Cycle 1
Health 2024-08-29 · Fire 2024-08-29
11 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
San Francisco, CA
Pacific Heights Transitional Care Center
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
2707 Pine Street, San Francisco, CA
(415) 563-7600
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
120
Certified beds
Average residents
109
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Aspen Skilled Healthcare
Operator or chain grouping
Approved since
1974-03-29
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
34 facilities
Chain averages 4 overall / 3 health / 3 staffing / 5 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
0.82
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.76
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.41
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
3.99
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.58
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.55
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.67
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.23
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.82
CMS adjusted RN staffing hours
Adjusted total hours
4.02
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
32%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,860
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.86
Composite VBP score used to determine payment impact.
Payment multiplier
0.9820
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.30% · Performance 21.39% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.48
Baseline 5.30% · Performance 7.39% · Measure score 1.48 · Achievement 1.48 · Improvement 0
Total nurse turnover
2.71
Baseline 50.81% · Performance 52.59% · Measure score 2.71 · Achievement 2.71 · Improvement 0
Adjusted total nurse staffing
3.35
Baseline 4.13 hours · Performance 4.03 hours · Measure score 3.35 · Achievement 3.35 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.11% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 306 · Observed rate 11.11% · Lower 95% interval 8.6% |
| Discharge to community | 56.82% |
50.57%
6.2 pts better
|
No Different than the National Rate · Eligible stays 298 · Observed rate 47.65% · Lower 95% interval 50.02% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.99% |
95.27%
2.7 pts better
|
Numerator 195 · Denominator 199 |
| Falls with major injury | 0.5% |
0.77%
0.3 pts better
|
Numerator 1 · Denominator 199 |
| Discharge self-care score | 76.15% |
53.69%
22.5 pts better
|
Numerator 99 · Denominator 130 |
| Discharge mobility score | 63.85% |
50.94%
12.9 pts better
|
Numerator 83 · Denominator 130 |
| Pressure ulcers or injuries, new or worsened | 1.01% |
2.29%
1.3 pts better
|
Numerator 2 · Denominator 199 · Adjusted rate 0.96% |
| Healthcare-associated infections requiring hospitalization | 7.39% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 169 · Observed rate 8.28% · Lower 95% interval 4.71% |
| Staff COVID-19 vaccination coverage | 10.11% |
8.2%
1.9 pts better
|
Numerator 18 · Denominator 178 |
| Staff flu vaccination coverage | 91.62% |
42%
49.6 pts better
|
Numerator 175 · Denominator 191 |
| Discharge function score | 68.46% |
56.45%
12 pts better
|
Numerator 89 · Denominator 130 |
| Transfer of health information to provider | 96.61% |
95.95%
0.7 pts better
|
Numerator 57 · Denominator 59 |
| Transfer of health information to patient | 91.84% |
96.28%
4.4 pts worse
|
Numerator 90 · Denominator 98 |
| Resident COVID-19 vaccinations up to date | 63.27% |
25.2%
38.1 pts better
|
Numerator 62 · Denominator 98 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
2.3
0.2 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.0 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.6
0.4 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.3 · 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 | 98.9% |
98.2%
0.7 pts better
|
95.5%
3.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
1.6%
1.6 pts better
|
3.3%
3.3 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 who have depressive symptoms | 1.1% |
6.8%
5.7 pts better
|
11.4%
10.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 0.0% · Q3 1.4% · Q4 0.0% · 4Q avg 1.1% |
| Percentage of long-stay residents who lose too much weight | 1.3% |
4.1%
2.8 pts better
|
5.4%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.6% · Q3 1.3% · Q4 0.0% · 4Q avg 1.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 1.9% |
13.7%
11.8 pts better
|
19.6%
17.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.6% · Q3 1.2% · Q4 1.3% · 4Q avg 1.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.6% |
14.2%
10.6 pts better
|
16.7%
13.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.9% · Q3 5.1% · Q4 5.7% · 4Q avg 3.6% · 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 | 13.6% |
11.0%
2.6 pts worse
|
16.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 17.8% · Q3 3.5% · Q4 16.2% · 4Q avg 13.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.8% |
