Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Pacific Heights Transitional Care Center during CMS and state inspections, most recent first.
Missing Annual Performance Evaluations for Unlicensed Staff: The facility failed to complete annual performance evaluations for three sampled unlicensed staff members. The DSD stated the facility used Annual Clinical Care Training Checklists for some staff, but these were not the approved performance evaluation form and did not document a true performance review or capture opportunities for additional training. The ADM confirmed the DSD was responsible for the evaluations and that the approved form had not been completed for the sampled staff.
Unsanitary Food Storage Areas and Unlabeled Thickening Powder: Facility staff failed to keep the walk-in refrigerator and walk-in freezer sanitary and failed to label and date a container of thickening powder. During kitchen observation, surveyors found food items and debris on the floors under the shelves in both areas, and the NSS identified the white powder as a fluid thickening agent that should have been labeled and dated. The NSS also stated the walk-in refrigerator was dimly lit, which may have prevented proper cleaning and supervision.
Incomplete dialysis communication and missing post-treatment documentation affected two residents receiving outpatient dialysis. One resident’s dialysis communication book had repeated blank post-dialysis pain assessments, and dialysis staff documented two medications given during treatment, including one illegible entry that could not be identified or found documented as clarified with the MD or RD. For another resident, the dialysis communication book was left at the dialysis center, and the facility could not locate records for the last dialysis session, including weights, meds, complications, or post-dialysis VS, pain, and access site condition.
Controlled medication accountability records did not match the MAR for a resident receiving oxycodone PRN for pain. The MAR showed two 5 mg tablets were administered, but the CDR did not show the sign-out, and the DON acknowledged the discrepancy and stated the CDR and MAR should match.
A resident with diabetes and obesity, who required moderate assistance, was left in a wheelchair in the lobby overnight after the elevator became inoperable. Staff were unable to return the resident to their room due to weight limitations and a non-functioning stair lift chair, resulting in the resident experiencing pain and fatigue. The facility lacked evidence of maintenance, staff training, and implementation of its elevator failure contingency plan.
The facility failed to notify physicians when medications were unavailable for administration to residents, leading to deficiencies in care. A resident with heart disease did not receive losartan and atorvastatin, another with diabetes missed Ozempic doses, and a third with heart failure did not receive Eliquis. Despite documentation of pending pharmacy deliveries, there was no evidence of physician notification, as confirmed by interviews with nursing staff and the DNS.
The facility failed to ensure timely delivery of medications for three residents, resulting in missed doses of critical medications such as losartan, atorvastatin, Ozempic, and Eliquis. Staff interviews revealed inadequate follow-up with the pharmacy and poor documentation practices.
A resident with intact cognition requested an additional window curtain for several months, but the facility failed to provide it, resulting in a deficiency. Despite a work order marked as ASAP, no action was taken until a later date, and the Environmental Services Manager confirmed the delay. The facility's policy emphasizes a homelike environment, but the resident's request was not fulfilled, as acknowledged by the administrator.
A resident on anticoagulant therapy for pulmonary embolism was not accurately coded in the MDS assessment to reflect their medication use. Despite documentation in the care plan and medication records, the MDS assessment failed to indicate the use of apixaban. The LTC MDS Coordinator admitted the error, noting it was missed by the responsible MDS staff. The DNS and Administrator were not involved in the MDS process but expected accurate assessments.
A facility failed to accurately complete a PASRR Level I Screening for a resident with bipolar disorder. The resident's diagnosis and psychotropic medication were not reflected in the screening, resulting in a negative Level I Screening. Facility staff, including the LTC MDS Coordinator and Medical Records Director, were unaware of the inaccuracy, and the oversight was acknowledged by the Director of Nursing Services and the Administrator.
A resident with a history of heart failure and pulmonary embolism was prescribed Eliquis, an anticoagulant, but the medication was not included in their care plan. Interviews with nursing staff confirmed that anticoagulant use should be documented in care plans, as per facility policy. The omission was identified as a deficiency during a survey.
