Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Chinese Hospital D/p Snf during CMS and state inspections, most recent first.
The facility failed to meet mandated reporting timeframes for abuse allegations and did not report investigation results to the State Survey Agency. A resident with Parkinsonism and dementia reported physical and verbal abuse by an RN, a hospital aide, and an LVN, including being dragged from bed, having medications delayed or withheld, and being mishandled during hygiene care. The Social Services Manager received these allegations but notifications to CDPH, the Ombudsman, and local law enforcement were sent about 22 hours later, despite facility policy requiring immediate reporting within specific time limits. The Human Resources department conducted the internal investigation but did not report its findings externally, and the facility’s written policy did not address the requirement to submit investigation results to CDPH within five working days.
The facility failed to ensure safe storage of residents' perishable food, risking foodborne illness for 18 residents. Observations showed a full freezer with ice build-up and no August temperature documentation. Staff interviews revealed unclear responsibilities and lack of training in monitoring refrigerator/freezer temperatures.
The facility failed to obtain physician orders and develop care plans for the use of female external catheters for two residents. One resident with multiple diagnoses, including obesity and chronic pain, was observed using a catheter without a physician's order. Another resident with a stage 4 pressure ulcer and other conditions also used a catheter without proper documentation in the care plan. The facility lacked a policy for the use of these catheters.
The facility failed to obtain physician orders and develop care plans for oral suctioning for two residents with dysphagia. One resident was observed with suctioning equipment filled with secretions, and another with a suction catheter and canister filled with fluid. Nursing staff confirmed the use of suctioning on a PRN basis, but no orders or care plans were found in the residents' records.
The facility failed to assess and plan for the use of bed rails for three residents, leading to potential risks of entrapment and injury. One resident with moderate impairment and another with right side weakness were observed using bed rails without proper assessment or care plans. A third resident on tube feeding also used bed rails without a physician's order or care plan, despite facility policy requiring these measures.
A facility failed to notify the local Ombudsman about a resident's discharge to a lower level of care, as required by federal regulations. The resident, with conditions like atrial fibrillation and obesity, was discharged after completing therapy. The Social Work Manager was unaware of the notification requirement, and the facility's policy did not include this federal mandate.
A facility failed to develop a comprehensive care plan for a resident prescribed Venlafaxine for depression. The resident, admitted with hypertension, cocaine abuse, and depression, had an active order for the medication. During a survey, a nurse confirmed the absence of a care plan for the antidepressant, despite facility policy requiring such plans based on resident assessments.
The facility did not post daily nurse staffing information on three consecutive days. The Interim Director of Nursing acknowledged the requirement but only provided daily nursing assignments and a monthly staff schedule, which did not meet the necessary criteria. The facility's policy requires staffing information to be available in a readable format to residents and visitors at any time and posted daily at the beginning of each shift.
The facility failed to ensure two residents were free from unnecessary psychotropic medication due to the absence of specific target behavior monitoring for Venlafaxine, used to treat depression. Both residents were administered the medication without documented behavior monitoring, as confirmed by staff, including a registered nurse and a pharmacist. The facility's policy requires monitoring to assess medication effectiveness, which was not followed in these cases.
The facility failed to ensure safe medication storage when prescription medications were left unattended on a medication cart in the hallway. A medication cart was found with bottles of medications belonging to a resident left on top while the LVN was inside a resident's room. The Interim Director of Nursing confirmed that the medications should not have been left unattended, as per the facility's drug storage policy.
A resident's oral suction equipment was improperly handled, with the tubing tip touching the floor, leading to contamination. Staff interviews confirmed the deficiency, and the facility's policy lacked specific guidance on oral suction equipment care.
Failure to Timely Report Abuse Allegations and Investigation Results
Penalty
Summary
The deficiency involves the facility’s failure to report multiple allegations of abuse within mandated timeframes and to report the results of its investigation to the State Survey Agency. A resident with Parkinsonism and dementia, admitted on an unspecified date and discharged on 5/23/25, reported to the Social Services Manager (SSM) on 12/20/24, before 5:00 PM, that an RN, a hospital aide, and an LVN physically and verbally abused him. The resident alleged he was intimidated, dragged from bed, given medications late, had laxatives shoved into his mouth, and was hosed down in the shower with soap put in his eyes. The resident also alleged that an LVN withheld his medications and made him suffer. Facility documents titled “Report of Suspected Dependent Adult/Elder Abuse” (Reports 1, 2, and 3), dated 12/21/24, reflected these allegations, but one report did not include the date and time the allegation was reported, and indicated the LVN was placed on leave effective 12/20/24. The SSM stated she reported the resident’s allegations to CDPH, the Ombudsman, and local police on 12/21/24, and fax transmittal records showed these notifications occurred at 3:00 PM on 12/21/24, approximately 22 hours after the allegation was made. The Director of Staff Development stated that allegations involving physical harm or serious bodily injury must be reported immediately, but not later than two hours, and other forms of abuse must be reported to CDPH and other agencies within 24 hours. The Chief Human Resources Officer stated that the Human Resources Office began its investigation the day after the report and concluded it on 1/10/25, and also stated that their department does not report to external agencies. The Chief Nursing Officer confirmed that reporting to CDPH is not an HR function and that the result of the investigation was not reported to CDPH. The facility’s abuse policy referenced federal and state reporting requirements and immediate reporting of alleged mistreatment, neglect, or abuse, and an appendix quick guide required abuse and serious bodily injury to be reported immediately but not later than two hours to CDPH, local police, and the Ombudsman; however, the policy did not include reporting the results of all investigations of abuse allegations to CDPH within five working days.