10.7%
2.9 pts better
|
14.9%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 10.1% · Q3 4.4% · Q4 7.7% · 4Q avg 7.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.0%
1 pts better
|
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% · 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 | 19.8% |
10.9%
8.9 pts worse
|
19.8%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 28.9% · Q3 10.1% · Q4 18.8% · 4Q avg 19.8% |
| Percentage of long-stay residents with pressure ulcers | 2.9% |
4.7%
1.8 pts better
|
5.1%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.0% · Q3 4.5% · Q4 2.9% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
94.0%
4.5 pts better
|
81.7%
16.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.3% · Q2 98.4% · Q3 97.3% · Q4 100.0% · 4Q avg 98.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.2% |
11.2%
1 pts worse
|
12.0%
0.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.2% · Observed 12.0% · Expected 11.0% · 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 0.0% · Q3 0.6% · Q4 1.3% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.9% |
93.2%
4.7 pts better
|
79.7%
18.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.6% |
23.2%
5.6 pts better
|
23.9%
6.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.6% · Observed 16.9% · Expected 22.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-04-28 · Fire 2021-04-28
9 health deficiencies
Top issue: Pharmacy Service (5 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2020-02-06 · Fire 2020-02-06
17 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
24 fire-safety deficiencies
Top issue: Emergency Preparedness (10 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-08-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-24
F · Potential for more than minimal harm
2024-08-29
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-24
E · Potential for more than minimal harm
2024-08-29
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-24
D · Potential for more than minimal harm
2024-08-29
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-09-24
D · Potential for more than minimal harm
2024-08-29
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-09-24
D · Potential for more than minimal harm
2024-08-29
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-09-24
D · Potential for more than minimal harm
2024-08-29
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-09-24
C · Minimal harm
2024-08-29
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-09-24
C · Minimal harm
2024-08-29
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-09-24
C · Minimal harm
2024-08-29
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-09-24
E · Potential for more than minimal harm
2021-04-28
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2021-05-27
E · Potential for more than minimal harm
2021-04-28
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2021-05-27
E · Potential for more than minimal harm
2021-04-28
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-05-27
E · Potential for more than minimal harm
2021-04-28
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-05-27
D · Potential for more than minimal harm
2021-04-28
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2021-05-27
D · Potential for more than minimal harm
2021-04-28
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-05-27
F · Potential for more than minimal harm
2020-02-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-04-15
F · Potential for more than minimal harm
2020-02-06
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2020-04-15
E · Potential for more than minimal harm
2020-02-06
E18 · Emergency Preparedness Deficiencies
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2020-04-15
E · Potential for more than minimal harm
2020-02-06
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2020-04-15
E · Potential for more than minimal harm
2020-02-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-04-15
E · Potential for more than minimal harm
2020-02-06
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2020-04-15
E · Potential for more than minimal harm
2020-02-06
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2020-04-15
E · Potential for more than minimal harm
2020-02-06
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2020-04-15
D · Potential for more than minimal harm
2020-02-06
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2020-04-15
D · Potential for more than minimal harm
2020-02-06
E20 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2020-04-15
D · Potential for more than minimal harm
2020-02-06
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2020-04-15
D · Potential for more than minimal harm
2020-02-06
E32 · Emergency Preparedness Deficiencies
Fire Safety
Provide primary/alternate means for communication.
