registered Dietician's recommendation for one of 13 sampled residents (Resident 21). This deficient practice contributed to Resident 21's weight loss.