A resident with a urinary catheter was not provided with proper catheter care, as observed in a facility. The CNA used incorrect cleaning techniques, such as wiping from the base to the tip of the penis and not cleaning the catheter tubing, contrary to the facility's policy. Interviews with staff, including the CNA, DSD, IP, DNS, and Administrator, confirmed the failure to adhere to proper procedures, increasing the risk of infection.
A resident with severe cognitive impairment and a history of heart failure and pulmonary embolism was prescribed Eliquis, an anticoagulant, without proper monitoring for side effects. The facility's staff confirmed that monitoring for bleeding and bruising should have been documented on the MAR, but this was not done, resulting in a deficiency.
A resident with multiple health conditions did not receive ordered weekly laboratory tests due to a breakdown in the facility's process. Nursing staff failed to verify the completion of a requisition form and specimen collection, resulting in missed testing. The DON acknowledged the procedural change requiring printed requisitions, but the nurse manager did not ensure compliance.
A facility failed to follow infection control procedures during medication administration for two residents. An RN was observed touching the lip-surface of water cups with bare hands, contrary to facility policy. Interviews with staff, including the IP and DNS, confirmed this practice could lead to cross-contamination and infection risk.
The facility did not post daily nurse staffing data in a location accessible to residents, as required by policy. Observations showed outdated data was only posted in the lobby, inaccessible to residents on upper floors. Staff interviews revealed that the Staffing Coordinator was on vacation, and the DNS failed to update the postings in her absence.
Missing Annual Performance Evaluations for Unlicensed Staff
Penalty
Summary
The facility failed to ensure annual performance reviews or evaluations were completed for three of three sampled unlicensed staff employee files, identified in the report as Unlicensed Staff A, Unlicensed Staff B, and Unlicensed Staff C. During interviews and record review, the Director of Staff Development stated that the facility did not do performance reviews and instead presented Annual Clinical Care Training Checklists for some staff. For Unlicensed Staff A, the checklist dated 7/21/25 was reviewed, but it was not identified as a performance evaluation and did not show how skills were assessed, such as by return demonstration or verbal explanation. The Director of Staff Development also stated the form would not capture situations such as an allegation involving a resident where additional training might have been helpful. For Unlicensed Staff B, the Director of Staff Development stated that no performance evaluation had been completed for 2025 or 2026 and acknowledged that all unlicensed staff were supposed to be completed by April 1, 2026, but none had been done yet. For Unlicensed Staff C, the Director of Staff Development stated the staff member had been hired in January 2025 and no performance evaluation had been completed by January 2026. The Administrator confirmed that the Director of Staff Development was responsible for annual performance evaluations for unlicensed staff and stated the Annual Clinical Care Training Checklist was not the approved performance evaluation form. The facility handbook stated that annual, documented reviews were established as a standard to formalize an interactive conversation about performance, goals, and objectives, and the approved Performance Evaluation form was also reviewed.
Unsanitary Food Storage Areas and Unlabeled Thickening Powder
Penalty
Summary
Facility staff failed to ensure the walk-in freezer and walk-in refrigerator were maintained in a sanitary manner and failed to ensure a container of thickening powder was labeled and dated. During a concurrent kitchen observation and interview with the Nutritional Service Supervisor on 3/9/26 at 9:17 AM, a clear plastic container about half full of white powder was observed on a shelf next to the cook top with no label and no opened date or expiration date. The NSS identified the powder as a fluid thickening agent and stated it should have been labeled and dated for a used-by date. During the same observation, two blue berries, a clear plastic lid for a disposable cup, a can of ginger ale, and a container of Ensure Plus were found on the floor of the walk-in refrigerator under the shelves. A handful of frozen peas and diced carrots, and four small frozen doughs were found on the floor of the walk-in freezer under the shelves. The NSS stated the walk-in refrigerator was dimly lit and confirmed this may have prevented staff from cleaning the area properly and may impede supervisory staff from checking whether the area was clean in a proper manner.
