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

Compare this facility

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

Chain footprint

264 facilities

Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.80

Registered nurse staffing · state 0.65 · national 0.68

LPN hours / resident day

0.74

Licensed practical nurse staffing · state 1.22 · national 0.87

Aide hours / resident day

2.38

Nurse aide staffing · state 2.64 · national 2.35

Total nurse hours

3.92

All reported nurse hours · state 4.51 · national 3.89

Licensed hours

1.54

RN + LPN hours · state 1.87 · national 1.54

Weekend hours

3.56

Weekend nurse staffing · state 4.08 · national 3.43

Weekend RN hours

0.53

Weekend registered nurse coverage · state 0.50 · national 0.47

Physical therapist

0.17

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.75

CMS adjusted RN staffing hours

Adjusted total hours

3.65

CMS adjusted total nurse staffing hours

Case-mix index

1.47

Higher values indicate more complex resident acuity

RN turnover

53%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

29%

Annual nurse turnover · state 38% · national 46%

SNF VBP

Value-based purchasing

Program rank

5,861

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

34.79

Composite VBP score used to determine payment impact.

Payment multiplier

0.9886

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

5.12

Baseline 19.50% · Performance 19.06% · Measure score 5.12 · Achievement 5.12 · Improvement 1.28

Healthcare-associated infections

0

Baseline 6.46% · Performance 8.18% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

7.64

Baseline 46.84% · Performance 32.47% · Measure score 7.64 · Achievement 7.64 · Improvement 6.04

Adjusted total nurse staffing

1.16

Baseline 3.51 hours · Performance 3.41 hours · Measure score 1.16 · Achievement 1.16 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 10.88%
10.72%
0.2 pts worse
No Different than the National Rate · Eligible stays 272 · Observed rate 11.03% · Lower 95% interval 8.47%
Discharge to community 59.7%
50.57%
9.1 pts better
Better than the National Rate · Eligible stays 285 · Observed rate 51.23% · Lower 95% interval 53.93%
Medicare spending per beneficiary 1.24
1.02
0.2 pts worse
Drug regimen review with follow-up 100%
95.27%
4.7 pts better
Numerator 228 · Denominator 228
Falls with major injury 0%
0.77%
0.8 pts better
Numerator 0 · Denominator 228
Discharge self-care score 75%
53.69%
21.3 pts better
Numerator 99 · Denominator 132
Discharge mobility score 68.18%
50.94%
17.2 pts better
Numerator 90 · Denominator 132
Pressure ulcers or injuries, new or worsened 0%
2.29%
2.3 pts better
Numerator 0 · Denominator 228 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization 8.18%
7.12%
1.1 pts worse
No Different than the National Rate · Eligible stays 185 · Observed rate 9.19% · Lower 95% interval 5.62%
Staff COVID-19 vaccination coverage 3.1%
8.2%
5.1 pts worse
Numerator 4 · Denominator 129
Staff flu vaccination coverage 52.94%
42%
10.9 pts better
Numerator 90 · Denominator 170
Discharge function score 81.06%
56.45%
24.6 pts better
Numerator 107 · Denominator 132
Transfer of health information to provider 100%
95.95%
4 pts better
Numerator 75 · Denominator 75
Transfer of health information to patient 84.21%
96.28%
12.1 pts worse
Numerator 96 · Denominator 114
Resident COVID-19 vaccinations up to date 23.14%
25.2%
2.1 pts worse
Numerator 28 · Denominator 121

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 · Adjusted 1.0 · Observed 1.3 · Expected 2.3 · Used in QM five-star
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 · Adjusted 1.4 · Observed 1.3 · Expected 1.6 · Used in QM five-star
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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
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 · 4Q avg 100.0%
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 · Q1 1.8% · Q2 2.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star
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 · Q1 26.0% · Q2 27.1% · Q3 20.0% · Q4 17.9% · 4Q avg 22.5%
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 · Q1 6.2% · Q2 2.3% · Q3 4.3% · Q4 6.2% · 4Q avg 4.8%
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 · Q1 4.2% · Q2 2.3% · Q3 4.0% · Q4 0.0% · 4Q avg 2.6%
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 · Q1 14.7% · Q2 17.6% · Q3 14.3% · Q4 7.5% · 4Q avg 13.3% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
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 · Q1 10.7% · 4Q avg 5.0% · Used in QM five-star
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 · Q1 4.4% · Q2 9.8% · Q3 6.5% · Q4 8.0% · 4Q avg 7.1% · Used in QM five-star
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 · Q1 1.5% · Q2 1.4% · Q3 1.7% · Q4 1.4% · 4Q avg 1.5% · Used in QM five-star
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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
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 · Q1 21.5% · Q2 24.1% · Q3 26.5% · Q4 15.9% · 4Q avg 21.8%
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 · Q1 1.5% · Q2 0.0% · Q3 1.7% · Q4 2.2% · 4Q avg 1.4% · Used in QM five-star
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 · Q1 100.0% · Q2 100.0% · Q3 99.5% · Q4 99.5% · 4Q avg 99.8%
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 · Adjusted 11.3% · Observed 12.6% · Expected 12.4% · Used in QM five-star
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 · Q1 0.0% · Q2 0.6% · Q3 0.7% · Q4 0.7% · 4Q avg 0.5% · Used in QM five-star
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 · 4Q avg 99.6%
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 · Adjusted 17.1% · Observed 18.4% · Expected 25.5% · Used in QM five-star

Survey summary

Recent inspection cycles

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)

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

100% 79 facilities 2019-01-01
Apt, Frederick

Corporate Officer · Individual

0% 252 facilities 2024-01-01
Hancock, Mark

5% Or Greater Indirect Ownership Interest · Individual

0% 253 facilities 2024-04-15
Jergensen, Joshua

Corporate Officer · Individual

0% 237 facilities 2024-01-01
Mitchell, John

Corporate Officer · Individual

0% 254 facilities 2024-01-01
Murray, Jason

5% Or Greater Indirect Ownership Interest · Individual

0% 250 facilities 2024-04-15
Pacs Group, Inc.

5% Or Greater Indirect Ownership Interest · Organization

0% 239 facilities 2023-06-30
Pacs Holdings, LLC

5% Or Greater Indirect Ownership Interest · Organization

0% 238 facilities 2023-06-30
Portier, David

Contracted Managing Employee · Individual

0% 3 facilities 2019-09-01
Russell, Matthew

W-2 Managing Employee · Individual

0% 3 facilities 2023-09-01

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