The state is threatening to shut down the San Francisco city-run elder care facility where a woman went missing and was later found dead nearby, after regulators found eight serious violations there during the last five years, NBC Bay Area’s Investigative Unit has learned.

The state’s Community Care Licensing Division made that threat against the city’s Residential Care Facility for the Elderly in October, following an investigation triggered by the death of Ruby Lee Andersen. Andersen, 75, went missing from there in mid-May of 2018 and was found dead in a nearby hospital power plant stairwell ten days later. She died of apparent kidney failure.

Although Andersen was diagnosed with dementia and was hearing voices, the facility’s sign out sheet shows she was allowed to leave unescorted – something the family’s attorney says was negligent.

“Ruby Lee Andersen should still be alive,” said Haig Harris, the lawyer for the Andersen family. Harris recently filed a claim against the city of San Francisco, the first step toward suing for wrongful death.

The state licensing authority put the Residential Care for the Elderly facility, which is part of the city’s Behavioral Health Center on the grounds of San Francisco General Hospital, on notice after finding eight serious violations there in five years.

“Licensee has been advised that failure to complete the above agreed upon actions” could lead to “possible administrator decertification or license revocation,” the report said.

Harris, shown the findings by NBC Bay Area, said the message was clear: “If they don’t clean up their act, they are at risk of losing that license.’’

Harris pointed to a key finding in the investigation – that five months after Andersen’s doctor recommended she be transferred to a skilled nursing facility because of dementia, she was still at the care center on Potrero Avenue.

“That’s a damning indictment of the care that Ruby Lee Andersen didn’t get -- or the care that she did get -- which was deficient, which resulted in her death.”

Among the conditions set by the licensing division in October, was a ban on accepting dementia patients. Regulators also called for beefed up training and resident health monitoring. The report stresses that for two years, the center will be subjected to rigorous and frequent inspections.

The city Public Health Department said in a statement that the facility provides a “safe and appropriate setting” for residents there. But at the same time, it has “accepted the compliance plan” set up by the state and “believes these changes improve the high level of care that is provided to residents at the facility.”

Pat McGinnis, a nursing home reform advocate based in San Francisco, said the intervention by the state is clearly warranted, given findings that include one resident suffered severely overgrown fingernails and toenails, and another went without medicine for 18 days in a dispute over Medicare.

“I think that most alarming is the fact that it is a 59-bed facility, that it is run by the city and county of San Francisco. We have medical professionals,” she said, “it’s right next to San Francisco General Hospital – one would think you would have the medical expertise to know better.”

For McGinnis, the Andersen violations were inexcusable.

“You can’t justify that behavior,” she said. “There’s nothing you can say that can justify what happened to that woman…”

McGinnis says understaffed regulators have to at least trust providers to get the basics right – something she says didn’t happen with the city run facility.

“You rely, somewhat, on the professional expertise of the people who are running these facilities to know” they can’t take someone with dementia without a dementia plan of operation. “That a person might wander out of the facility and get killed.’ Which is what happened.”

The public health department said it could not comment on details involving the Andersen case, citing privacy concerns. But in its statement, it said the facility provided a compliance plan to regulators to address their concerns and the licensing division accepted it. The plan specifies the facility will not take patients with a dementia diagnosis, will monitor residents for changes in their medical condition and “take appropriate steps when a resident’s condition changes, and includes staff education and training on facility requirements.”