Incomplete dialysis communication and missing post-treatment documentation
Penalty
Summary
Dialysis communication books for two residents receiving outpatient dialysis were incomplete or unavailable, and required post-dialysis documentation was missing. For one resident, the dialysis communication book lacked post-dialysis pain assessments on multiple dialysis dates, and on one dialysis day the book documented that dialysis staff administered calcitriol and a second medication that was written illegibly. During review, the Unit Manager could not identify the second medication and could not find documentation that staff clarified the medications administered by dialysis staff or communicated them to the physician and/or Registered Dietitian. For another resident, the dialysis communication book was left at the dialysis center, and the facility could not locate documentation from the resident’s last dialysis session. The Unit Manager stated there was no documentation found for pre- and post-dialysis weights, medications administered, or other complications from that session. The facility also could not find documentation of post-dialysis assessments for vital signs, pain, or dialysis site condition after the resident’s last dialysis treatment.
Controlled Medication Accountability Record Did Not Match MAR
Penalty
Summary
The facility failed to ensure accountability of controlled medications when the Controlled Drug Record for one sampled resident did not reconcile with the Medication Administration Record. Resident 66 had a physician order dated 1/20/26 for oxycodone 5 mg, with directions to give 1 tablet by mouth every 6 hours as needed for breakthrough pain rated 4-7, and 2 tablets by mouth every 6 hours as needed for breakthrough pain rated 8-10. During a concurrent interview and record review on 3/11/26, the MAR showed that two tablets of oxycodone 5 mg were administered to Resident 66 on 1/22/26 at 9:08 AM, but the CDR did not show the medication was signed out at that date and time. The LVN and NM verified the MAR documented the administration but the CDR did not reflect the sign-out. The DON later stated she was aware of the concern with narcotic accountability for Resident 66 and stated that the information in the CDR and MAR should match.
Resident Left Without Bed Due to Elevator Failure and Lack of Alternative Arrangements
Penalty
Summary
A deficiency occurred when a resident with diagnoses including diabetes and obesity, who was cognitively intact and required partial to moderate assistance with transfers, was left without access to a bed or bedroom for over thirteen hours. The resident was unable to return to his room after the facility's elevator became inoperable, and staff informed him that he was too heavy to be carried back to his floor. As a result, the resident spent the entire night sitting in a wheelchair in the facility lobby, experiencing back and leg pain and significant fatigue. Facility records and staff interviews revealed that the stair lift chair, which could have served as an alternative means of transport, was not operational due to a faulty battery, and there was no evidence of maintenance or staff training on its use. The facility's contingency plan for elevator failure was not implemented, and there was no documentation of alternative arrangements for residents unable to use the stairs. The Quality Assurance and Performance Improvement (QAPI) program did not address the elevator malfunction contingency plan, and the facility was unable to provide evidence of alternative arrangements as required by their own policy.
Failure to Notify Physician of Unavailable Medications
Penalty
Summary
The facility failed to notify the physician when medications were not available for administration to residents, leading to deficiencies in care. Resident #38, who had a medical history of hypertensive heart disease with heart failure and hyperlipidemia, did not receive prescribed medications, losartan potassium and atorvastatin calcium, on multiple occasions. The Medication Administration Record (MAR) indicated that the medications were not administered due to pending pharmacy delivery, but there was no documented evidence that the physician was notified of these missed doses. Interviews with nursing staff and the Director of Nursing Services (DNS) confirmed that the physician should have been informed, but this was not done. Resident #308, diagnosed with type two diabetes mellitus with hyperglycemia, also experienced a failure in medication administration. The resident's prescribed medication, Ozempic, was not available for administration on several scheduled dates. The MAR and progress notes indicated that the medication was on order, but there was no documentation of physician notification. Interviews revealed that the nurse manager was informed, but the physician was not directly notified, which was against the expected protocol. Resident #96, with a history of acute on chronic diastolic congestive heart failure and pulmonary embolism, did not receive the anticoagulant medication Eliquis as prescribed. The MAR showed that the medication was pending delivery, and there was no evidence that the physician was informed of the missed doses. Interviews with nursing staff and the DNS reiterated the expectation that the physician should be notified when medications are unavailable, but this was not adhered to in these cases.
