Cycle 1
Health 2025-02-20 · Fire 2025-02-20
3 health deficiencies
Top issue: Infection Control (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
San Francisco, CA
Central Gardens Post Acute
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
1355 Ellis Street, San Francisco, CA
(415) 567-2967
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
92
Certified beds
Average residents
87
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.80
Registered nurse staffing
LPN hours / resident day
0.74
Licensed practical nurse staffing
Aide hours / resident day
2.38
Nurse aide staffing
Weekend hours
3.56
Weekend nurse staffing
RN turnover
53%
Annual RN turnover
Total nurse turnover
29%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
2.3
1.3 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.6
0.2 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
98.2%
1.8 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.9% |
1.6%
0.7 pts better
|
3.3%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 22.5% |
6.8%
15.7 pts worse
|
11.4%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 4.8% |
4.1%
0.7 pts worse
|
5.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 2.6% |
13.7%
11.1 pts better
|
19.6%
17 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 13.3% |
14.2%
0.9 pts better
|
16.7%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 5.0% |
11.0%
6 pts better
|
16.3%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.1% |
10.7%
3.6 pts better
|
14.9%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.5% |
1.0%
0.5 pts worse
|
1.0%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
1.2%
1.2 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.8% |
10.9%
10.9 pts worse
|
19.8%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 1.4% |
4.7%
3.3 pts better
|
5.1%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
94.0%
5.8 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.3% |
11.2%
0.1 pts worse
|
12.0%
0.7 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.5%
1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.6% |
93.2%
6.4 pts better
|
79.7%
19.9 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.1% |
23.2%
6.1 pts better
|
23.9%
6.8 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-05-26 · Fire 2023-05-26
10 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2019-10-04 · Fire 2019-10-04
21 health deficiencies
Top issue: Resident Rights (4 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-02-20
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-06
D · Potential for more than minimal harm
2025-02-20
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-03-06
D · Potential for more than minimal harm
2025-02-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-06
D · Potential for more than minimal harm
2025-02-20
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-03-06
D · Potential for more than minimal harm
2025-02-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-06
D · Potential for more than minimal harm
2025-02-20
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-03-06
C · Minimal harm
2025-02-20
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2025-03-06
C · Minimal harm
2025-02-20
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2025-03-06
F · Potential for more than minimal harm
2023-05-26
K347 · Smoke Deficiencies
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2023-06-20
E · Potential for more than minimal harm
2023-05-26
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-06-20
D · Potential for more than minimal harm
2023-05-26
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-06-20
D · Potential for more than minimal harm
2023-05-26
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-06-20
D · Potential for more than minimal harm
2023-05-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-20
D · Potential for more than minimal harm
2023-05-26
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-06-20
D · Potential for more than minimal harm
2023-05-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-06-20
D · Potential for more than minimal harm
2023-05-26
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-06-20
F · Potential for more than minimal harm
2019-10-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-11-26
F · Potential for more than minimal harm
2019-10-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-11-26
E · Potential for more than minimal harm
2019-10-04
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2019-11-26
D · Potential for more than minimal harm
2019-10-04
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-11-26
D · Potential for more than minimal harm
2019-10-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-11-26
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-02-20
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-03-13
D · Potential for more than minimal harm
2025-02-20
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-03-13
D · Potential for more than minimal harm
2025-02-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-13
E · Potential for more than minimal harm
2024-04-25
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-05-31
E · Potential for more than minimal harm
2024-04-25
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-05-31
D · Potential for more than minimal harm
2024-01-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-01
E · Potential for more than minimal harm
2023-05-26
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-06-24
E · Potential for more than minimal harm
2023-05-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-24
D · Potential for more than minimal harm
2023-05-26
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2023-06-24
D · Potential for more than minimal harm
2023-05-26
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-06-24
D · Potential for more than minimal harm
2023-05-26
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-06-24
D · Potential for more than minimal harm
2023-05-26
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-06-24
D · Potential for more than minimal harm
2023-05-26
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-06-24
D · Potential for more than minimal harm
2023-05-26
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-06-24
D · Potential for more than minimal harm
2023-05-19
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-06-06
D · Potential for more than minimal harm
2023-05-19
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-06-06
D · Potential for more than minimal harm
2023-03-15
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-03-30
E · Potential for more than minimal harm
2023-03-14
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-04-04
E · Potential for more than minimal harm
2023-03-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-04-04
E · Potential for more than minimal harm
2023-03-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-04
E · Potential for more than minimal harm
2023-03-13
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-03-30
D · Potential for more than minimal harm
2023-03-13
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-03-30
F · Potential for more than minimal harm
2019-10-04
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-11-12
F · Potential for more than minimal harm
2019-10-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-11-12
E · Potential for more than minimal harm
2019-10-04
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2019-11-12
E · Potential for more than minimal harm
2019-10-04
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2019-11-12
E · Potential for more than minimal harm
2019-10-04
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-11-12
E · Potential for more than minimal harm
2019-10-04
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2019-11-12
E · Potential for more than minimal harm
2019-10-04
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2019-11-12
D · Potential for more than minimal harm
2019-10-04
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2019-11-12
D · Potential for more than minimal harm
2019-10-04
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2019-11-12
D · Potential for more than minimal harm
2019-10-04
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2019-11-12
D · Potential for more than minimal harm
2019-10-04
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-11-12
D · Potential for more than minimal harm
2019-10-04
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2019-11-12
Penalties and ownership
What sits behind the stars
Ownership
Providence Group Inc
5% Or Greater Direct Ownership Interest · Organization
Apt, Frederick
Corporate Officer · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Jergensen, Joshua
Corporate Officer · Individual
Mitchell, John
Corporate Officer · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Portier, David
Contracted Managing Employee · Individual
Russell, Matthew
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Sequoias San Francisco Convalescent Hospital
San Francisco, CA
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Victorian Post Acute
San Francisco, CA
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Pacific Heights Transitional Care Center
San Francisco, CA
5-star overall rating with 4-star inspections with $25,490 in total fines with 11 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
Jump out