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 The Avenues Transitional Care Center during CMS and state inspections, most recent first.
A resident with quadriplegia, dementia, and high fall risk was left unsupervised in a high bed with side rails down during incontinent care. The staff member left the room to get supplies, leaving the resident on their side, and the ordered low air loss mattress was not in use. The resident fell from the bed, sustained serious injuries, and later died. Facility records showed lack of staff training on fall safety and failure to follow care plan interventions.
The facility failed to meet food safety standards when a dirty frying pan was found among clean ones, wet trays were improperly stored, and a dented can was found in dry storage. The DM acknowledged these issues, which could lead to contamination and foodborne illnesses among 133 residents.
The facility failed to follow physician orders for two residents by not obtaining monthly MUAC measurements as an alternative to weights, which were refused. Additionally, the facility did not monitor or document bruising at injection sites for a resident self-administering insulin, potentially affecting insulin absorption and well-being.
The facility failed to ensure proper accountability and administration of medications for several residents. Controlled Drug Records did not reconcile with Medication Administration Records, leading to unaccounted medications. An LVN administered the wrong medication to a resident and left another resident's medication at the bedside without ensuring it was ingested. Additionally, a shared pill cutter was not cleaned between uses, risking drug interactions. These actions violated facility policies and raised concerns about medication management.
The facility failed to properly store and label medications, with one storage room exceeding recommended temperatures, an undated multi-dose vial in the refrigerator, and expired lidocaine patches found in a medication cart. The DON and RNS acknowledged these issues, which contravened facility policies.
The facility failed to implement its infection control program, with deficiencies including improper storage of a urinal, lack of hand hygiene by a janitor handling soiled linens, and nursing staff not performing hand hygiene during medication administration. Additionally, an RN administered medication without gloves, posing infection risks.
Two residents with severe cognitive impairments were not treated with dignity during meal assistance, as CNAs stood over them while feeding, contrary to facility policy. Despite knowing the requirement to sit at eye level, the CNAs did not follow this procedure, impacting the residents' dignity and respect.
A facility failed to ensure safe self-administration of medications for a resident who was observed with multiple prescription medications left on their overbed table. The resident, with no cognitive impairment, had a care plan specifying self-administration of insulin but not other medications. An LVN admitted to leaving the medications at the bedside, contrary to facility policy, and the interdisciplinary team did not determine if the medications could be self-administered.
A resident on heparin for DVT prophylaxis was not monitored for bleeding, despite the facility's policy requiring such monitoring. The resident, readmitted with a femur fracture and rectal hemorrhage, had no documented evidence of bleeding monitoring in their medical record. The ADON confirmed the lack of monitoring, which contradicted the facility's anticoagulation protocol.
The facility failed to ensure two residents were free from unnecessary antipsychotic medications. One resident continued PRN Seroquel beyond 14 days without reevaluation, and another resident lacked behavioral monitoring for Seroquel use. The facility's policy requires non-pharmacological interventions and behavioral monitoring for residents on psychotropic medications, which were not followed.
The facility failed to honor the food preferences of two residents, leading to a deficiency in dietary services. One resident, requiring a mechanical soft diet, was served hard carrots, while another was served a regular menu despite a preference for chow mein or potstickers. These incidents highlight a failure to adhere to the facility's policy on respecting residents' food preferences.
The facility did not meet the required minimum room size of 80 square feet per resident for 47 out of 48 rooms. Observations showed rooms occupied by two or three residents, with only one room meeting the standard. Interviews with residents indicated no major concerns about room size. The Administrator requested a waiver for room size variance from the California Department of Public Health.
A resident's comprehensive MDS assessment was completed 23 days after admission, exceeding the required 14-day period. The resident had multiple diagnoses, including osteoarthritis and schizoaffective disorder. The MDS Coordinator acknowledged the delay, which contravened both facility policy and regulatory requirements.
