Cycle 1
Health 2025-03-24 · Fire 2025-03-24
12 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
San Francisco, CA
The Avenues Transitional Care Center
3-star overall rating with 3-star inspections with $12,685 in total fines with 11 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
2043 19th Avenue, San Francisco, CA
(415) 661-8787
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
140
Certified beds
Average residents
129
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
0.88
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.63
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.40
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
3.90
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.51
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.65
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.59
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.16
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.93
CMS adjusted RN staffing hours
Adjusted total hours
4.13
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
20%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
44%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,804
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.61
Composite VBP score used to determine payment impact.
Payment multiplier
0.9956
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.73% · Performance 22.50% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
5.41
Baseline 6.74% · Performance 6.22% · Measure score 5.41 · Achievement 5.41 · Improvement 2.51
Total nurse turnover
7.36
Performance 33.61% · Measure score 7.36 · Achievement 7.36 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
4.28
Baseline 3.96 hours · Performance 4.29 hours · Measure score 4.28 · Achievement 4.28 · Improvement 1.33
SNF QRP
Medicare quality reporting measures
| 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 220 · Observed rate 9.09% · Lower 95% interval 7.56% |
| Discharge to community | 55.02% |
50.57%
4.5 pts better
|
No Different than the National Rate · Eligible stays 235 · Observed rate 48.09% · Lower 95% interval 48.57% |
| Medicare spending per beneficiary | 1.18 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 89.66% |
95.27%
5.6 pts worse
|
Numerator 156 · Denominator 174 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 174 |
| Discharge self-care score | 67.86% |
53.69%
14.2 pts better
|
Numerator 76 · Denominator 112 |
| Discharge mobility score | 66.07% |
50.94%
15.1 pts better
|
Numerator 74 · Denominator 112 |
| Pressure ulcers or injuries, new or worsened | 0.57% |
2.29%
1.7 pts better
|
Numerator 1 · Denominator 174 · Adjusted rate 0.5% |
| Healthcare-associated infections requiring hospitalization | 6.22% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 171 · Observed rate 5.26% · Lower 95% interval 3.41% |
| Staff COVID-19 vaccination coverage | 64.97% |
8.2%
56.8 pts better
|
Numerator 128 · Denominator 197 |
| Staff flu vaccination coverage | 83.95% |
42%
42 pts better
|
Numerator 204 · Denominator 243 |
| Discharge function score | 70.54% |
56.45%
14.1 pts better
|
Numerator 79 · Denominator 112 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 67 · Denominator 67 |
| Transfer of health information to patient | 95.95% |
96.28%
0.3 pts worse
|
Numerator 71 · Denominator 74 |
| Resident COVID-19 vaccinations up to date | 66% |
25.2%
40.8 pts better
|
Numerator 66 · Denominator 100 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.0 |
2.3
0.7 pts worse
|
1.9
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.0 · Observed 2.5 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.9 |
1.6
1.3 pts worse
|
1.8
1.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 2.1 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
98.5%
1.3 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 99.1% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| 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 | 1.0% |
1.6%
0.6 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.9% · Q3 1.0% · Q4 1.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.4% |
6.8%
1.6 pts worse
|
11.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 9.9% · Q3 11.1% · Q4 8.1% · 4Q avg 8.4% |
| Percentage of long-stay residents who lose too much weight | 1.6% |
4.1%
2.5 pts better
|
5.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 3.2% · Q3 1.1% · Q4 0.0% · 4Q avg 1.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 3.9% |
13.7%
9.8 pts better
|
19.6%
15.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 4.0% · Q3 5.4% · Q4 3.3% · 4Q avg 3.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.5% |
14.2%
3.7 pts better
|
16.7%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 9.5% · Q3 10.0% · Q4 12.5% · 4Q avg 10.5% · 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 | 10.4% |
11.0%
0.6 pts better
|
16.3%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 14.2% · Q3 10.6% · Q4 11.3% · 4Q avg 10.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.5% |
10.7%
2.2 pts better
|
14.9%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.2% · Q2 12.0% · Q3 9.3% · Q4 2.8% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.3% |
1.0%
0.7 pts better
|
1.0%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
1.2%
0.5 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 0.0% · Q4 1.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.4% |
10.9%
7.5 pts worse
|
19.8%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 24.5% · Q2 12.5% · Q3 15.6% · Q4 20.7% · 4Q avg 18.4% |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
4.7%
2.6 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 3.2% · Q3 2.2% · Q4 0.7% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
94.0%
5.6 pts better
|
81.7%
17.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 99.5% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.0% |
11.2%
0.8 pts worse
|
12.0%
About the same
|
Short Stay · 20240701-20250630 · Adjusted 12.0% · Observed 11.9% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.5%
0.4 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 1.6% · Q3 1.5% · Q4 0.7% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.4% |
93.2%
5.2 pts better
|
79.7%
18.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.6% |
23.2%
4.4 pts worse
|
23.9%
3.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.6% · Observed 25.9% · Expected 22.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-26 · Fire 2024-01-26
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2021-04-09 · Fire 2021-04-09
8 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-03-24
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-04-07
E · Potential for more than minimal harm
2025-03-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-07
D · Potential for more than minimal harm
2025-03-24
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-04-07
D · Potential for more than minimal harm
2025-03-24
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-04-07
D · Potential for more than minimal harm
2025-03-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-07
D · Potential for more than minimal harm
2025-03-24
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2025-04-07
D · Potential for more than minimal harm
2025-03-24
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2025-04-07
D · Potential for more than minimal harm
2025-03-24
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-04-07
C · Minimal harm
2025-03-24
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-04-07
C · Minimal harm
2025-03-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-07
F · Potential for more than minimal harm
2024-01-26
E35 · Emergency Preparedness Deficiencies
Fire Safety
Provide family notifications of emergency plan.
