Inspection Reports for
The Avenues Transitional Care Center
2043 19th Ave, San Francisco, CA 94116, United States, CA, 94116
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
83% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 2, 2025
Visit Reason
The inspection was conducted due to a complaint investigation following a fall incident involving Resident 1, who fell from bed resulting in injury, hospitalization, and subsequent death.
Complaint Details
The complaint investigation substantiated that Resident 1 fell from bed due to staff leaving the resident unattended in an unsafe position without proper fall prevention measures. The fall resulted in injury, hospitalization, and death. Staff interviews and record reviews confirmed failure to use a low air loss mattress and inadequate training of CNA 1.
Findings
The facility failed to prevent an avoidable fall for Resident 1, who was left unattended in a high bed position with bed rails down. The fall caused serious injuries including a traumatic brain injury leading to death. The investigation revealed inadequate supervision, failure to use a low air loss mattress, and lack of proper staff training on fall prevention.
Deficiencies (1)
Failure to ensure a nursing home area is free from accident hazards and provide adequate supervision to prevent accidents.
Report Facts
Residents sampled: 4
Fall risk score: 51
Injury measurements: 4
Injury measurements: 4
Injury measurements: 1
Injury measurements: 1
Injury measurements: 1
Injury measurements: 1
BIMS score: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nurse Assistant | Named in relation to failure to provide adequate supervision and fall prevention leading to Resident 1's fall |
| Nurse Supervisor | Nurse Supervisor | Interviewed regarding the fall incident and staff actions |
| RN 1 | Registered Nurse | Witnessed the fall incident and provided immediate assistance |
| Director of Staff Development | Director of Staff Development | Reviewed CNA 1's employee file and training records |
Inspection Report
Routine
Deficiencies: 13
Date: Mar 24, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, medication administration, treatment and care, pharmaceutical services, food preferences, infection control, and facility room size.
Findings
The facility was found deficient in multiple areas including failure to ensure resident dignity during feeding, unsafe medication self-administration practices, failure to monitor nutritional status and injection sites, medication accountability issues, medication errors, improper medication storage, failure to honor food preferences, infection control lapses, and inadequate resident room sizes.
Deficiencies (13)
Failure to ensure residents were treated with dignity and respect during feeding when CNAs stood over residents instead of sitting at eye level.
Failure to ensure safe self-administration of medications including leaving multiple prescription medications on bedside table without proper interdisciplinary team determination.
Failure to follow physician's order to obtain monthly mid upper arm circumference measurements and monitor injection sites for bruising.
Failure to ensure accountability of controlled medications with discrepancies between Controlled Drug Records and Medication Administration Records.
Medication administration errors including administering wrong medication and failure to observe resident taking medication.
Failure to clean shared pill cutter between medication preparations.
Failure to monitor for bleeding in resident on heparin therapy.
Failure to ensure residents were free from unnecessary antipsychotic medications and lack of behavioral monitoring for psychotropic medication use.
Failure to properly store medications and biologicals including medication storage room temperature exceeding manufacturer recommendations, open undated multi-dose vial, and expired medication patches available for use.
Failure to honor food preferences for residents resulting in serving incorrect food textures and meals not matching meal tickets.
Failure to ensure food safety including dirty frying pan, wet stacked serving trays, and dented canned goods in dry storage.
Failure to implement infection prevention and control program including improper urinal storage, lack of hand hygiene by janitorial and nursing staff, failure to disinfect blood pressure cuff, and failure to wear gloves during medication administration.
Resident rooms did not meet minimum required size of 80 square feet per resident in 47 of 48 rooms.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 2
Residents affected: 5
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 133
Residents affected: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Named in dignity during feeding deficiency | |
| CNA 2 | Named in dignity during feeding deficiency | |
| LVN 2 | Licensed Vocational Nurse | Named in medication self-administration and monitoring deficiency |
| ADON | Assistant Director of Nursing | Interviewed regarding multiple deficiencies including dignity, medication, and infection control |
| DSD | Director of Staff Development | Interviewed regarding dignity during feeding |
| RNS 2 | Registered Nurse Supervisor | Interviewed regarding nutritional monitoring deficiencies |
| RNS 3 | Registered Nurse Supervisor | Interviewed regarding medication accountability deficiencies |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including medication errors, infection control, and room size |
| LVN 1 | Licensed Vocational Nurse | Observed and interviewed regarding hand hygiene and medication administration deficiencies |
| RN 1 | Registered Nurse | Observed and interviewed regarding glove use during medication administration |
| Janitor 1 | Observed and interviewed regarding hand hygiene during linen handling | |
| HS | Housekeeping Supervisor | Interviewed regarding hand hygiene practices |
| IP | Infection Preventionist | Interviewed regarding hand hygiene practices |
| DM | Dietary Manager | Interviewed regarding food preferences and food safety |
| RD | Registered Dietitian | Interviewed regarding food preferences and food safety |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: May 21, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments and care planning, specifically focusing on timely completion of the Minimum Data Set (MDS) comprehensive assessment and baseline care plan for newly admitted residents.
Findings
The facility failed to complete the Minimum Data Set comprehensive assessment within the required 14-day period for Resident 1, completing it 23 days after admission. Additionally, the baseline care plan was not developed within 48 hours of admission as required, being completed on day 8 instead. These delays could result in delayed identification of resident needs affecting their physical, mental, and psychosocial well-being.
Deficiencies (2)
Failure to complete the Minimum Data Set comprehensive assessment within 14 days of admission for Resident 1.
Failure to develop a baseline care plan within 48 hours of admission for Resident 1.