A facility failed to develop a baseline care plan within 48 hours for a resident admitted with multiple health issues, including osteoarthritis, repeated falls, liver disease, schizoaffective disorder, and traumatic brain injury. The baseline care plan, which is crucial for addressing immediate health and safety needs, was completed several days late, as confirmed by the MDS Coordinator.
Failure to Prevent Avoidable Fall Resulting in Resident Injury and Death
Penalty
Summary
A resident with quadriplegia, dementia, and a history of physical injury was admitted to the facility and assessed as being at high risk for falls, with severe cognitive impairment and total dependence on staff for mobility and toileting. The care plan specified that the resident's bed should be kept in a low position and that two or more staff were required for toileting hygiene and repositioning. Despite these interventions, the resident was left alone in a high bed position with both side rails down while a CNA left the room to obtain additional supplies during incontinent care. During this period of unsupervised time, the resident rolled from the bed and fell to the floor, sustaining multiple injuries including a head injury, abrasions, and skin tears. The CNA reported leaving the resident on their side and did not return the resident to a supine position before leaving. The resident's low air loss mattress, which was ordered to prevent skin breakdown, had been removed at the time of the incident. The facility's documentation and staff interviews confirmed that the CNA had not received specific training on the use of low air loss mattresses or fall safety, and competency validation for peri-care was not documented in the employee file. The facility's policies required a hazard-free environment and adequate supervision to prevent accidents, but these were not followed in this case. The resident's fall resulted in a traumatic brain injury, hospitalization, and subsequent death. The facility's investigation identified the resident's positioning and the absence of the low air loss mattress as contributing factors to the fall.
Food Safety Violations in Kitchen Practices
Penalty
Summary
The facility failed to adhere to food safety requirements as observed during a survey. A dirty frying pan with dried food debris was found stacked among clean frying pans under the food preparation counter. The dietary manager (DM) acknowledged that these were supposed to be clean pans, but one was visibly dirty with dried scrambled egg remains and scratches, indicating improper cleaning and storage practices. Additionally, large metal serving trays were found stacked wet under the food preparation counter, with some trays still moist and dripping. The DM confirmed that the trays were indeed wet, which contradicts the 2022 Federal Food Code that requires equipment and utensils to be air-dried before storage. Furthermore, a dented can of mushrooms was found among undented canned products in the dry storage room, which the DM admitted should not have been there. This is contrary to FDA guidelines that consider dented cans as potentially hazardous. These deficiencies have the potential to contaminate clean cooking utensils and promote the growth of foodborne illnesses among the 133 residents.
Failure to Monitor Nutritional Status and Injection Sites
Penalty
Summary
The facility failed to adhere to physician orders for two residents, Resident 32 and Resident 78, by not obtaining monthly measurements of mid upper arm circumference (MUAC) as an alternative to monthly weights, which both residents refused. Resident 32, who has severe cognitive impairment and a history of refusing care, had no recorded weights since May 2024 and no documentation of MUAC measurements, despite a physician's order from September 2023 to obtain these monthly. Similarly, Resident 78, who has no cognitive impairment but a history of refusing weights, also had no recorded weights or MUAC measurements for the year 2024, despite a similar physician's order. The lack of documentation and adherence to these orders had the potential to result in unplanned and undesirable weight loss for both residents. Additionally, the facility failed to monitor and document the condition of Resident 78's injection sites for bruising, as required by a physician's order. Resident 78, who self-administers insulin, showed signs of bruising on the right lower abdomen, which was not documented in the resident's medical records. The Assistant Director of Nursing acknowledged the oversight and stated that the nurses should have checked for bruising, notified the physician, and updated the care plan accordingly. The failure to monitor and document the injection sites could lead to uneven insulin absorption and negatively affect Resident 78's physical and psychosocial well-being. The facility's policy on weight assessment and intervention, as well as the policy on changes in a resident's condition or status, were not followed in these cases. The multidisciplinary team is expected to prevent, monitor, and intervene for undesirable weight loss, and the nursing staff is required to notify the physician of any significant changes in a resident's condition. However, these protocols were not adhered to, resulting in deficiencies in the care provided to Residents 32 and 78.
