Pacific Heights Transitional Care Center

2707 Pine Street · San Francisco, CA · 94115 · 4155637600

120 certified beds For profit - Limited Liability company Chain: Aspen Skilled Healthcare

  • Inspection results have improved across recent cycles.

Red flags

No red flags in the current CMS record. Genuinely good news — pair it with an in-person tour before deciding.

Score breakdown

Inspection record 30% of score 62
Serious harm & abuse 20% 100
Staffing 20% 79
Federal penalties 15% 70
Trend 10% 85
Context 5% 100

Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.

CMS ratings & staffing

Overall: 5 of 5 Inspections: 4 of 5 Staffing: 4 of 5 Quality measures: 5 of 5

Total nurse hours / resident-day4.113.48 min · 4.1 strong
RN hours / resident-day0.770.55–0.75
Weekend hours / resident-day3.76≈ weekday level
Nursing turnover / year50%median 45%
Fines (3-yr window)1 · $25,490

Inspection citations (28 in the current record)

  • Potential for harm · D March 13, 2026

    Provide safe, appropriate dialysis care/services for a resident who requires such services.

    Corrected April 3, 2026 · Quality of Life and Care

  • Potential for harm · E March 13, 2026

    Observe each nurse aide's job performance and give regular training.

    Corrected April 3, 2026 · Nursing and Physician Services

  • Potential for harm · D March 13, 2026

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

    Corrected April 3, 2026 · Pharmacy Service

  • Potential for harm · E March 13, 2026

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    Corrected April 3, 2026 · Nutrition and Dietary

  • Potential for harm · D January 29, 2025 · found via complaint

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    Deficient, Provider has plan of correction · Quality of Life and Care

  • Potential for harm · E August 29, 2024

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

    Corrected September 26, 2024 · Resident Rights

  • Potential for harm · D August 29, 2024

    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.

    Corrected September 26, 2024 · Resident Rights

  • Potential for harm · D August 29, 2024

    Ensure each resident receives an accurate assessment.

    Corrected September 26, 2024 · Resident Assessment and Care Planning

  • Potential for harm · D August 29, 2024

    PASARR screening for Mental disorders or Intellectual Disabilities

    Corrected September 26, 2024 · Resident Assessment and Care Planning

  • Potential for harm · D August 29, 2024

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    Corrected September 26, 2024 · Resident Assessment and Care Planning

  • Potential for harm · D August 29, 2024

    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

    Corrected September 26, 2024 · Quality of Life and Care

  • Potential for harm · E August 29, 2024

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

    Corrected September 26, 2024 · Pharmacy Service

  • Potential for harm · D August 29, 2024

    Ensure each resident’s drug regimen must be free from unnecessary drugs.

    Corrected September 26, 2024 · Pharmacy Service

  • Potential for harm · D August 29, 2024

    Provide timely, quality laboratory services/tests to meet the needs of residents.

    Corrected September 26, 2024 · Administration

  • Potential for harm · D August 29, 2024

    Provide and implement an infection prevention and control program.

    Corrected September 26, 2024 · Infection Control

  • No harm found · C August 29, 2024

    Post nurse staffing information every day.

    Corrected September 26, 2024 · Nursing and Physician Services

  • Potential for harm · D September 12, 2023 · found via complaint

    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

    Corrected October 3, 2023 · Environmental

  • Potential for harm · E July 20, 2023

    Provide and implement an infection prevention and control program.

    Corrected August 18, 2023 · Infection Control

  • Potential for harm · E July 3, 2023 · found via complaint

    Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

    Corrected August 4, 2023 · Environmental

  • Potential for harm · D June 2, 2023 · found via complaint

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    Corrected August 4, 2023 · Resident Assessment and Care Planning

  • Potential for harm · E April 28, 2021

    Ensure services provided by the nursing facility meet professional standards of quality.

    Corrected June 11, 2021 · Resident Assessment and Care Planning

  • Potential for harm · F April 28, 2021

    Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

    Corrected June 11, 2021 · Pharmacy Service

  • Potential for harm · E April 28, 2021

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

    Corrected June 11, 2021 · Pharmacy Service

  • Potential for harm · D April 28, 2021

    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.

    Corrected June 11, 2021 · Pharmacy Service

  • Potential for harm · E April 28, 2021

    Ensure medication error rates are not 5 percent or greater.

    Corrected June 11, 2021 · Pharmacy Service

Showing the 25 most recent. The Safety Report includes every citation with full findings.

Federal penalties

DateTypeAmount / length
January 29, 2025Fine$25,490

Family & resident reviews — a separate signal, never mixed into the score

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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 056176 · certified since March 29, 1974. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.