Failure to Ensure Timely Medication Delivery
Penalty
Summary
The facility failed to ensure timely receipt of medications from the pharmacy for three residents, leading to missed doses of critical medications. Resident #38, who had a medical history of hypertensive heart disease with heart failure and hyperlipidemia, did not receive prescribed doses of losartan potassium and atorvastatin calcium on multiple occasions. The medication administration records indicated that the medications were pending or on order, but there was no documented evidence that the physician was notified about the unavailability of these medications. Interviews with staff revealed a lack of follow-up with the pharmacy and inadequate documentation of the issue. Resident #308, diagnosed with type two diabetes mellitus, did not receive the prescribed Ozempic injections on three separate occasions. The medication was identified as a high-cost drug requiring prior authorization, which was delayed. The facility did not realize the medication was missing until it was due to be administered, and there was a lack of consistent follow-up with the pharmacy to expedite the delivery. The Director of Nursing Services and other staff acknowledged the oversight and the need for better communication and documentation. Resident #96, with a history of acute on chronic diastolic congestive heart failure and pulmonary embolism, missed doses of the anticoagulant Eliquis. The medication was pending delivery, and there was insufficient follow-up with the pharmacy to ensure timely receipt. Interviews with nursing staff and the Director of Nursing Services highlighted the responsibility of charge nurses to ensure medication availability and the need for continuous follow-up until medications are received.
Failure to Provide Homelike Environment
Penalty
Summary
The facility failed to provide a homelike environment for a resident, identified as Resident #55, who had requested an additional window curtain for several months. The resident, who was admitted on 05/27/2021 and had intact cognition as indicated by a BIMS score of 15, expressed the need for a curtain that fully covered the window in their room. Despite the resident's request, the facility did not fulfill this need, which was observed during a visit on 08/26/2024. The facility's policy on providing a homelike environment emphasizes the importance of a clean, comfortable, and personalized setting. However, a work order for the additional curtain, dated 07/26/2024, was marked as ASAP but was not completed, and no further work orders were recorded for the resident's room in August. The Environmental Services Manager confirmed that no replacement curtains or blinds were ordered until 08/28/2024, indicating a delay in addressing the resident's request. The facility's administrator acknowledged that residents should be able to fully close their curtains, highlighting the oversight in meeting the resident's needs.
Inaccurate MDS Assessment for Anticoagulant Use
Penalty
Summary
The facility failed to ensure the accuracy of a Minimum Data Set (MDS) assessment for a resident who was on anticoagulant therapy. The resident, admitted with a medical history of pulmonary embolism, was prescribed apixaban, an anticoagulant, to prevent thrombosis or embolism. Despite the resident's care plan and medication administration records indicating the use of apixaban, the admission MDS assessment did not reflect that the resident was taking an anticoagulant medication. This discrepancy was identified during a review of the resident's records. The Long-Term Care (LTC) MDS Coordinator acknowledged that the MDS assessment was incorrectly coded, as it failed to indicate the resident's anticoagulant use. The error was attributed to the other MDS Coordinator responsible for completing the assessment. Interviews with the Director of Nursing Services (DNS) and the Administrator revealed that neither was directly involved in the MDS process, although they expected the assessments to be accurate. The oversight in coding was recognized as a missed step in the assessment process.
