Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Central Gardens Post Acute during CMS and state inspections, most recent first.
A resident with a history of delusional disorders and schizophrenia was readmitted to the facility with an inaccurate Level I PASARR completed by a hospital, which failed to reflect their mental health diagnoses. The admissions team did not identify the error, resulting in a negative PASARR and no Level II Evaluation. Interviews with facility staff confirmed the oversight.
A facility failed to maintain a medication error rate below 5%, resulting in a 6.67% error rate due to two errors affecting a resident. A nurse administered an incorrect dosage of lurasidone and attempted to give ear drops via the nasal route. The errors were confirmed by the DON and CP, highlighting the importance of verifying medication details before administration.
A facility failed to implement enhanced barrier precautions for a resident requiring such measures. An LVN was observed providing care to a resident with a feeding tube without wearing a gown, despite the requirement for enhanced barrier precautions. The Infection Preventionist, Director of Nursing, and Administrator confirmed that staff should wear both a gown and gloves in these situations.
The facility failed to promptly report allegations of resident-to-resident abuse and theft to the State Agency (CDPH) as required by their policy. Incidents involved a resident with dementia splashing liquid on his roommate and another resident alleging theft by a former roommate. Discrepancies in the reporting process, including issues with voicemail notifications and fax transmissions, were noted.
The facility failed to develop baseline care plans within 48 hours of admission and did not provide a copy of the care plan summary to three residents or their representatives. This resulted in incomplete care plans and potential inadequate care for the residents.
A resident with a lumbar fracture and back surgery did not receive pain medication or bathroom assistance throughout the night. The resident, who only speaks Cantonese, had to walk to the bathroom unassisted and wet her bed, as no staff responded to her call light. The facility also failed to use interpreter services to communicate with the resident.
Inaccurate PASARR Screening for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that a Level I Pre-Admission Screening and Resident Review (PASARR) accurately reflected the presence of diagnosed mental illnesses for a resident. The resident, who had a medical history including delusional disorders and schizophrenia, was readmitted to the facility with a Level I PASARR completed by a local hospital that did not reflect these mental health diagnoses. The PASARR inaccurately indicated that the resident did not have a serious diagnosed mental disorder, resulting in a negative Level I PASARR and no requirement for a Level II Evaluation. Interviews with facility staff, including the Director of Nursing (DON), Admissions Director, and Administrator, revealed that the admissions team was responsible for reviewing PASARRs for accuracy. However, the admissions team failed to identify the inaccuracy in the resident's PASARR, which did not include the resident's mental health diagnoses. The DON and Admissions Director acknowledged the oversight, and the Administrator confirmed that the PASARR completed by the hospital was inaccurate and should have been corrected by the admitting staff.
Medication Administration Errors Lead to Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a rate of 6.67% due to two errors out of 30 opportunities. These errors affected one resident during medication administration. The resident, who had a medical history of unspecified bipolar disorder and intact cognition, was observed during a medication pass where Registered Nurse (RN) #1 made two significant errors. The first error involved the incorrect dosage of lurasidone hydrochloride, where RN #1 initially placed only one 20 mg tablet into the medication cup instead of the prescribed two tablets. The second error occurred when RN #1 attempted to administer Debrox otic solution into the resident's nasal passage instead of the ears. The errors were identified during an observation and interview with RN #1, who admitted to not reading the medication label correctly and being nervous, which led to the mistakes. The Director of Nursing (DON) and the Consultant Pharmacist (CP) both confirmed that these actions were medication errors, emphasizing the importance of verifying the right dose, route, and resident before administration. The Administrator also acknowledged the errors, reiterating the expectation for nurses to adhere to the correct medication administration procedures.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff implemented enhanced barrier precautions (EBP) when providing care to a resident requiring such precautions. Specifically, a Licensed Vocational Nurse (LVN) was observed entering the room of Resident #155, who required EBP due to the presence of an indwelling medical device (feeding tube), without wearing a gown. The LVN donned gloves but proceeded to touch the resident and manipulate the feeding tube without the additional protective barrier of a gown, which is necessary to minimize the risk of spreading germs. The incident was confirmed through interviews with the Infection Preventionist (IP) and the Director of Nursing (DON), both of whom stated that staff should wear both a gown and gloves when providing care to residents requiring EBP. The Administrator also confirmed that staff had been trained to wear gowns in such situations. Resident #155 had been admitted to the facility with a medical history that included a gastrostomy status and required tube feeding due to dysphagia, necessitating the use of EBP during high-contact care activities.