Medication Administration and Accountability Deficiencies
Penalty
Summary
The facility failed to ensure the accountability of controlled medications for five residents, as the Controlled Drug Records (CDR) did not reconcile with the Medication Administration Records (MAR). For Resident 105, a tablet of oxycodone was signed out but not documented on the MAR. Similarly, Resident 119's lorazepam was signed out but not recorded on the MAR. Resident 81 had two instances where oxycodone was signed out but not documented. Resident 30's oxycodone was documented on the MAR but not signed out on the CDR. Lastly, Resident 36 had four instances of oxycodone signed out but not documented on the MAR. These discrepancies resulted in unaccounted medications, raising concerns about potential abuse and diversion. The facility also failed to administer the correct prescribed medication to Resident 28. During a medication pass, an LVN administered Geri-Tussin DM instead of the prescribed guaifenesin. This error was acknowledged by the DON, who stated that medication errors should not occur. Additionally, the facility failed to ensure that Resident 432 ingested the full dose of prescribed medication. The LVN left a cup of ClearLax water on the resident's bedside table, and the resident did not finish the medication while the LVN was present. The DON confirmed that medications should not be left at the bedside and that residents should be observed to ensure they ingest the full dose. Furthermore, the facility did not adhere to proper cleaning protocols for shared medical equipment. An LVN used a shared pill cutter to split medications for Resident 432 without cleaning it between uses. This practice was acknowledged by the LVN and the DON, who noted that it could lead to potential drug interactions and expose residents to medication residue. The facility's policy requires that shared items be cleaned and disinfected between uses, which was not followed in this instance.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper storage of medications and biologicals, leading to potential ineffectiveness and safety concerns. In one of the medication storage rooms, the temperature consistently exceeded the manufacturer's recommended range of 68 to 77 degrees Fahrenheit, reaching up to 81 degrees. This was observed over a period of several months, with the temperature exceeding the limit on numerous occasions. The Director of Nursing (DON) acknowledged that the elevated temperature could render medications ineffective, as evidenced by the storage of vancomycin, which requires specific temperature conditions. Additionally, the facility did not properly label a multi-dose vial of Tuberculin Purified Protein Derivative (TPPD) in the medication storage room refrigerator. The vial was opened and undated, contrary to the facility's policy that requires labeling with the date of opening. The DON confirmed awareness of the issue and stated that the vial should have been labeled to ensure timely disposal, as vials in use for more than 30 days should be discarded. Furthermore, expired medications were found in the facility's medication cart. Three lidocaine 5% patches with an expiration date of October 2020 were discovered in a bag labeled with a resident's name. The Registered Nurse Supervisor (RNS) acknowledged the presence of these expired patches and confirmed they were available for use, which is against the facility's policy that mandates the removal and disposal of expired medications. The DON also confirmed awareness of the expired patches and reiterated the expectation for staff to discard such medications.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to implement its infection control program in several instances. In one case, a urinal used by a resident was improperly stored inside a trash bin at the bedside, rather than in the designated holder. The resident confirmed using the urinal in this manner, and staff interviews revealed that this practice was against infection control protocols, which require urinals to be stored in a holder to prevent contamination. Another deficiency was observed during the collection of soiled linen on the second floor. A janitor failed to perform hand hygiene before and after glove use while handling soiled linens. The janitor admitted to not performing hand hygiene due to a lack of gloves in the hallway and limited English proficiency. Interviews with the housekeeping supervisor and infection preventionist confirmed that hand hygiene is required before donning and after doffing gloves, especially when handling potentially infectious materials like soiled linens. Additionally, nursing staff did not adhere to hand hygiene protocols during medication preparation and administration. An LVN was observed not performing hand hygiene before preparing and administering medications to two residents and failed to disinfect a blood pressure cuff before and after use. Furthermore, an RN administered medication without wearing gloves, even when handling oral secretions. These actions were acknowledged by the staff involved and were identified as risks for cross-contamination and infection by the Director of Nursing.