Pacific Heights Transitional Care Center

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

56.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 298 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 80.5% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 123 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.60 therapist hours per resident per day in 2026Q1 — more than 88% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 18% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 120 beds and averages 114.7 residents a day — about 96% occupied, or roughly 5 beds typically open. It runs essentially full — expect a waiting list. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.09 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.82 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.55 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 3.74 hrs/resident/day on weekends vs 4.24 on weekdays — 12% thinner on weekends. RN hours go from 0.91 to 0.60 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 42% is about the same as the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

25 citations, most serious first. The 10 most serious are shown; the remaining 15 are one tap away and print in full.

• Potential for harm · E2026-03-13 · tag F0730 — pattern
  Observe each nurse aide's job performance and give regular training.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, the facility failed to ensure three out of three sampled staff employee files, (Unlicensed Staff A, Unlicensed Staff B and Unlicensed Staff C) had annual performance reviews or evaluations (systemic [entire organization], periodic process that assesses an employee's job performance, skills, and accomplishments against established company goals) performed for the year(s) 2025 and 2026.These failures had the likelihood for missed opportunities to provide specific education-based training for unlicensed staff members to capture potential safety concerns and improve outcomes like improving resident care concerns.During an interview on 3/12/26 at 2:29 PM with Director of Staff Development (DSD), DSD stated they had been in the position with the facility for approximately two years and had the responsibility of managing all of the unlicensed staff at the facility who provide care to the residents within the facility. During a concurrent interview and record review on 3/12/26 at 2:55 PM with DSD, the employee file of Unlicensed Staff A (USA) was…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2026-03-13 · tag F0812 — failed to store, cook, and serve food safely — pattern
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, facility staff failed to ensure their walk-in freezer and walk-in refrigerator were maintained in a sanitary manner and a container of thickening powder was dated and labelled. These failures had the potential for food to be stored in an unsanitary manner and for residents to be exposed to expired food products.Findings:During a concurrent kitchen observation and interview with the Nutritional Service Supervisor (NSS) on 3/9/26 at 9:17 AM, these observations were made with the NSS:A clear plastic container, 1/2 full of a white powder was stored on a shelf next to the cook top. The container had no label and there was no opened date nor expiration date on the container.two blue berries, a clear plastic lid for a disposable cup, a can of ginger ale (8 fluid ounce, fluid ounce is a unit of liquid measurement), and a container of Ensure plus (dietary supplement, 8 fluid ounce) were found on the floor of the walk-in refrigerators (under the shelves).A handful of frozen peas and diced carrots, and four small frozen doughs were found on…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-13 · tag F0698 — failed to provide proper dialysis care — isolated
  Provide safe, appropriate dialysis care/services for a resident who requires such services.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview and record review, three issues were identified regarding dialysis communication books for Resident 7 and 27, two out of four resident receiving outpatient dialysis.1. Resident 7's dialysis communication book was missing important information. 2. Two medications were administered by dialysis staff to Resident 7. One was not clarified and both were not communicated to the physician and/or dietitian.3. Residents 27's dialysis communication book was left at the dialysis center and information regarding the latest dialysis session was not charted in the nursing notes.These failures had the potential to negatively impact continuity of care for Residents 7 and 27.Findings:Review of Resident 7's medical records titled dialysis communication book on 3/11/26 at 1:29 PM indicated documentations regarding post dialysis pain assessments were left blank on these dialysis dates: 3/10/26, 3/7/26, 3/5/26, 3/3/26, 2/28/26, 2/26/26, 2/24/26, 2/21/26, 2/19/26, 2/17/26, 2/14/26, 2/12/26, 2/10/26, 2/7/26, 2/5/26, and 2/3/26. Additionally, on 3/10/26, dialysis staff documented in the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2026-03-13 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interviews, and record reviews, the facility failed to ensure the accountability of controlled medications (medication with high potential for abuse and addiction) when the Controlled Drug Record (CDR, accountability records, an inventory sheet that keeps records of the usage of controlled medications) for one of six sampled residents (Resident 66) did not reconcile with the Medication Administration Record (MAR). This failure resulted in inaccurate accountability and the potential for abuse and diversion of controlled medications. Review of Resident 66's Physician's Order, dated 1/20/26, indicated oxycodone (a controlled narcotic medication for pain) 5 mg (milligram, unit of measurement), Give 1 tablet (5 mg) by mouth every 6 hours as needed for breakthrough pain (moderate pain 4-7 [pain scale]). and Give 2 (10 mg) tablet by mouth every 6 hours as needed for breakthrough pain (severe pain 8-10). During a concurrent interview and record review on 3/11/26 at 2:40 PM with License Vocational Nurse (LVN) 2 and Nurse Manager (NM) 2, Resident 66's CDR and MAR were reviewed. The…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-01-29 · tag F0684 — failed to provide proper treatment and quality of care — isolated
