3 health deficiencies
Top issue: Infection Control (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
San Francisco, CA
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
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
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
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
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
| 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
| 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
Top issue: Infection Control (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Resident Assessment and Care Planning (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 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
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-06
Fire Safety
Use approved construction type or materials.
Corrected 2025-03-06
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-06
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-03-06
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-06
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-03-06
Fire Safety
Provide primary/alternate means for communication.
Corrected 2025-03-06
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2025-03-06
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2023-06-20
Fire Safety
Use approved construction type or materials.
Corrected 2023-06-20
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-06-20
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-06-20
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-06-20
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-06-20
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-06-20
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-06-20
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-11-26
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-11-26
Fire Safety
Use approved construction type or materials.
Corrected 2019-11-26
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-11-26
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-11-26
Inspection history
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-03-13
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-03-13
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-13
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-05-31
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
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-05-01
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-06-24
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-24
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
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
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
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
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
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
Health
Respond appropriately to all alleged violations.
Corrected 2023-06-06
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-06-06
Health
Keep all essential equipment working safely.
Corrected 2023-03-30
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
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
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-04
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-03-30
Health
Respond appropriately to all alleged violations.
Corrected 2023-03-30
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
Health
Provide and implement an infection prevention and control program.
Corrected 2019-11-12
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2019-11-12
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
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-11-12
Health
Ensure that residents are free from significant medication errors.
Corrected 2019-11-12
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
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2019-11-12
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2019-11-12
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
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-11-12
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
5% Or Greater Direct Ownership Interest · Organization
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Individual
Corporate Officer · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Contracted Managing Employee · Individual
W-2 Managing Employee · Individual
Nearby options
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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
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