Corrected 2020-04-15
D · Potential for more than minimal harm
2020-02-06
E34 · Emergency Preparedness Deficiencies
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2020-04-15
D · Potential for more than minimal harm
2020-02-06
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2020-04-15
D · Potential for more than minimal harm
2020-02-06
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2020-04-15
D · Potential for more than minimal harm
2020-02-06
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2020-04-15
D · Potential for more than minimal harm
2020-02-06
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2020-04-15
D · Potential for more than minimal harm
2020-02-06
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2020-04-15
D · Potential for more than minimal harm
2020-02-06
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2020-04-15
D · Potential for more than minimal harm
2020-02-06
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2020-04-15
D · Potential for more than minimal harm
2020-02-06
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2020-04-15
D · Potential for more than minimal harm
2020-02-06
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-04-15
D · Potential for more than minimal harm
2020-02-06
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2020-04-15
D · Potential for more than minimal harm
2020-02-06
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2020-04-15
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-01-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Not marked corrected
E · Potential for more than minimal harm
2024-08-29
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-09-26
E · Potential for more than minimal harm
2024-08-29
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 2024-09-26
D · Potential for more than minimal harm
2024-08-29
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 2024-09-26
D · Potential for more than minimal harm
2024-08-29
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-08-29
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-08-29
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 2024-09-26
D · Potential for more than minimal harm
2024-08-29
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-08-29
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-08-29
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-08-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-26
C · Minimal harm
2024-08-29
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-09-26
D · Potential for more than minimal harm
2023-09-12
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-10-03
E · Potential for more than minimal harm
2023-07-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-18
E · Potential for more than minimal harm
2023-07-03
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-08-04
D · Potential for more than minimal harm
2023-06-02
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 2023-08-04
D · Potential for more than minimal harm
2023-03-30
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-04-07
D · Potential for more than minimal harm
2023-03-30
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-04-07
F · Potential for more than minimal harm
2021-04-28
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 2021-06-11
E · Potential for more than minimal harm
2021-04-28
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-06-11
E · Potential for more than minimal harm
2021-04-28
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2021-06-11
E · Potential for more than minimal harm
2021-04-28
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2021-06-11
E · Potential for more than minimal harm
2021-04-28
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 2021-06-11
E · Potential for more than minimal harm
2021-04-28
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 2021-06-11
E · Potential for more than minimal harm
2021-04-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-06-11
D · Potential for more than minimal harm
2021-04-28
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2021-06-11
E · Potential for more than minimal harm
2020-02-06
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 2020-04-16
E · Potential for more than minimal harm
2020-02-06
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 2020-04-16
E · Potential for more than minimal harm
2020-02-06
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2020-04-16
E · Potential for more than minimal harm
2020-02-06
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 2020-04-16
D · Potential for more than minimal harm
2020-02-06
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2020-04-16
D · Potential for more than minimal harm
2020-02-06
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 2020-04-16
D · Potential for more than minimal harm
2020-02-06
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 2020-04-16
D · Potential for more than minimal harm
2020-02-06
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2020-04-16
D · Potential for more than minimal harm
2020-02-06
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2020-04-16
D · Potential for more than minimal harm
2020-02-06
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2020-04-16
D · Potential for more than minimal harm
2020-02-06
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2020-04-16
Penalties and ownership
What sits behind the stars
$25,490
2025-01-29
Fine
Fine · fine $25,490
Fine
Ownership
Skbm LLC
5% Or Greater Direct Ownership Interest · Organization
Asfp, LLC
Operational/Managerial Control · Organization
Aspen Skilled Healthcare Inc
5% Or Greater Indirect Ownership Interest · Organization
Bradshaw, Jeffrey
5% Or Greater Indirect Ownership Interest · Individual
Bradshaw, Jeffrey
Operational/Managerial Control · Individual
Bradshaw, Jeffrey
Corporate Director · Individual
Bradshaw, Jeffrey
Corporate Officer · Individual
Brady, Vern
5% Or Greater Indirect Ownership Interest · Individual
Brady, Vern
Corporate Director · Individual
Brady, Vern
Corporate Officer · Individual
Case, Ryan
5% Or Greater Indirect Ownership Interest · Individual
Case, Ryan
Corporate Director · Individual
Case, Ryan
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Laurel Heights Community Care
San Francisco, CA
5-star overall rating with 4-star inspections with $8,018 in total fines with 4 recent health deficiencies with 2 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
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
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