The home failed to provide pharmacy services and a licensed pharmacist needed to meet each resident’s medication needs. Cited April 2021 — widespread issue, potential for harm.
View the original federal record
F-Tag 755 — 42 CFR §483.45 — S/S: F
Nursing home report
PACIFIC HEIGHTS TRANSITIONAL CARE CENTER
SAN FRANCISCO, CA · Medicare-certified · 120 beds
Needs attention
For-profitChain member
Data as of July 1, 2026
5 of 5 overall
Pacific Heights Transitional Care Center has an overall 5-star rating, with 4 stars for health inspections and staffing and 5 stars for quality measures. Reported nurse staffing is 4.09 hours per resident per day, just below the 4.1 federal benchmark, and it had $25,490 in fines in the last 24 months, including a recent federal penalty.
Facility ratings
Health inspections
Staffing
4.093 hrs/resident/day
Quality measures
Last inspection: March 13, 2026Penalties, last 24 months: $25,490recent federal penalty
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 4.093.
Staffing detail
- Registered nurses
- 0.82
- Licensed practical nurses
- 0.73
- Nurse aides
- 2.55
- Weekend nursing
- 3.74
Hours per resident per day.
Total staff turnover: 42%
Registered nurse turnover: 46%
Resident outcomes
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Negative outcomes
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Long-stay residents on antipsychotic medication
1.8%1.7%No change
Residents with a fall causing major injury
0%1.3%Worsening
Residents with pressure ulcers (bedsores)
4.5%3%Improving
Residents with a urinary tract infection
0%2.8%Worsening
Residents who lost too much weight
1.3%1.5%No change
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
4.4%7.9%Worsening
Residents whose ability to walk got worse
3.5%13.8%Worsening
Long-stay residents on antianxiety or sleep medication
1.2%4.2%Worsening
Short-stay residents newly given an antipsychotic
0.6%0%Improving
Residents with a long-term catheter
0%0%No change
Residents with new or worsening incontinence
10.1%10%No change
Residents with depressive symptoms
1.4%5.9%Worsening
Positive outcomes
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Long-stay residents given the seasonal flu vaccine
—98.9%—
Long-stay residents given the pneumonia vaccine
100%100%No change
Short-stay residents given the seasonal flu vaccine
—97.9%—
Short-stay residents given the pneumonia vaccine
97.3%99%Improving
What the inspectors found
The home failed to properly watch nurse aides' work and provide regular training. Cited March 2026 — limited pattern, potential for harm.
View the original federal record
F-Tag 730 — 42 CFR §483.35(e)(7) — S/S: E
The home failed to make sure food was safely sourced, stored, prepared, and served according to professional standards. Cited March 2026 — limited pattern, potential for harm.
View the original federal record
F-Tag 812 — 42 CFR §483.60(i) — S/S: E
The home failed to promptly tell the resident, doctor, and family about changes or problems affecting the resident. Cited August 2024 — limited pattern, potential for harm.
View the original federal record
F-Tag 580 — 42 CFR §483.10(g)(14) — S/S: E
The nursing home failed to provide and carry out an infection prevention and control program to help keep residents from getting or spreading infections. Cited July 2023 — limited pattern, potential for harm.
View the original federal record
F-Tag 880 — 42 CFR §483.80(a) — S/S: E
Recent history
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- STAFFING
Reported nurse staffing met or exceeded the federal recommendation.
- INSPECTION
Health inspection found 4 health deficiencies.
See what inspectors found
- PENALTY
A federal fine of $25,490 was recorded.
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- INSPECTION
Health inspection found 11 health deficiencies.
See what inspectors found
Penalties & enforcement
On record with Medicare: 1 fine · $25,490 in total fines.
- $25,490
Federal fine
Jan 29, 2025
Operator & ownership
Recent ownership change · Sep 1, 2017
Now operated by Pacific Heights Transitional Care Center, previously Kindred Nursing and Rehabilitation-golden Gate.
- Ownership
- For profit - Limited Liability company
- Chain
- Part of ASPEN SKILLED HEALTHCARE · 35 homes · 3.7 stars avg
- Occupancy
- 114.7 residents on an average day (96% of 120 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 52 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.