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that two residents were treated with dignity and respect during meal assistance. Resident 92, who was admitted with severe cognitive impairment and required total assistance with eating, was observed being fed by CNA 1 while the CNA stood over the resident. This was contrary to the facility's policy, which requires CNAs to sit at eye level with residents during feeding to maintain dignity and respect. Interviews with the CNA, Assistant Director of Nursing, and Director of Staff Development confirmed that the proper procedure was not followed. Similarly, Resident 7, who also had severe cognitive impairment and required assistance with eating, was fed by CNA 2 while the CNA stood at the bedside. Despite acknowledging the requirement to sit while feeding, CNA 2 did not retrieve a chair and continued to stand throughout the meal. The facility's policy on resident rights emphasizes treating all residents with kindness, respect, and dignity, which was not adhered to in these instances.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure the safe self-administration of medications for a resident, identified as Resident 78, who was observed with multiple prescription medications left on their overbed table. The medications included hydralazine, amlodipine, Eliquis, valsartan, and amiodarone, which were left by an LVN who acknowledged that the resident preferred to take medications after breakfast. The LVN admitted that they should have stayed to encourage the resident to take the medications immediately and should not have left them at the bedside. Resident 78 was admitted with diagnoses including type 1 diabetes mellitus, end-stage kidney disease, and dependence on renal dialysis. The resident's Minimum Data Set assessment indicated no cognitive impairment and no impairment in the range of motion, requiring only setup or clean-up assistance with daily activities. Despite this, the interdisciplinary team did not determine if the medications left on the overbed table could be self-administered by the resident, and there was no active order for self-administration of medication. The facility's policy on self-administration of medications requires an assessment of the resident's mental and physical abilities and documentation of findings. However, the resident's care plan only specified self-administration of insulin Lispro and Glargine, with no mention of other medications. The Assistant Director of Nursing confirmed that there was no order for self-administration and that medications should not be left at the bedside, highlighting a lack of adherence to the facility's policy and procedure.
Failure to Monitor Resident on Heparin for Bleeding
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medication, specifically in the case of a resident who was not monitored for bleeding while on heparin, an anticoagulant. The resident was readmitted to the facility with a fracture of the left femur and a hemorrhage of the anus and rectum. The physician's order prescribed heparin injections twice daily for 30 days as a prophylactic measure against deep vein thrombosis (DVT). However, there was no evidence in the resident's medical record of monitoring for bleeding, a known adverse effect of heparin. During an interview and record review, the Assistant Director of Nursing confirmed that the resident was on heparin and had not been monitored for signs and symptoms of bleeding. The facility's policy on anticoagulation required staff and physicians to monitor for possible complications in individuals receiving anticoagulation therapy. The prescribing information for heparin also indicated that hemorrhage is a common adverse reaction, underscoring the necessity for monitoring. This oversight had the potential to result in undetected adverse effects from the medication.
