CALIFORNIA PACIFIC MEDICAL CTR - ST. LUKE'S CAMPUS

Nursing Home Inspector

3555 CESAR CHAVEZ STREET
SAN FRANCISCO, CA 94110
San Francisco County
Phone: 415-647-8600
Provider Number: 555243
Last Inspection: 03/30/2017

About the Nursing Home

Number of Beds: 79
Number of Residents: 52
Beds Available: 27
Percent Occupancy: 66%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: Non profit - Corporation
Within Hospital?: YES

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

29

Facility
34

County
32

CA
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

29

2017
28

2016
18

2014

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

3/30/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep each resident free from drugs that restrain them, unless needed for medical treatment. Isolated : Minimal 3 5/11/2017
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Pattern : Minimal 4 5/11/2017
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 5/11/2017
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 5/11/2017
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Minimal 3 5/11/2017
 
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Pattern : Minimal 4 5/11/2017
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Pattern : Minimal 4 5/11/2017
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 5/11/2017
 

2/12/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep residents' personal and medical records private and confidential. Pattern : Minimal 4 3/28/2016
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 3/28/2016
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 3/28/2016
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 3/28/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Minimal 3 3/28/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 3/28/2016
 
Failed To: Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. Pattern : Minimal 4 3/28/2016
 
Failed To: Train all employees on what to do in an emergency, and carry out unannounced staff drills. Isolated : Minimal 3 3/28/2016
 

12/19/2014 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 1/23/2015
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Pattern : Minimal 4 1/23/2015
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 1/23/2015
 
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 1/23/2015
 
Failed To: Keep all essential equipment working safely. Pattern : Minimal 4 1/23/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

10/3/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that residents are fully informed and understand their health status, care and treatments. Isolated : Minimal 3 10/20/2017
 

9/25/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 10/19/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg CA State Avg
Number of Residents 52 111.90 84.47
Registered Nurses 3.05 1.38 0.81
Licensed Practical / Vocational Nurses 2.32 0.99 1.06
Certified Nursing Assistants 3.15 2.72 2.59
Total Staff Hours 8.52 5.08 4.46

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% CA State Avg%
of high risk long-stay residents with pressure ulcers 20 3 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 94 96 96
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 96 96 95
of long-stay residents experiencing one or more falls with major injury 0 2 1
of long-stay residents who have depressive symptoms 1 0 0
of long-stay residents who lose too much weight 11 7 5
of long-stay residents who received an antianxiety or hypnotic medication 14 12 19
of long-stay residents who received an antipsychotic medication 6 9 11
of long-stay residents who self-report moderate to severe pain 2 4 3
of long-stay residents who were physically restrained 7 0 0
of long-stay residents whose ability to move independently worsened 13 14 15
of long-stay residents whose need for help with daily activities has increased 12 14 10
of long-stay residents with a catheter inserted and left in their bladder 22 2 2
of long-stay residents with a urinary tract infection 20 3 2
of low risk long-stay residents who lose control of their bowels or bladder 36 43 44
of short-stay residents assessed and appropriately given the pneumococcal vaccine 84 83 86
of short-stay residents who had an outpatient emergency department visit 5 7 11
of short-stay residents who made improvements in function 52 73 66
of short-stay residents who newly received an antipsychotic medication 2 1 1
of short-stay residents who self-report moderate to severe pain 30 14 8
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 92 83 84
of short-stay residents who were rehospitalized after a nursing home admission 22 20 21
of short-stay residents who were successfully discharged to the community 52 50 51
of short-stay residents with pressure ulcers that are new or worsened 1 0 0