Corrected 2024-02-29
F · Potential for more than minimal harm
2024-01-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-29
E · Potential for more than minimal harm
2024-01-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-02-29
E · Potential for more than minimal harm
2024-01-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-02-29
D · Potential for more than minimal harm
2024-01-26
E31 · Emergency Preparedness Deficiencies
Fire Safety
Provide emergency officials' contact information.
Corrected 2024-02-29
D · Potential for more than minimal harm
2024-01-26
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-02-29
D · Potential for more than minimal harm
2024-01-26
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-02-29
D · Potential for more than minimal harm
2024-01-26
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-02-29
D · Potential for more than minimal harm
2024-01-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-29
D · Potential for more than minimal harm
2024-01-26
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-02-29
D · Potential for more than minimal harm
2024-01-26
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-02-29
E · Potential for more than minimal harm
2021-04-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-04-27
E · Potential for more than minimal harm
2021-04-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-04-27
D · Potential for more than minimal harm
2021-04-09
K225 · Egress Deficiencies
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2021-04-27
D · Potential for more than minimal harm
2021-04-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-04-27
Inspection history
Recent health citations
G · Actual harm
2025-10-02
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 2025-10-20
F · Potential for more than minimal harm
2025-03-24
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 2025-04-20
E · Potential for more than minimal harm
2025-03-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-20
E · Potential for more than minimal harm
2025-03-24
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 2025-04-20
E · Potential for more than minimal harm
2025-03-24
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 2025-04-20
E · Potential for more than minimal harm
2025-03-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-20
D · Potential for more than minimal harm
2025-03-24
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 2025-04-20
D · Potential for more than minimal harm
2025-03-24
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-04-20
D · Potential for more than minimal harm
2025-03-24
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-04-20
D · Potential for more than minimal harm
2025-03-24
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 2025-04-20
D · Potential for more than minimal harm
2025-03-24
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 2025-04-20
B · Minimal harm
2025-03-24
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2025-04-20
D · Potential for more than minimal harm
2024-05-21
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-21
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 2024-06-21
D · Potential for more than minimal harm
2024-01-26
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 2024-02-25
E · Potential for more than minimal harm
2023-04-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-05-16
D · Potential for more than minimal harm
2023-04-05
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 2023-05-16
D · Potential for more than minimal harm
2021-04-09
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2021-06-11
D · Potential for more than minimal harm
2021-04-09
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2021-06-11
D · Potential for more than minimal harm
2021-04-09
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-06-11
D · Potential for more than minimal harm
2021-04-09
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2021-06-11
D · Potential for more than minimal harm
2021-04-09
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
C · Minimal harm
2021-04-09
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2021-06-11
Penalties and ownership
What sits behind the stars
$12,685
2025-10-02
Fine
Fine · fine $12,685
Fine
Ownership
Asjk LLC
Operational/Managerial Control · Organization
Basa, Edil
Operational/Managerial Control · Individual
Bradshaw, Jeffrey
Operational/Managerial Control · Individual
Case, Ryan
Operational/Managerial Control · Individual
Go, Maria
Operational/Managerial Control · Individual
Jamali, Mehran
Operational/Managerial Control · Individual
Orgill, Craig
Operational/Managerial Control · Individual
Rawe, Colton
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Laguna Honda Hospital & Rehabilitation Ctr D/P SNF
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
#2
Lawton Skilled Nursing & Rehabilitation Center
San Francisco, CA
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
St. Anne's Home
San Francisco, CA
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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