Deficiency in Safe Storage of Residents' Perishable Food
Penalty
Summary
The facility failed to have a system in place to ensure the safe storage of residents' personal perishable food, which had the potential to result in foodborne illness for 18 residents. The policy and procedure for bringing in outside food required that perishable food be stored in the resident refrigerator and freezer located in the dining room, with temperatures systematically monitored and logged. However, observations revealed that the freezer was very full, with ice build-up on the inside walls and ceiling, and there was no documentation for August 2024 regarding temperature monitoring. Interviews with staff indicated a lack of clarity and responsibility regarding the monitoring and documentation of the refrigerator and freezer temperatures. The Licensed Vocational Nurse (LVN) and Interim Director of Nursing (IDON) confirmed that the nursing staff was responsible for checking the freezer, but there was no clear understanding of the documentation process. The Food and Nutrition Services Manager (FNSM) stated that their staff did not oversee the resident refrigerator and freezer, and the Director of Staff Development (DSD) was unaware of the appropriate temperatures for the equipment. Additionally, there was no training provided to nursing staff on monitoring the refrigerator/freezer, and maintenance issues such as ice build-up were not reported to Facilities.
Lack of Physician Orders and Care Plans for External Catheters
Penalty
Summary
The facility failed to obtain a physician's order and develop a comprehensive care plan for the use of female external catheters for two residents. Resident 158, who was admitted with diagnoses including obesity, chronic pain, adult failure to thrive, and major depressive disorder, was observed with a catheter draining urine to a canister attached to a suction machine. During an interview, the resident acknowledged the use of the catheter, and a registered nurse confirmed that there was no physician's order for the use of the Purewick catheter. Similarly, Resident 201, admitted with diagnoses including a stage 4 pressure ulcer, hemiplegia, and chronic respiratory failure with hypoxia, was observed with a similar setup. An LVN and the Interim Director of Nursing confirmed the use of a Purewick catheter to prevent the pressure ulcer from being wet. However, a review of the resident's care plan revealed no documentation of the catheter's use, and the facility could not provide a policy and procedure for the use of female external catheters, only a manufacturer's guide.
Lack of Physician Orders and Care Plans for Oral Suctioning
Penalty
Summary
The facility failed to obtain a physician's order and develop a comprehensive care plan for oral suctioning for two residents. Resident 151, who was admitted with diagnoses including transient ischemic attack, dysphagia, and depression, was observed with oral suctioning equipment at the bedside filled with secretions. Despite the use of this equipment, there was no physician's order for oral suctioning in the resident's clinical records, nor was there a care plan addressing the need for suctioning of oral secretions. Similarly, Resident 205, admitted with encephalopathy and dysphagia, was observed with a suction catheter and canister filled with fluid. Interviews with nursing staff confirmed that suctioning was performed on an as-needed basis, yet there was no physician's order or care plan for this procedure in the resident's records. The absence of these critical documents was acknowledged by the nursing staff during a review of the residents' orders and care plans.
Failure to Assess and Plan for Bed Rail Use
Penalty
Summary
The facility failed to ensure that residents were properly assessed for the risks associated with the use of bed rails, and that the risks and benefits were reviewed with the residents or their representatives. This deficiency was observed in three residents. Resident 151, who was moderately impaired, was found with both upper bed rails up during observations, yet their Bed Rail Assessment (BRA) indicated that side rails were not indicated, and there was no care plan for their use. Similarly, Resident 159, who had right side weakness, was observed using both bed rails for mobility, but their BRA also stated that side rails were not indicated, and there was no care plan in place. Resident 207, who was on tube feeding and had been in the facility for several months, was observed using bed rails to reposition himself. However, there was no physician's order or care plan for the use of bed rails, despite a consent form being completed earlier in the year. The facility's policy requires a physician's order, assessment, consent, and care plan for the use of bed rails, which was not adhered to in these cases. These practices had the potential to put residents at risk for entrapment, accidents, or injuries due to the improper use of bed rails.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the local Ombudsman in writing about the discharge of a resident to a lower level of care, which is a requirement under federal regulations. The resident, who had been admitted with conditions including atrial fibrillation and obesity, was discharged after completing therapy and being deemed stable for discharge with home care. The discharge was facilitated by the Institute on Aging, which helped apply for an assisted living waiver, allowing the resident to move to a board and care home. During an interview, the Social Work Manager admitted to being unaware of the requirement to notify the Ombudsman about the discharge. A review of the facility's policy on transfer and discharge requirements revealed that it did not include the federal regulation mandating notification to the Ombudsman for all discharges.
