The Avenues Transitional Care Center
2043 19th Avenue · San Francisco, CA · 94116 · 4156618787
140 certified beds For profit - Limited Liability company Chain: Aspen Skilled Healthcare
Why this verdict
- Inspection results are getting worse cycle over cycle, not better.
- Staffing hours comfortably above national benchmarks.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
No red flags in the current CMS record. Genuinely good news — pair it with an in-person tour before deciding.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 5 of 5 Inspections: 3 of 5 Staffing: 5 of 5 Quality measures: 5 of 5
| Total nurse hours / resident-day | 3.98 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.89 | 0.55–0.75 |
| Weekend hours / resident-day | 3.76 | ≈ weekday level |
| Nursing turnover / year | 43% | median 45% |
| Fines (3-yr window) | 1 · $12,685 |
Inspection citations (21 in the current record)
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Actual harm · G October 2, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected October 20, 2025 · Quality of Life and Care
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Potential for harm · D March 24, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected April 20, 2025 · Resident Rights
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Potential for harm · D March 24, 2025
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected April 20, 2025 · Resident Rights
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Potential for harm · E March 24, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected April 20, 2025 · Quality of Life and Care
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Potential for harm · E March 24, 2025
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected April 20, 2025 · Pharmacy Service
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Potential for harm · D March 24, 2025
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected April 20, 2025 · Pharmacy Service
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Potential for harm · D March 24, 2025
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 April 20, 2025 · Pharmacy Service
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Potential for harm · E March 24, 2025
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.
Corrected April 20, 2025 · Pharmacy Service
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Potential for harm · D March 24, 2025
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected April 20, 2025 · Nutrition and Dietary
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Potential for harm · F March 24, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected April 20, 2025 · Nutrition and Dietary
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Potential for harm · E March 24, 2025
Provide and implement an infection prevention and control program.
Corrected April 20, 2025 · Infection Control
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No harm found · B March 24, 2025
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected April 20, 2025 · Environmental
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Potential for harm · D May 21, 2024 · found via complaint
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected June 21, 2024 · Resident Assessment and Care Planning
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Potential for harm · D May 21, 2024 · found via complaint
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected June 21, 2024 · Resident Assessment and Care Planning
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Potential for harm · D January 26, 2024
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected February 25, 2024 · Nutrition and Dietary
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Potential for harm · D April 9, 2021
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected June 11, 2021 · Resident Rights
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Potential for harm · D April 9, 2021
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected June 11, 2021 · Resident Rights
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Potential for harm · D April 9, 2021
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected June 11, 2021 · Resident Assessment and Care Planning
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Potential for harm · D April 9, 2021
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.
Corrected June 11, 2021 · Quality of Life and Care
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Potential for harm · D April 9, 2021
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.
Corrected June 11, 2021 · Pharmacy Service
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No harm found · C April 9, 2021
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Corrected June 11, 2021 · Environmental
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| October 2, 2025 | Fine | $12,685 |
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 055963 · 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.