Deficiency Records for San Francisco Post Acute
Updated as of February 01, 2023
This is not the most recent data for San Francisco Post Acute. For the most recent information, click here.
A list of the most recent deficiencies for San Francisco Post Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-10-19 | 2021-12-21 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-10-19 | 2021-12-21 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-10-19 | 2021-12-21 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2021-10-19 | 2021-12-21 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2021-10-19 | 2021-12-21 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-10-19 | 2021-12-21 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-10-19 | 2021-12-21 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-10-19 | 2021-12-21 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-10-19 | 2021-12-21 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-10-19 | 2021-12-21 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-10-19 | 2021-12-21 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-10-19 | 2021-12-21 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2021-10-19 | 2021-12-21 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-10-19 | 2021-12-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-10-19 | 2021-12-21 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2021-10-19 | 2021-12-21 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2021-10-19 | 2021-12-21 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-10-19 | 2021-12-21 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-10-19 | 2021-12-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-10-19 | 2021-12-21 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-10-19 | 2021-12-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-10-19 | 2021-12-21 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-10-19 | 2021-12-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-10-19 | 2021-12-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-10-19 | 2021-12-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-10-19 | 2021-12-21 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-10-14 | 2021-11-29 | N |
| 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. | Health | 2021-10-14 | 2021-11-29 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2021-10-14 | 2021-11-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-14 | 2021-11-29 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2020-12-23 | 2021-02-25 | Y |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2020-12-23 | 2021-02-25 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2020-12-23 | 2021-02-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-07-21 | 2020-10-05 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-03-22 | 2019-06-19 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-03-22 | 2019-06-19 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-03-22 | 2019-05-17 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2019-03-22 | 2019-05-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-22 | 2019-05-17 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-03-22 | 2019-05-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-22 | 2019-05-17 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-04-10 | 2019-05-01 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-04-10 | 2019-05-01 | N |
| Use approved construction type or materials. | Fire Safety | 2019-04-10 | 2019-05-01 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-04-10 | 2019-05-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-10 | 2019-05-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-04-10 | 2019-05-01 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-04-10 | 2019-05-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-04-10 | 2019-05-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-10 | 2019-05-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-04-10 | 2019-05-01 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-04-10 | 2019-05-01 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-04-13 | 2018-07-09 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-04-13 | 2018-07-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-04-13 | 2018-07-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-04-13 | 2018-07-09 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2018-05-31 | 2018-06-18 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2018-05-31 | 2018-06-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-05-31 | 2018-06-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-05-31 | 2018-06-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-05-31 | 2018-06-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-05-31 | 2018-06-18 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2018-04-13 | 2018-05-30 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-04-13 | 2018-05-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-04-13 | 2018-05-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-04-13 | 2018-05-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-04-13 | 2018-05-30 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-04-13 | 2018-05-30 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-04-13 | 2018-05-30 | N |
| 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. | Health | 2018-04-13 | 2018-05-30 | N |