Lack of Comprehensive Care Plan for Antidepressant Use
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident, identified as Resident 159, who was prescribed Venlafaxine, a medication used to treat depression. This deficiency was identified during a survey involving observation, interview, and record review. Resident 159 was admitted with diagnoses including hypertension, cocaine abuse, and depression. The Order Summary Report indicated that the resident had an active order for Venlafaxine starting from 7/19/24. During an interview and record review on 8/7/24, a registered nurse confirmed the absence of a care plan for the resident's antidepressant medication, acknowledging that there should have been a plan of care in place. The facility's policy requires the use of resident assessments to develop, review, and revise comprehensive care plans, which was not adhered to in this case.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to provide daily nurse staffing information on three consecutive days, specifically on 8/5/24, 8/6/24, and 8/7/24. During an interview on 8/5/24, the Interim Director of Nursing (IDON) acknowledged that the staffing information should be posted daily. However, the facility only provided daily nursing assignments and a monthly staff schedule, which did not meet the required staffing data. On 8/7/24, when asked again, the IDON indicated that the Census and Direct Care service Hours Per Patient Day (DHPPD) was posted at the nursing station. The facility's policy, dated 4/20/23, mandates that staffing information be readily available in a readable format to residents and visitors at any time, and it should be posted daily at the beginning of each shift.
Lack of Behavior Monitoring for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that two residents, identified as Residents 158 and 159, were free from unnecessary psychotropic medication due to the lack of specific target behavior monitoring for the use of Venlafaxine, a medication used to treat depression. Resident 158 was admitted with diagnoses including obesity, chronic pain, adult failure to thrive, and major depressive disorder. The clinical records for Resident 158 showed that Venlafaxine was administered daily without documentation of specific target behavior monitoring for depression. This was confirmed by a registered nurse who acknowledged the absence of behavior monitoring for the use of Venlafaxine. Similarly, Resident 159, who was admitted with diagnoses including hypertension, cocaine abuse, heart failure, and depression, was also administered Venlafaxine without specific target behavior monitoring. The registered nurse and the pharmacist both confirmed the lack of behavior monitoring for the use of Venlafaxine in Resident 159's case. The Interim Director of Nursing stated that behavior monitoring is typically done every shift to assess the effectiveness of the medication or the need for dose adjustments. The facility's policy on Drug Regimen Review/Pharmaceutical Care Monitoring indicated that the pharmacist should identify and report irregularities, such as the use of medication without adequate monitoring.
Unsafe Medication Storage Practices
Penalty
Summary
The facility failed to ensure safe medication storage practices when several prescription medications were left unattended on top of a medication cart. During an observation and interview, it was noted that a medication cart was positioned in the hallway outside a resident's room, with bottles of prescription medications belonging to a resident left on top. These medications included metoprolol, oxcarbazepine, lisinopril, and tamsulosin. The Licensed Vocational Nurse (LVN) responsible for the cart was inside a resident's room, leaving the medications unattended. The Interim Director of Nursing confirmed that the medications should not have been left unattended, as per the facility's policy on drug storage, which mandates that all drugs be stored in designated areas within medication carts or lockable cabinets.
Infection Control Deficiency: Contaminated Suction Equipment
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper handling of oral suction equipment for a resident. The deficiency was observed when the tip of the oral suction tubing was found touching the floor, which is considered contaminated. This incident involved a resident who was admitted with diagnoses including transient ischemic attack, dysphagia, and depression, and was noted to have a moderately impaired mental status. During an observation, the suction equipment was seen at the resident's bedside with the canister filled with secretions, and the tubing tip in contact with the floor. Interviews with facility staff, including a registered nurse, the interim director of nursing, and the infection preventionist, confirmed the improper handling of the suction tubing. Each staff member acknowledged that the tubing should not be touching the floor due to the risk of contamination and potential spread of infection. The facility's policy on cleaning and disinfection did not specifically address the care for oral suction equipment, which contributed to the oversight in maintaining proper infection control practices.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near San Francisco
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| City View Post Acute | 0.7 mi | — | 3 | 0 |
| San Francisco Towers | 0.7 mi | — | 12 | 0 |
| Victorian Post Acute | 1.2 mi | — | 0 | 0 |
| Sequoias San Francisco Convalescent Hospital | 1.3 mi | — | 13 | 0 |
| Central Gardens Post Acute | 1.4 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.