Failure to Monitor and Discontinue Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary antipsychotic medications. For one resident, there was no evidence of non-pharmacological interventions being attempted before the use of PRN Seroquel, and the medication was ordered for more than 14 days without discontinuation or reevaluation by a physician. The resident was readmitted with diagnoses including vascular dementia, psychotic disorder with delusion, and mood disorder. The Assistant Director of Nursing (ADON) confirmed that the PRN Seroquel should have been discontinued after 14 days, but it remained active for 23 days. For another resident, there was no evidence of specific behavioral monitoring for the use of Seroquel. The resident was admitted with diagnoses including dementia, psychotic disturbance, and mood disturbance. The ADON acknowledged that the resident's behaviors were not monitored for the effectiveness of the medication, which is necessary to determine if the medication is working and to note any changes in the resident's episodes. The facility's policy requires staff to monitor and document residents' behaviors when receiving psychotropic medication, but this was not done for the resident.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor the food preferences of two residents, leading to a deficiency in dietary services. Resident 36, who required a mechanical soft diet with soft vegetables, was served a regular menu that included hard carrots. This was observed during a kitchen tray line inspection, where the dietary manager confirmed the hardness of the carrots using a metal ladle. The cook subsequently replaced the hard vegetables with diced, soft carrots from the substitute menu. Resident 68 was also affected, as he was served a regular menu of fried rice, mixed vegetables, and pork slices, despite his meal ticket indicating a preference for chow mein with chicken or potstickers. Initially, the cook stated that the resident did not want chow mein, but after further inquiry, it was confirmed by the registered dietitian that the resident still wanted potstickers. These incidents demonstrate a failure to adhere to the facility's policy on respecting residents' food preferences, as outlined in their procedures.
Facility Fails to Meet Room Size Requirements for Residents
Penalty
Summary
The facility failed to ensure that 47 out of 48 resident rooms met the required minimum of 80 square feet per resident. During an observation conducted on March 18, 2025, it was noted that rooms on the first, second, and third floors were occupied by two or three residents, with curtains used to divide each bed. The Administrator confirmed that all rooms were equipped for three residents except for rooms 8, 25, and 41, which were for two residents. However, only one room met the required size standard. Interviews with residents revealed that some did not express concerns about the room size. Resident 1 in Room 10 stated that the space was "okay," and Resident 28, through an AI translator device, denied any issues with her room size. A review of facility-submitted documents, including a Client Accommodations Analysis and a Room Size Waiver Request, listed the rooms with less than 80 square feet per resident. The Administrator had requested a waiver for variance in room size from the California Department of Public Health.
Delayed MDS Assessment Completion
Penalty
Summary
The facility failed to complete a comprehensive Minimum Data Set (MDS) assessment for a resident within the required 14-day period following admission. The resident, who was admitted with multiple diagnoses including osteoarthritis, repeated falls, liver disease, schizoaffective disorder, and traumatic brain injury, had their MDS assessment completed 23 days after admission, which is 9 days late. This delay was acknowledged by the MDS Coordinator during an interview. The facility's policy, as well as the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, mandates that the admission assessment be completed by the end of the 14th day, counting the admission day as day one. The failure to adhere to this requirement could potentially delay the identification of the resident's needs and significant issues affecting their well-being.
Failure to Timely Develop Baseline Care Plan
Penalty
Summary
The facility failed to develop a baseline care plan within 48 hours of admission for a resident, as required by their policy. The baseline care plan is essential to address the resident's immediate health and safety needs, including specific health concerns and risks such as elopement or falls. The resident in question was admitted with multiple diagnoses, including osteoarthritis, repeated falls, liver disease, schizoaffective disorder, and traumatic brain injury. Despite these significant health issues, the baseline care plan was not completed until several days after the admission. The review of the resident's records showed that the baseline care plan was completed and signed by both the resident and an LVN on a date that was beyond the 48-hour requirement. During an interview, the MDS Coordinator confirmed that the baseline care plan was completed late, acknowledging that it should have been done by the eighth day of admission. This delay in completing the baseline care plan could potentially lead to delayed identification of the resident's needs and significant issues affecting their well-being.
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What surveyors actually found near you
We read the 905 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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Illustrative
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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) |
|---|---|---|---|---|
| Laguna Honda Hospital & Rehabilitation Ctr D/p Snf | 1.1 mi | ★★★★★ | 5 | 0 |
| Lawton Skilled Nursing & Rehabilitation Center | 1.3 mi | ★★★★★ | 9 | 0 |
| St. Anne's Home | 2.8 mi | ★★★★★ | 0 | 0 |
| Hayes Convalescent Hospital | 2.8 mi | ★★★★★ | 2 | 0 |
| San Francisco Health Care | 2.8 mi | ★★★★★ | 5 | 0 |
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