San Francisco Towers

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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; [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.