5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
San Francisco, CA
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
5767 Mission Street, San Francisco, CA
(415) 584-3294
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Beds
53
Certified beds
Average residents
51
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1977-09-01
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
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
RN hours / resident day
0.66
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.07
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.51
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.23
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.72
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.84
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.70
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.52
CMS adjusted RN staffing hours
Adjusted total hours
3.35
CMS adjusted total nurse staffing hours
Case-mix index
1.72
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
28%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Program rank
5,493
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
36
Composite VBP score used to determine payment impact.
Payment multiplier
0.9895
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
3.80
Baseline 21.15% · Performance 19.67% · Measure score 3.80 · Achievement 3.80 · Improvement 3.08
Healthcare-associated infections
5.49
Baseline 8.15% · Performance 6.26% · Measure score 5.49 · Achievement 5.28 · Improvement 5.49
Total nurse turnover
4.09
Baseline 35.09% · Performance 46.97% · Measure score 4.09 · Achievement 4.09 · Improvement 0
Adjusted total nurse staffing
1.02
Baseline 3.83 hours · Performance 3.37 hours · Measure score 1.02 · Achievement 1.02 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.48% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 229 · Observed rate 10.04% · Lower 95% interval 7.52% |
| Discharge to community | 61.01% |
50.57%
10.4 pts better
|
Better than the National Rate · Eligible stays 259 · Observed rate 51.35% · Lower 95% interval 55.51% |
| Medicare spending per beneficiary | 1.35 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 179 · Denominator 179 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 179 |
| Discharge self-care score | 73.12% |
53.69%
19.4 pts better
|
Numerator 68 · Denominator 93 |
| Discharge mobility score | 59.14% |
50.94%
8.2 pts better
|
Numerator 55 · Denominator 93 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 179 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.26% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 142 · Observed rate 5.63% · Lower 95% interval 3.91% |
| Staff COVID-19 vaccination coverage | 14.68% |
8.2%
6.5 pts better
|
Numerator 16 · Denominator 109 |
| Staff flu vaccination coverage | 75.56% |
42%
33.6 pts better
|
Numerator 102 · Denominator 135 |
| Discharge function score | 83.87% |
56.45%
27.4 pts better
|
Numerator 78 · Denominator 93 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 73 · Denominator 73 |
| Transfer of health information to patient | 92.86% |
96.28%
3.4 pts worse
|
Numerator 78 · Denominator 84 |
| Resident COVID-19 vaccinations up to date | 79.82% |
25.2%
54.6 pts better
|
Numerator 87 · Denominator 109 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
2.3
0.5 pts better
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.8 · Expected 2.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.6
0.7 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.9 · Expected 1.8 · 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 | 0.0% |
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 | 2.3% |
6.8%
4.5 pts better
|
11.4%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q4 5.0% · 4Q avg 2.3% |
| Percentage of long-stay residents who lose too much weight | 2.2% |
4.1%
1.9 pts better
|
5.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 8.3% · Q3 0.0% · Q4 0.0% · 4Q avg 2.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.3% |
13.7%
7.4 pts better
|
19.6%
13.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 8.3% · Q3 4.5% · Q4 0.0% · 4Q avg 6.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.7% |
14.2%
4.5 pts better
|
16.7%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · 4Q avg 9.7% · 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 need for help with daily activities has increased | 3.3% |
10.7%
7.4 pts better
|
14.9%
11.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 4.3% · Q3 4.8% · Q4 0.0% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.3% |
1.0%
1.3 pts worse
|
1.0%
1.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 0.0% · 4Q avg 2.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
1.2%
0.2 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.8% |
10.9%
5.9 pts worse
|
19.8%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.1% · Q2 34.3% · Q4 4.3% · 4Q avg 16.8% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
4.7%
4.7 pts better
|
5.1%
5.1 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 short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
94.0%
6 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 15.2% |
11.2%
4 pts worse
|
12.0%
3.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 15.2% · Observed 16.9% · Expected 12.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.1% |
1.5%
0.6 pts worse
|
1.6%
0.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 3.4% · Q3 2.1% · Q4 1.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
93.2%
6.8 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.9% |
23.2%
3.7 pts worse
|
23.9%
3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.9% · Observed 28.6% · Expected 25.3% · Used in QM five-star |
Survey summary
Top issue: Resident Assessment and Care Planning (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Nutrition and Dietary (7 deficiencies)
9 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Top issue: Nutrition and Dietary (2 deficiencies)
26 fire-safety deficiencies
Top issue: Emergency Preparedness (11 deficiencies)
Fire safety
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-26
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-26
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-12-26
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-26
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2023-10-27
Fire Safety
Establish methods for sharing information.
Corrected 2023-10-27
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2023-10-27
Fire Safety
Provide family notifications of emergency plan.
Corrected 2023-10-27
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-27
Fire Safety
Use approved construction type or materials.
Corrected 2023-10-27
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-27
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-10-27
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-10-27
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-12-21
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-12-21
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-12-21
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2021-12-21
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-12-21
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2021-12-21
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2021-12-21
Fire Safety
Establish procedures for tracking staff and patients during an emergency.
Corrected 2021-12-21
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2021-12-21
Fire Safety
Establish policies and procedures for volunteers.
Corrected 2021-12-21
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2021-12-21
Fire Safety
Provide emergency officials' contact information.
Corrected 2021-12-21
Fire Safety
Provide a means of sharing information on occupancy/needs.
Corrected 2021-12-21
Fire Safety
Establish staff and initial training requirements.
Corrected 2021-12-21
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2021-12-21
Fire Safety
Implement emergency and standby power systems.
Corrected 2021-12-21
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2021-12-21
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2021-12-21
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2021-12-21
Fire Safety
Provide properly protected cooking facilities.
Corrected 2021-12-21
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2021-12-21
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2021-12-21
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2021-12-21
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-12-21
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2021-12-21
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2021-12-21
Inspection history
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-03
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-01-03
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-01-03
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2025-01-03
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 2025-01-03
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-05-21
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2023-11-04
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2023-11-04
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 2023-11-04
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-04
Health
Dispose of garbage and refuse properly.
Corrected 2023-11-04
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-11-04
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-11-04
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-11-04
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-11-04
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-11-04
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2023-11-04
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-11-04
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 2023-11-04
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-11-04
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 2021-11-29
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2021-11-29
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-11-29
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-11-29
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
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
5% Or Greater Indirect Ownership Interest · Organization
W-2 Managing Employee · Individual
Nearby options
San Francisco, CA
3-star overall rating with 2-star inspections with 18 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
Daly City, CA
1-star overall rating with 1-star inspections with $48,836 in total fines with 17 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
San Francisco, CA
3-star overall rating with 2-star inspections with abuse icon flag with $55,499 in total fines with 11 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
Jump out