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and record review, the facility failed to ensure a bed / bedroom was accessible to one of three sampled residents (Resident 1) when Resident 1 did not have a bed to sleep on for the night. The facility failure resulted to Resident 1 sitting up on the wheelchair in the facility lobby for over thirteen (13) hours during the night until the next day. Findings: A review of the admission records indicated Resident 1 was admitted with diagnoses including diabetes (abnormally high blood sugar level) and obesity (having too much body fat). A review of Minimum `Data Set (MDS, a standardized assessment tool) dated 11/22/24, Brief Interview of Mental Status (BIMS, a brief memory test to help determine cognitive functioning such as orientation, attention and recall ability) score of 15 indicated Resident 1 was cognitively intact. Functional status indicated Resident 1 required partial/moderate assistance (helper does less than half the effort) to supervision (helper provides verbal cues and contact guard assistance) with transfer, independent with bed mobility,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has plan of correction
• Potential for harm · E2024-08-29 · tag F0580 — failed to tell family and doctor about changes — pattern
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, record review, and facility policy review, the facility failed to notify the physician when medications were not available for administration to 1 (Resident #38) of 1 resident reviewed for notification of change and 2 (Resident #308 and Resident #96) of 5 residents reviewed for unnecessary medications. Findings included: A facility policy titled, Change in a Resident's Condition or Status, revised in 05/2017, specified, 1. The nurse will notify the resident's Attending Physician or physician on call when there has been a(an): e. need to alter the resident's medical treatment significantly. 1. An admission Record revealed the facility admitted Resident #38 on 07/18/2024. According to the admission Record, the resident had a medical history that included diagnoses of hypertensive heart disease with heart failure and hyperlipidemia (elevated cholesterol level). An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/24/2024, revealed Resident #38 had a BIMS score of 15, which indicated the resident had intact cognition. Resident #38's care…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-08-29 · tag F0755 — failed to provide safe pharmacy services — pattern
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  2. An admission Record indicated the facility admitted Resident #308 on 08/02/2024. According to the admission Record, the resident had a medical history that included a diagnosis of type two diabetes mellitus with hyperglycemia (high blood sugar). An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/08/2024, revealed Resident #308 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Per the MDS, the resident had received six insulin injections during the seven days prior to the assessment. The MDS revealed the physician had not changed the resident's insulin orders in the previous seven days. Resident #308's care plan included a focus area, initiated on 08/02/2024, that indicated the resident was at risk for hypoglycemia (low blood sugar) and hyperglycemia. An intervention initiated on 08/02/2024 directed staff to administer prescribed insulin as ordered. Resident #308's Order Recap [recapitulation] Report for the timeframe from 08/02/2024 through 08/28/2024 revealed an order, started on…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-08-29 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observation, interview, and facility document and policy review, the facility failed to ensure each resident was provided a homelike environment, which affected 1 (Resident #55) of 2 residents reviewed for environmental concerns. Specifically, the facility failed to provide a window curtain upon Resident #55's request. Findings included: A facility policy titled, Quality of Life- Homelike Environment, revised 05/2017, revealed, Residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The policy further revealed, 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. Clean, sanitary and orderly environment; b. Comfortable (minimum glare) yet adequate (suitable to the task) lighting. c. Inviting colors and decor. An admission Record revealed the facility admitted Resident #55 on 05/27/2021. A quarterly Minimum Data Set (MDS), with an Assessment…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-08-29 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, interview, facility policy review, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure the accuracy of a Minimum Data Set (MDS) assessment for 1 (Resident #2) of 5 residents reviewed for unnecessary medications. Specifically, the facility failed to code Resident #2's MDS assessment to reflect the use of an anticoagulant. Findings included: The Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, dated 10/2023, indicated, N0415E1. Anticoagulant (e.g. [exempli gratia, for example], warfarin, heparin, or low-molecular weight heparin): Check if an anticoagulant medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days. N0415E2. Anticoagulant: Check if there is an indication noted for all anticoagulant medications taken by the resident any time during the observation period (or since admission/entry…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-08-29 · tag F0645 — isolated
  PASARR screening for Mental disorders or Intellectual Disabilities
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on interview, record review, facility policy review, and review of the California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level I Assessment Guide, the facility failed to ensure a Level I PASRR was accurately completed for 1 (Resident #4) of 1 resident reviewed for PASRR requirements. Specifically, the facility failed to ensure Resident #4's Level I PASRR Screening reflected the presence of a serious diagnosed mental disorder. Findings included: A facility policy titled, Preadmission Screening & Resident Review (PASRR), dated 11/30/2023, revealed, 1. Initial admission from General Acute Care Hospital: a. General Acute Care Hospitals (GACHs) located in California are enrolled and utilizing the Department of Health Care Services' (DHCS') PASRR Online System to complete the PASRR process prior to discharging an individual to a SNF [skilled nursing facility], regardless of payer source. b. Facility will: i. Confirm that the PASRR process was completed by the Hospital (including admission from the Emergency Department) by accepting and…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

$25,490 in federal fines across 1 penalty.

• $25,490 — penalty dated 2025-01-29

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

Part of a chain

This home belongs to ASPEN SKILLED HEALTHCARE — 35 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 32 rows in the source record cover these 20 parties — each is shown once here with every role it holds. Nothing is omitted.

5 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $1.2M paid to related parties (affiliated landlords or management companies) in its most recent cost report.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in CA