State issues fine to convalescent home where woman was smothered to death 

The state's Department of Public Health announced today that it issued its most severe citation and a $100,000 fine to a convalescent center in San Francisco's Outer Mission neighborhood where a resident was killed allegedly at the hands of a staff member last year.

Convalescent Center Mission Street, a facility at 5767 Mission St. that has since changed its name to San Francisco Nursing Center, was cited by the department for inadequate care that led to the death of 87-year-old Barbara McIver on March 22, 2010.

Maximo Hong Fajardo Jr., a certified nursing assistant who had only been working at the center for two weeks, allegedly smothered McIver to death with a pillow, police and prosecutors said.

Following the alleged murder, Fajardo ran from the convalescent home and went on a carjacking spree punctuated by multiple crashes until he was arrested in The City's Potrero Hill neighborhood.

Fajardo is currently awaiting trial on murder charges.

The state's Department of Public Health announced today that the center has received an "AA" citation and fine of $100,000 for failing to protect a resident from physical abuse by a staff member.

Department spokesman Ralph Montano said only about 20 AA citations are issued each year to the state's roughly 1,300 nursing facilities. According to the department's website, an any long term care facility may receive the citation, which is a violation that has been "determined to have been a direct proximate cause of death of a patient or resident of a long term care facility."

"It's not something that happens very frequently," Montano said.

McIver, who suffered from dementia and various physical maladies, was killed on Fajardo's first day of work after a two-week training period, according to a report the department released today about the incident.

Despite having no experience working with elderly or frail residents, he was assigned to care for seven residents on that first day, which also coincided with a bathing day for the residents, according to the report.

The report cited the center's "systemic failure in monitoring, supervising and evaluating (Fajardo's) performance on his first day at work" as the reason for the penalty.

Facility staff were also unable to assist the center's director of nursing in providing CPR to McIver before paramedics arrived, according to the report.

Along with the $100,000 fine, the center could have its license revoked if it receives a second "AA" fine in the next 24 months, Montano said.

Officials at the center were not immediately available today to comment on the citation and fine.

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