The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited October 2025 — isolated incident, actual harm.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — S/S: G
Nursing home report
THE AVENUES TRANSITIONAL CARE CENTER
SAN FRANCISCO, CA · Medicare-certified · 140 beds
Needs attention
For-profitChain member
5 of 5 overall
THE AVENUES TRANSITIONAL CARE CENTER in San Francisco has an overall 5-star rating, with strong staffing and quality ratings but a lower 3-star health inspection rating. It also has a recent federal penalty, $12,685 in fines over the last 24 months, and reported nurse staffing of 3.98 hours per resident per day, slightly below the federal benchmark of 4.1.
Facility ratings
Health inspections
Staffing
3.9762 hrs/resident/day
Quality measures
Last inspection: October 2, 2025Penalties, last 24 months: $12,685recent federal penalty
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 3.9762.
Staffing detail
- Registered nurses
- 0.89
- Licensed practical nurses
- 0.63
- Nurse aides
- 2.45
- Weekend nursing
- 3.76
Hours per resident per day.
Total staff turnover: 43%
Registered nurse turnover: 20%
Resident outcomes
How often residents experience these outcomes, with the direction over the past year.
Long-stay residents on antipsychotic medication
9.3%Worsening
Residents with a fall causing major injury
1%Steady
Residents with pressure ulcers (bedsores)
1.9%Improving
Residents with a urinary tract infection
0.3%Steady
Residents who lost too much weight
1.1%Improving
Residents who were physically restrained
0%Steady
Residents needing more help with daily activities
7.1%Improving
Residents whose ability to walk got worse
10.5%Improving
Show all measures
Long-stay residents on antianxiety or sleep medication
3.9%Improving
Short-stay residents newly given an antipsychotic
0.9%Improving
Residents with a long-term catheter
0.3%Improving
Residents with new or worsening incontinence
14.7%Improving
Residents with depressive symptoms
9.1%Improving
Long-stay residents given the seasonal flu vaccine
100%Steady
Long-stay residents given the pneumonia vaccine
100%Steady
Short-stay residents given the seasonal flu vaccine
98.4%Steady
Short-stay residents given the pneumonia vaccine
99.9%Improving
What the inspectors found
The home failed to make sure food was safely sourced, stored, prepared, and served according to professional standards. Cited March 2025 — widespread issue, potential for harm.
View the original federal record
F-Tag 812 — 42 CFR §483.60(i) — S/S: F
The nursing home failed to provide appropriate treatment and care according to residents' orders, preferences, and goals. Cited March 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 684 — 42 CFR §483.25 — 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 March 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 880 — 42 CFR §483.80(a) — S/S: E
The home failed to provide pharmacy services and a licensed pharmacist needed to meet each resident’s medication needs. Cited March 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 755 — 42 CFR §483.45 — S/S: E
Recent history
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- PENALTY
A federal fine of $12,685 was recorded.
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- INSPECTION
Health inspection found 11 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 2 health deficiencies.
See what inspectors found
Penalties & enforcement
On record with Medicare: 1 fine · $12,685 in total fines.
- $12,685
Federal fine
Oct 2, 2025
Operator & ownership
- Ownership
- For profit - Limited Liability company
- Chain
- Part of ASPEN SKILLED HEALTHCARE · 35 homes · 3.5 stars avg
- Occupancy
- 130.5 residents on an average day (93% of 140 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.