B+
81/100THE AVENUES TRANSITIONAL CARE CENTER Inspection Report, Violations & Safety Grade (SAN FRANCISCO, California)
2043 19TH AVENUE, SAN FRANCISCO, California 94116
Phone: 4156618787
CMS Overall:4/5
Overview & Bed Count
Certified Beds
140
Avg Residents/Day
133.7
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
San Francisco
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No
CMS Star Ratings
Overall4/5
Health3/5
Staffing4/5
Quality5/5
Nurse Staffing Check
| Metric | This Facility | California Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.83 | 0.68 | +0.15 |
| Total Nurse Hours per Resident per Day | 3.91 | 4.54 | -0.63 |
| CMS Staffing Rating | 4/5 | 3.3/5 | - |
| Nursing Staff Turnover | 40.0% | 36.6% | - |
Health Citation History
21 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-10-02 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G – Actual Harm |
| 2025-03-24 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2025-03-24 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | E – Moderate Harm Potential |
| 2025-03-24 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E – Moderate Harm Potential |
| 2025-03-24 | Pharmacy Service Deficiencies | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | E – Moderate Harm Potential |
| 2025-03-24 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | E – Moderate Harm Potential |
| 2025-03-24 | Resident Rights Deficiencies | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | D – Moderate Harm Potential |
| 2025-03-24 | Resident Rights Deficiencies | Allow residents to self-administer drugs if determined clinically appropriate. | D – Moderate Harm Potential |
| 2025-03-24 | Pharmacy Service Deficiencies | Ensure each resident’s drug regimen must be free from unnecessary drugs. | D – Moderate Harm Potential |
| 2025-03-24 | Pharmacy Service Deficiencies | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | D – Moderate Harm Potential |
| 2025-03-24 | Nutrition and Dietary Deficiencies | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | D – Moderate Harm Potential |
| 2025-03-24 | Environmental Deficiencies | Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | B – Minimal Harm Potential |
| 2024-05-21 | Resident Assessment and Care Planning Deficiencies | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | D – Moderate Harm Potential |
| 2024-05-21 | Resident Assessment and Care Planning Deficiencies | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | D – Moderate Harm Potential |
| 2024-01-26 | Nutrition and Dietary Deficiencies | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | D – Moderate Harm Potential |
| 2021-04-09 | Resident Rights Deficiencies | Ensure that residents are fully informed and understand their health status, care and treatments. | D – Moderate Harm Potential |
| 2021-04-09 | Resident Rights Deficiencies | Allow residents to self-administer drugs if determined clinically appropriate. | D – Moderate Harm Potential |
| 2021-04-09 | Resident Assessment and Care Planning Deficiencies | Ensure services provided by the nursing facility meet professional standards of quality. | D – Moderate Harm Potential |
| 2021-04-09 | Quality of Life and Care Deficiencies | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | D – Moderate Harm Potential |
| 2021-04-09 | Pharmacy Service Deficiencies | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | D – Moderate Harm Potential |
| 2021-04-09 | Environmental Deficiencies | Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | C – Minimal Harm Potential |
Fire Safety Citation History
25 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2025-03-24 | Smoke Deficiencies | Properly select, install, inspect, or maintain portable fire extinguishes. | E – Moderate Harm Potential |
| 2025-03-24 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | E – Moderate Harm Potential |
| 2025-03-24 | Construction Deficiencies | Use approved construction type or materials. | D – Moderate Harm Potential |
| 2025-03-24 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | D – Moderate Harm Potential |
| 2025-03-24 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | D – Moderate Harm Potential |
| 2025-03-24 | Miscellaneous Deficiencies | Provide a written emergency evacuation plan. | D – Moderate Harm Potential |
| 2025-03-24 | Gas, Vacuum, and Electrical Systems Deficiencies | Meet requirements for the use of electrical equipment. | D – Moderate Harm Potential |
| 2025-03-24 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper medical gas storage and administration areas. | D – Moderate Harm Potential |
| 2025-03-24 | Emergency Preparedness Deficiencies | Conduct testing and exercise requirements. | C – Minimal Harm Potential |
| 2025-03-24 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | C – Minimal Harm Potential |
| 2024-01-26 | Emergency Preparedness Deficiencies | Provide family notifications of emergency plan. | F – Moderate Harm Potential |
| 2024-01-26 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | F – Moderate Harm Potential |
| 2024-01-26 | Smoke Deficiencies | Have approved installation, maintenance and testing program for fire alarm systems. | E – Moderate Harm Potential |
| 2024-01-26 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | E – Moderate Harm Potential |
| 2024-01-26 | Emergency Preparedness Deficiencies | Provide emergency officials' contact information. | D – Moderate Harm Potential |
| 2024-01-26 | Construction Deficiencies | Use approved construction type or materials. | D – Moderate Harm Potential |
| 2024-01-26 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | D – Moderate Harm Potential |
| 2024-01-26 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | D – Moderate Harm Potential |
| 2024-01-26 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | D – Moderate Harm Potential |
| 2024-01-26 | Miscellaneous Deficiencies | Provide a written emergency evacuation plan. | D – Moderate Harm Potential |
| 2024-01-26 | Gas, Vacuum, and Electrical Systems Deficiencies | Meet requirements for the use of electrical equipment. | D – Moderate Harm Potential |
| 2021-04-09 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | E – Moderate Harm Potential |
| 2021-04-09 | Gas, Vacuum, and Electrical Systems Deficiencies | Have generator or other power source capable of supplying service within 10 seconds. | E – Moderate Harm Potential |
| 2021-04-09 | Egress Deficiencies | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | D – Moderate Harm Potential |
| 2021-04-09 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | D – Moderate Harm Potential |
Total Penalties & Fines
$12,685
Total Fine Amount (CMS)
1
Number of Fines
1
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2025-10-02 | Fine | $12,685 | - |
Need Help Finding Safe Care?
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3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.
Need Help Finding Safe Care?
Our family advisors can help you find vetted, top-rated facilities in the SAN FRANCISCO area at no cost.
Find Safe, Vetted Facilities Near SAN FRANCISCO
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
(Free Family Advisor Call)Download Inspection & Tour Checklist PDF
3-Year Complete Report ($19)
Advisor service is free for families. We may receive referral compensation.