2 health deficiencies
Top issue: Infection Control (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
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
2121 Pine Street, San Francisco, CA
(415) 922-5085
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
90
Certified beds
Average residents
87
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1967-10-31
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
0.58
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
0.75
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.52
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
3.86
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.33
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.69
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.46
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.52
CMS adjusted RN staffing hours
Adjusted total hours
3.43
CMS adjusted total nurse staffing hours
Case-mix index
1.54
Higher values indicate more complex resident acuity
RN turnover
18%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Program rank
6,542
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.54
Composite VBP score used to determine payment impact.
Payment multiplier
0.9871
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
3.47
Baseline 22.23% · Performance 20.16% · Measure score 3.47 · Achievement 2.74 · Improvement 3.47
Healthcare-associated infections
1.13
Baseline 6.74% · Performance 7.50% · Measure score 1.13 · Achievement 1.13 · Improvement 0
Total nurse turnover
8.41
Baseline 40.58% · Performance 29.31% · Measure score 8.41 · Achievement 8.41 · Improvement 6.67
Adjusted total nurse staffing
0
Baseline 3.40 hours · Performance 2.99 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.77% |
10.72%
2 pts worse
|
No Different than the National Rate · Eligible stays 238 · Observed rate 13.45% · Lower 95% interval 9.85% |
| Discharge to community | 52.7% |
50.57%
2.1 pts better
|
No Different than the National Rate · Eligible stays 271 · Observed rate 46.49% · Lower 95% interval 46.04% |
| Medicare spending per beneficiary | 1.46 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 232 · Denominator 232 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 232 |
| Discharge self-care score | 58.21% |
53.69%
4.5 pts better
|
Numerator 78 · Denominator 134 |
| Discharge mobility score | 54.48% |
50.94%
3.5 pts better
|
Numerator 73 · Denominator 134 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 232 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.5% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 192 · Observed rate 7.81% · Lower 95% interval 5.36% |
| Staff COVID-19 vaccination coverage | 7.69% |
8.2%
0.5 pts worse
|
Numerator 8 · Denominator 104 |
| Staff flu vaccination coverage | 51.03% |
42%
9 pts better
|
Numerator 74 · Denominator 145 |
| Discharge function score | 72.39% |
56.45%
15.9 pts better
|
Numerator 97 · Denominator 134 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 68 · Denominator 68 |
| Transfer of health information to patient | 78.81% |
96.28%
17.5 pts worse
|
Numerator 93 · Denominator 118 |
| Resident COVID-19 vaccinations up to date | 18.8% |
25.2%
6.4 pts worse
|
Numerator 25 · Denominator 133 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
2.3
1.1 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.6 · Expected 2.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.8 |
1.6
0.2 pts worse
|
1.8
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 1.8 · Expected 1.7 · 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 | 0.4% |
1.6%
1.2 pts better
|
3.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.8% |
6.8%
1 pts worse
|
11.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 7.4% · Q3 10.0% · Q4 7.4% · 4Q avg 7.8% |
| Percentage of long-stay residents who lose too much weight | 3.5% |
4.1%
0.6 pts better
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 5.6% · Q3 5.0% · Q4 0.0% · 4Q avg 3.5% |
| 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 3.6% · Q2 3.6% · Q3 3.3% · Q4 4.8% · 4Q avg 3.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.0% |
14.2%
9.2 pts better
|
16.7%
11.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 4.8% · Q3 4.1% · Q4 2.1% · 4Q avg 5.0% · 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 | 9.2% |
11.0%
1.8 pts better
|
16.3%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q3 4.5% · 4Q avg 9.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 1.8% |
10.7%
8.9 pts better
|
14.9%
13.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 0.0% · Q3 0.0% · Q4 3.4% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
1.0%
0.6 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · 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 | 18.4% |
10.9%
7.5 pts worse
|
19.8%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 18.1% · Q3 11.1% · Q4 27.0% · 4Q avg 18.4% |
| Percentage of long-stay residents with pressure ulcers | 0.5% |
4.7%
4.2 pts better
|
5.1%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 0.0% · Q3 1.2% · Q4 0.0% · 4Q avg 0.5% · 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 | 13.7% |
11.2%
2.5 pts worse
|
12.0%
1.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.7% · Observed 14.2% · Expected 11.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.0% · Q4 2.7% · 4Q avg 0.8% · 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 | 25.1% |
23.2%
1.9 pts worse
|
23.9%
1.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.1% · Observed 24.9% · Expected 23.6% · Used in QM five-star |
Survey summary
Top issue: Infection Control (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Quality of Life and Care (6 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Top issue: Nutrition and Dietary (3 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-02-25
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-02-25
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-02-25
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-02-25
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-05-11
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-05-11
Fire Safety
Properly provide smoke detection systems in areas open to corridors.
Corrected 2023-05-11
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-05-11
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-05-11
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 2023-05-11
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-05-11
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-05-11
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-05-11
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-05-11
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-05-11
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2023-05-11
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2023-05-11
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-05-11
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-10-15
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-10-15
Fire Safety
Implement emergency and standby power systems.
Corrected 2019-10-15
Fire Safety
Use approved construction type or materials.
Corrected 2019-10-15
Fire Safety
Have stairways and smokeproof enclosures used as exits that meet safety requirements.
Corrected 2019-10-15
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2019-10-15
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-10-15
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2019-10-15
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2019-10-15
Inspection history
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-03-14
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-14
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-06-05
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-06-05
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-06-02
Health
Dispose of garbage and refuse properly.
Corrected 2023-06-02
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-06-02
Health
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Corrected 2023-06-02
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-06-02
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-06-02
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-06-02
Health
Assess the resident when there is a significant change in condition
Corrected 2023-06-02
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-06-02
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-06-02
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-02
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-06-02
Health
Provide care or services that was trauma informed and/or culturally competent.
Corrected 2023-06-02
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2023-06-02
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-06-02
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-06-02
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 2023-06-02
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-02
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2023-06-02
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-06-02
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2019-11-07
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2019-11-07
Health
Post nurse staffing information every day.
Corrected 2019-11-07
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2019-11-07
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected 2019-11-07
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2019-11-07
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2019-11-07
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 2019-11-07
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2019-11-07
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 2019-11-07
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2019-11-07
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2019-11-07
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
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Individual
W-2 Managing Employee · Individual
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