Failure to Promptly Report Allegations of Abuse
Penalty
Summary
The facility failed to ensure the allegation of resident-to-resident abuse was promptly reported to the State Agency (SA), the California Department of Public Health (CDPH), in accordance with the facility's policy and procedure. This failure involved four sampled residents. The incident in question occurred when a resident with dementia splashed liquid on his roommate's face. Although the facility took immediate action to separate the residents and notify relevant parties, there were discrepancies in the reporting process to CDPH, including issues with voicemail notifications and fax transmissions, which were not confirmed by CDPH staff records. Another incident involved a resident alleging that his former roommate stole his identification card and $32.00 in cash. The facility conducted an investigation, notified the Ombudsman, CDPH, and local police, and attempted to contact the accused resident. However, there were inconsistencies in the reporting process, as CDPH did not receive the SOC 341 form on the date claimed by the facility, and there was no record of voicemail notifications. The facility's policy and procedure for reporting abuse, neglect, exploitation, or misappropriation were not followed as required. The policy mandates immediate reporting within two hours of an allegation involving abuse or resulting in serious injury. The facility's failure to adhere to these guidelines resulted in delayed reporting to the state agency, which could potentially lead to further harm to the residents involved.
Failure to Develop and Provide Baseline Care Plans
Penalty
Summary
The facility failed to ensure that a baseline care plan was developed within 48 hours of admission for three residents, and a copy of the baseline care plan summary was not provided to the residents or their representatives. Resident 5 was admitted with diagnoses including rhabdomyolysis, kidney disease, pulmonary hypertension, and major depressive disorder. The baseline care plan for Resident 5 was incomplete, with the section E marked as 'not applicable.' Similarly, Resident 6, admitted with cancer of the prostate, cervical disc degeneration, and glaucoma, had an incomplete baseline care plan, with sections for social services, rehabilitative services, and activity preferences completed after the 48-hour window. Resident 7, admitted with kidney disease, congestive heart failure, atrial fibrillation, and depression, also had an incomplete baseline care plan with section E marked as 'not applicable.' During an interview and concurrent record review, the Director of Nursing (DON) acknowledged that Resident 6's baseline care plan was not completed on time and confirmed that all sections should be completed within 48 hours. The DON also clarified that 'na' written on the Baseline Care Plan Summary meant that it was not reviewed and provided to the resident. The facility's policy and procedure, revised in December 2022, indicated that a baseline care plan should be developed within 48 hours of admission and that a written summary should be provided to the resident or their representative. The failure to adhere to this policy resulted in the residents and their representatives not receiving the necessary information about the initial plan of care, potentially leading to inadequate care and services rendered to the residents.
Failure to Provide Pain Management and Bathroom Assistance
Penalty
Summary
The facility failed to provide necessary care and assistance to Resident 1, who was admitted for physical and occupational therapy services following a lumbar fracture and back surgery. Despite being alert and oriented, Resident 1, who does not speak English, did not receive pain medication or bathroom assistance throughout the night. The resident's son reported that his mother had been waiting for pain medication since the previous day and had to walk to the bathroom unassisted, which was against her care plan. She also wet her bed and remained in it until the morning, as no staff responded to her call light all night. The resident's medical history included back pain, high blood pressure, gout, urinary tract infection, and liver disease. Despite these conditions, the facility did not provide timely pain management or assistance with toileting, leading to undue suffering and neglect. The facility also failed to use interpreter services to communicate with the resident, who only speaks Cantonese. The Director of Nursing acknowledged the son's concerns but did not address the immediate needs of the resident, resulting in a significant lapse in care.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near San Francisco
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sequoias San Francisco Convalescent Hospital | 0.2 mi | ★★★★★ | 13 | 0 |
| Victorian Post Acute | 0.4 mi | ★★★★★ | 0 | 0 |
| Pacific Heights Transitional Care Center | 0.6 mi | ★★★★★ | 6 | 0 |
| Laurel Heights Community Care | 0.7 mi | ★★★★★ | 0 | 0 |
| San Francisco Towers | 0.7 mi | ★★★★★ | 12 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.