Failure to Accurately Complete PASRR Level I Screening
Penalty
Summary
The facility failed to ensure a Level I Preadmission Screening and Resident Review (PASRR) was accurately completed for a resident with a serious diagnosed mental disorder. The resident, who was admitted to the facility from a hospital, had a documented diagnosis of bipolar disorder and was prescribed mirtazapine, an antidepressant medication. However, the PASRR Level I Screening completed by the hospital did not reflect the resident's diagnosis of bipolar disorder or the prescription of psychotropic medication, resulting in a negative Level I Screening and no requirement for a Level II evaluation. Interviews with facility staff revealed a lack of awareness and oversight regarding the accuracy of the PASRR Level I screenings. The Long-Term Care (LTC) MDS Coordinator, who was responsible for reviewing and updating inaccurate screenings, was not aware of any inaccuracies. The Medical Records Director confirmed the resident's diagnosis and medication but did not address the discrepancy in the screening. The Director of Nursing Services and the Administrator acknowledged the oversight, indicating that the admission team and the MDS Coordinator should have submitted an updated Level I screening for the resident.
Anticoagulant Medication Not Included in Care Plan
Penalty
Summary
The facility failed to ensure that the use of an anticoagulant medication was addressed in the comprehensive care plan for a resident with a history of acute on chronic diastolic heart failure and pulmonary embolism. The resident was admitted to the facility and initially was not on anticoagulant medication. However, an order for Eliquis, an anticoagulant, was placed and later adjusted following a hospitalization. Despite these changes, the resident's care plan did not include a focus area related to the use of anticoagulant medication. Interviews with nursing staff, including registered nurses and the Director of Nursing Services, confirmed that the use of anticoagulant medications should be included in a resident's care plan. The facility's policy on comprehensive, person-centered care plans requires that they incorporate identified problem areas and risk factors, and be updated as residents' conditions change. The omission of the anticoagulant medication from the care plan was identified as a deficiency during the survey.
Improper Catheter Care Leads to Deficiency
Penalty
Summary
The facility failed to ensure urinary catheter care was completed in a sanitary manner for Resident #202, who was sampled for urinary catheter use. The facility's policy on urinary catheter care, dated March 2021, outlined specific steps to prevent catheter-associated urinary tract infections, including washing the genitalia and perineum thoroughly with soap and water, rinsing well, and drying. The policy also specified the correct method for cleaning a male resident's penis and catheter tubing. However, during an observation, Certified Nursing Assistant (CNA) #12 did not follow these procedures. CNA #12 used the same washcloth to clean the resident's penis from the base towards the meatus, did not rinse the area before drying, and failed to clean the catheter tubing. Resident #202, admitted to the facility on October 21, 2021, had a medical history that included hydronephrosis, tubulo-interstitial nephritis, benign prostatic hyperplasia, obstructive and reflux uropathy, and retention of urine. The resident's care plan, initiated on May 9, 2024, indicated a risk for complications, including urinary tract infections, due to the use of an indwelling urinary catheter. A physician's order required catheter care to be provided every shift, with specific instructions to cleanse the site with soap and warm water, rinse, and pat dry. Despite these directives, CNA #12 did not adhere to the proper cleaning technique, increasing the risk of infection. Interviews with staff, including CNA #12, CNA #13, the Director of Staff Development (DSD), the Infection Preventionist (IP), the Director of Nursing Services (DNS), and the Administrator, revealed a lack of adherence to the facility's catheter care procedures. CNA #12 admitted to not following the correct procedure due to the resident's sensitivity. Other staff members confirmed that the correct procedure involved cleaning from the tip of the penis towards the base and ensuring the catheter tubing was cleaned. The failure to follow these procedures was acknowledged as increasing the potential risk of urinary tract infections due to improper cleaning techniques.
