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
Data as of July 1, 2026
5 of 5 overall
THE AVENUES TRANSITIONAL CARE CENTER has a 5 out of 5 star overall rating, with 5-star staffing and quality measures but a lower 3-star health inspection rating. Reported nurse staffing is 3.97 hours per resident per day versus the 4.1 federal benchmark, and it had $12,685 in fines in the last 24 months with a recent federal penalty flag.
Facility ratings
Health inspections
Staffing
3.9701 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 3.9701.
Staffing detail
- Registered nurses
- 0.91
- Licensed practical nurses
- 0.60
- Nurse aides
- 2.46
- Weekend nursing
- 3.73
Hours per resident per day.
Total staff turnover: 38%
Registered nurse turnover: 17%
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
7.5%7.3%No change
Residents with a fall causing major injury
1%0.9%No change
Residents with pressure ulcers (bedsores)
2.2%0.7%Improving
Residents with a urinary tract infection
0%0%No change
Residents who lost too much weight
1.1%4.7%Worsening
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
9.3%3.7%Improving
Residents whose ability to walk got worse
10.6%0%Improving
Long-stay residents on antianxiety or sleep medication
5.4%4.7%Improving
Short-stay residents newly given an antipsychotic
1.5%0.9%Improving
Residents with a long-term catheter
0%0%No change
Residents with new or worsening incontinence
15.6%21.1%Worsening
Residents with depressive symptoms
11.1%5.7%Improving
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
—100%—
Long-stay residents given the pneumonia vaccine
100%100%No change
Short-stay residents given the seasonal flu vaccine
—98.4%—
Short-stay residents given the pneumonia vaccine
100%100%No change
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 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
The home failed to properly label and securely store medications and biologicals. Cited March 2025 — limited pattern, potential for harm.
View the original federal record
F-Tag 761 — 42 CFR §483.45(g) — 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
Recent ownership change · Sep 1, 2017
Now operated by The Avenues Transititional Care Center, previously Kindred Nursing and Rehabilitation-nineteenth Avenue.
- Ownership
- For profit - Limited Liability company
- Chain
- Part of ASPEN SKILLED HEALTHCARE · 35 homes · 3.7 stars avg
- Occupancy
- 134.5 residents on an average day (96% 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.