Alma Via of San Francisco

Prohibit tying or restricting resident hands or feet

87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal... Postural supports may be used under the following conditions.(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. This was not met as evidenced by: Based on interviews, two staff member restrained R1 with a gait belt limiting the use of R1s hands which poses an immediate health, safety and personal rights risk to resident in care.

87507(g)(4) Admissions Agreements - Modification conditions, including the requirement for the provision of at least 60 days prior written notice to the resident of any rate or rate structure change, or as soon as the licensee is notified of SSI/SSP rate changes. This requirement was not met as evidence by:** Based upon review of R1’s records of rate increase notices and payment ledger and invoices, LPA found that the facility failed to provide proper notice of rate increase that identifies modification conditions and rate structure changes in documented noticed dated 7/31/2020 and failed to follow modification conditions in documented notice dated 4/30/2021. This serves as a potential health, safety and personal rights risk to resident in care.

****THIS IS AN AMENDMENT****to original report dated 4/11/2025. LPA did not determine a deficiency during visit. Citation removed. No citation issued.

Facility personnel sufficiency and competence

Personnel Requirements: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This was not met as evidence by: Administrator failed to prevent resident (R1) from eloping the facility. Based upon interview with Administrator, it was found staff (S1) was asleep during the incident, and not properly supervised resident (R1). Record review shows R1 is diagnosed with dementia, at wander risk and unable to leave the facility unassisted. This serves as an immediate health & and safety risk.

Safe, healthful, comfortable accommodations

To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This was not met as evidence by: Based upon interviews with Executive Director, staff (S1), review of facility records and LPA observation, facility failed to ensure resident has safe accommodations and equipment as resident (R1) sustained injury from falling off wheelchair lift during transport. This serves as a potential health & safety & personal rights risk to residents in care.

Freedom to leave and not be locked in

87468.1 Personal Rights of Residents in All Facilities..(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights:..(6)To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night..This requirement was not met as evidenced by facility staff prevented R1 and R2 from leaving the facility which posed a potential health and safety risks for persons in care.