The Avenues Transitional Care Center
2043 19th Avenue, San Francisco, CA 94116 · San Francisco County · 140 certified beds · avg 135 residents/day · certified since Mar 29, 1974
Part of chain: ASPEN SKILLED HEALTHCARE (35 facilities, chain avg rating 3.7★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 5/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Oct 2, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Oct 20, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (21)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Oct 2, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Mar 24, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Mar 24, 2025 | E · Potential for harm, repeated | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Mar 24, 2025 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Mar 24, 2025 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Mar 24, 2025 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Mar 24, 2025 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. |
| Mar 24, 2025 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Mar 24, 2025 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Mar 24, 2025 | D · Potential for harm, one-off | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Mar 24, 2025 | D · Potential for harm, one-off | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. |
| Mar 24, 2025 | B · Minimal risk, repeated | The facility had resident rooms smaller than required — at least 80 square feet per person in shared rooms and 100 square feet in single rooms. |
| May 21, 2024 | D · Potential for harm, one-off | The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. · from a complaint |
| May 21, 2024 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · from a complaint |
| Jan 26, 2024 | D · Potential for harm, one-off | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. |
| Apr 9, 2021 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Apr 9, 2021 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Apr 9, 2021 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Apr 9, 2021 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Apr 9, 2021 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Apr 9, 2021 | C · Minimal risk, facility-wide | The facility had resident rooms smaller than required — at least 80 square feet per person in shared rooms and 100 square feet in single rooms. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (1 → 11).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2021 | 6 | 0 | D |
| 2024 | 3 | 0 | D |
| 2025 | 12 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $12,685.
| Date | Type | Amount / length |
|---|---|---|
| Oct 2, 2025 | Fine | $12,685 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | California avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.29 | 4.31 | 3.95 | top 39% in California; top 29% in the U.S. |
| Registered Nurse hours | 0.99 | 0.61 | 0.69 | top 11% in California; top 16% in the U.S. |
| Weekend total nurse staffing | 4.03 | 3.90 | 3.50 | top 31% in California; top 22% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.63 | 0.51 | 0.48 | top 19% in California; top 21% in the U.S. |
| Total nursing staff turnover (%) | 38.0 | 36.7 | 45.8 | bottom 44% in California; top 31% in the U.S. |
| RN turnover (%) | 16.7 | 38.1 | 42.9 | top 13% in California; top 9% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.97, RN 0.91, weekend 3.73. Staffing rating: 5/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 5/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Asjk LLC | Organization | Direct Ownership Interest | NOT APPLICABLE | 12/20/2018 |
| Aspen Skilled Healthcare INC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 12/20/2018 |
| Bradshaw, Jeffrey | Individual | Indirect Ownership Interest | NOT APPLICABLE | 12/20/2018 |
| Bradshaw, Peter | Individual | Indirect Ownership Interest | NOT APPLICABLE | 07/07/2023 |
| Brady, Vern | Individual | Indirect Ownership Interest | NOT APPLICABLE | 09/01/2017 |
| Case, Ryan | Individual | Indirect Ownership Interest | NOT APPLICABLE | 12/20/2018 |
| Elsner, Eric | Individual | Indirect Ownership Interest | NOT APPLICABLE | 12/20/2018 |
| Kirkwood, Jared | Individual | Indirect Ownership Interest | NOT APPLICABLE | 01/01/2019 |
| Orgill, Craig | Individual | Indirect Ownership Interest | NOT APPLICABLE | 01/01/2019 |
| Parti, Rajesh | Individual | Indirect Ownership Interest | NOT APPLICABLE | 12/20/2018 |
| Parti, Shruty | Individual | Indirect Ownership Interest | NOT APPLICABLE | 12/20/2018 |
| Paxman, Marcus | Individual | Indirect Ownership Interest | NOT APPLICABLE | 04/01/2022 |
| Sequoia Healthcare Group LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 01/01/2023 |
| SKBM II LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 12/20/2018 |
| SKBM LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 12/20/2018 |
| Asjk LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 12/20/2018 |
| Asjk LLC | Organization | ADP of the SNF | NOT APPLICABLE | 12/20/2018 |
| Aspen Healthcare Services LLC | Organization | ADP of the SNF | NOT APPLICABLE | 01/01/2023 |
| Basa, Edil | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/30/2023 |
| Basa, Edil | Individual | ADP of the SNF | NOT APPLICABLE | 05/30/2023 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Can you give me examples of how your staff protect residents' dignity in everyday care, like bathing and dressing?"
- "If my family member is able to manage their own medications, would you allow it, and how is that decided?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Laguna Honda Hospital & Rehabilitation Ctr D/P SNF | 1.1 mi | San Francisco, CA | ★★★☆☆ | 2/5 | abuse |
| Lawton Skilled Nursing & Rehabilitation Center | 1.3 mi | San Francisco, CA | ★★★★★ | 5/5 | |
| St. Anne's Home | 2.8 mi | San Francisco, CA | ★★★☆☆ | 4/5 | |
| Hayes Convalescent Hospital | 2.8 mi | San Francisco, CA | ★★★★★ | 5/5 | |
| San Francisco Health Care | 2.8 mi | San Francisco, CA | ★☆☆☆☆ | 1/5 | |
| California Pacific Medical Ctr- Davies Campus Hosp | 3.0 mi | San Francisco, CA | ★★★★★ | 5/5 | |
| Jewish Home & Rehab Center D/P SNF | 3.1 mi | San Francisco, CA | ★★★★★ | 4/5 | |
| San Francisco Post Acute | 3.2 mi | San Francisco, CA | ★★★★★ | 4/5 | |
| Pacific Heights Transitional Care Center | 3.4 mi | San Francisco, CA | ★★★★★ | 5/5 | |
| Laurel Heights Community Care | 3.4 mi | San Francisco, CA | ★★★★★ | 4/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 055963.