Failure to Monitor Anticoagulant Side Effects
Penalty
Summary
The facility failed to monitor for potential side effects or adverse drug reactions related to the use of an anticoagulant for a resident with severe cognitive impairment. The resident, who had a medical history of acute on chronic diastolic heart failure and a personal history of pulmonary embolism, was admitted to the facility and prescribed Eliquis, an anticoagulant. Despite the prescription, there were no orders to monitor for side effects or adverse drug reactions, and the Medication Administration Record (MAR) and Treatment Administration Record (TAR) lacked documentation of such monitoring. Interviews with nursing staff, including registered nurses and the Director of Nursing Services, confirmed that residents on anticoagulants should be monitored for bleeding and bruising, and this should be documented on the MAR. However, it was acknowledged that the resident did not have an order for monitoring, and the necessary documentation was absent. The responsibility for ensuring the monitoring order was in place was attributed to the admitting nurse, but this was not executed, leading to the deficiency.
Failure to Obtain Ordered Laboratory Tests
Penalty
Summary
The facility failed to obtain laboratory testing as ordered by the physician for a resident with a history of cancer, diabetes, hypertension, anemia, and hyperlipidemia. The resident was admitted with a care plan that included monitoring for complications and following up on laboratory tests. An order was placed for weekly complete blood count (CBC) and basic metabolic panel (BMP) tests, but there was no documented evidence that these tests were completed on the specified date. Interviews with nursing staff revealed a breakdown in the process of ensuring laboratory tests were conducted. The night nurse was responsible for printing the requisition form, and the floor nurse was tasked with ensuring the specimen was collected. However, the nurse on duty assumed the laboratory staff completed the tests without verifying the requisition or specimen collection. The Director of Nursing Services acknowledged the change in procedure requiring the facility to print requisition forms, but the nurse manager failed to ensure the requisition was in place, leading to the missed laboratory testing.
Infection Control Breach During Medication Administration
Penalty
Summary
The facility failed to adhere to its infection prevention and control procedures during medication administration, as observed with two residents. The facility's policy on medication administration, dated August 18, 2022, requires staff to follow established infection control procedures, including handwashing and antiseptic techniques. However, during an observation on August 28, 2024, a registered nurse (RN) was seen placing her bare hand around the lip-surface of a water cup provided to Resident #305 for taking medications. This action was repeated with Resident #56, despite the RN sanitizing her hands beforehand. Interviews conducted with the RN, a nurse manager, the Infection Preventionist (IP), the Director of Nursing Services (DNS), and the Administrator confirmed that touching the lip-surface of water cups with bare hands is against infection control protocols. The IP and DNS emphasized that even after hand sanitization, the RN's hands would not be considered clean enough to touch the lip-surface of the cups, which could lead to cross-contamination and infection risk. The Administrator expected nurses to hold water cups below the lip-surface to prevent contamination.
Failure to Post Daily Nurse Staffing Data in Accessible Location
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted daily at the beginning of each shift in a prominent location accessible to residents. The facility's policy required that the number of licensed nurses and unlicensed nursing personnel responsible for direct care be posted within two hours of each shift's start. However, observations revealed that the staffing data was only posted in the first-floor lobby, which was not accessible to residents whose rooms were located on the second through fifth floors. The posted data was outdated, with the same document from several days prior being displayed over multiple days. Interviews with facility staff, including the Staffing Coordinator, RN, and Director of Nursing Services (DNS), confirmed the failure to update and appropriately post the staffing data. The Staffing Coordinator, who was responsible for posting the data, was on vacation, and in her absence, the DNS or a morning nurse manager was supposed to handle the task. However, the DNS admitted to not completing the postings, and the data remained outdated and inaccessible to residents. The Administrator acknowledged that the data was only posted in the lobby and should have been updated by 9:00 AM each day.
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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) |
|---|---|---|---|---|
| Laurel Heights Community Care | 0.1 mi | ★★★★★ | 0 | 0 |
| Victorian Post Acute | 0.6 mi | ★★★★★ | 0 | 0 |
| Sequoias San Francisco Convalescent Hospital | 0.6 mi | ★★★★★ | 13 | 0 |
| Central Gardens Post Acute | 0.6 mi | ★★★★★ | 0 | 0 |
| San Francisco Health Care | 0.8 mi | ★★★★★ | 5 | 0 |
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