Report Facts
Days late for MDS assessment: 9
Days late for baseline care plan: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Coordinator | Acknowledged late completion of admission MDS assessment and baseline care plan |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Jan 26, 2024
Visit Reason
The inspection was conducted to assess compliance with regulations regarding resident food preferences and dietary accommodations at The Avenues Transitional Care Center.
Findings
The facility failed to ensure that resident food preferences were consistently honored, specifically for Resident #115 who requested ice cream with lunch and dinner but did not receive it as documented. Interviews and record reviews confirmed the failure to provide requested food items despite documented orders and facility policies.
Deficiencies (1)
Failure to ensure resident food preferences were provided for Resident #115, specifically not serving ice cream as requested during lunch and dinner meals.
Report Facts
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Stated unawareness of Resident #115's request for ice cream with lunch and dinner |
| Dietary Manager | Dietary Manager | Confirmed ice cream was available but not listed on Resident #115's tray ticket and was unaware of the request |
| Director of Nursing | Director of Nursing | Stated expectation that residents' food preferences be honored and tray tickets updated accordingly |
| Administrator | Administrator | Stated expectation for interdisciplinary team meetings to document and honor resident food preferences |
Inspection Report
Routine
Deficiencies: 3
Date: Apr 5, 2023
Visit Reason
The inspection was conducted to assess compliance with safety, infection prevention, and medication security standards in the nursing home.
Findings
The facility failed to ensure a safe environment by leaving a medication cart unlocked and unattended, lacking fire safety signage for oxygen use in a resident's room, and failing to maintain proper infection prevention practices as multiple staff did not perform hand hygiene between tasks.
Deficiencies (3)
Medication cart was left unlocked and unattended, risking unauthorized access to medications.
No fire safety signage indicating oxygen use in a resident's room.
Failure to maintain infection prevention and control program; staff did not perform hand hygiene between tasks.
Report Facts
Oxygen flow rate: 4
BIMS score: 7
Number of staff failing hand hygiene: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 1 | LVN | Acknowledged medication cart was unlocked and lack of oxygen signage |
| Director of Nursing | DON | Stated medication cart should always be locked and oxygen signage should be present |
| Certified Nursing Assistant 1 | CNA | Observed failing to perform hand hygiene while holding dirty gloves |
| Certified Nursing Assistant 2 | CNA | Acknowledged not performing hand hygiene and stated being in a hurry |
| Certified Nursing Assistant 3 | CNA | Acknowledged not performing hand hygiene after leaving isolation room |
| Infection Preventionist | IP | Explained hand hygiene policy and importance |
Inspection Report
Deficiencies: 3
Date: Feb 3, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory standards related to care planning, implementation of physician orders, and staff competency in assessing and staging pressure injuries for one resident.
Findings
The facility failed to update the care plan to include a Low Air Loss mattress as an intervention for a resident with a Stage III pressure injury, delayed implementation of the physician's order for the mattress by 14 days, and did not ensure that two registered nurses had the necessary training and competency to accurately assess and stage the pressure injury. These deficiencies had the potential to delay wound healing and place the resident at risk of further harm.
Deficiencies (3)
Failed to update/revise the Skin Integrity care plan to include the Low Air Loss mattress as an intervention for a resident with a Stage III pressure injury.
Failed to implement the Physician's Order for a Low Air Loss mattress until 14 days after it was ordered.
Failed to ensure two Registered Nurses had the training and competency to accurately assess and stage a pressure injury.
Report Facts
Days delay in implementing mattress order: 14
Pressure Injury size: 1.4
Pressure Injury size: 0.6
Pressure Injury size: 0.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding care plan updates, mattress order implementation, and nurse competency |
| RN 1 | Registered Nurse | Assessed and staged pressure injury; lacked documented competency |
| RN 2 | Registered Nurse | Assessed and staged pressure injury; lacked documented competency |
Inspection Report
Routine
Deficiencies: 6
Date: Apr 9, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication administration, informed consent for psychotropic medications, self-administration of medications, medication labeling, feeding tube care, and room size standards at The Avenues Transitional Care Center.
Findings
The facility failed to verify informed consent for psychotropic medications for two residents, did not properly assess and educate a resident self-administering eye drops, staff signed medication administration records before giving medications, medications with expired dates were found in storage, a resident received the wrong enteral feeding formula and had an outdated feeding tube dressing, and all resident rooms measured less than the required minimum square footage.
Deficiencies (6)
Failed to verify that the physician and resident's representative signed informed consent for psychotropic medications for Residents 42 and 54.
Failed to verify resident's ability to self-administer medication and ensure interdisciplinary team evaluation for Resident 93.
Staff signed electronic Medication Administration Records before administering medications to residents.
Resident 59 received the wrong enteral feeding formula and feeding tube site dressing was not changed as required.
Failed to ensure medication labeling included current expiration dates and staff followed cautionary instructions on medication labels for Resident 91; expired medications found in medication carts and refrigerators.
Resident rooms did not meet minimum size requirements of 80 square feet per resident in multiple occupancy rooms.
Report Facts
Residents sampled: 24
Residents affected: 7
Medication administration observation time: 8
Feeding tube rate: 62
Feeding tube duration: 20
Room count: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 2 | Licensed Vocational Nurse | Administered medications, acknowledged signing MAR before administration, observed medication administration practices |
| Assistant Director of Nursing | ADON | Acknowledged lack of informed consent verification and physician signatures for psychotropic medications |
| RN 2 | Registered Nurse | Acknowledged honoring resident's request to self-administer medication without education or assessment |
| RN 4 | Charge Nurse/Medication Nurse | Discovered wrong enteral feeding formula and reported to ADON |
| LVN 3 | Licensed Vocational Nurse | Acknowledged expired medications in medication cart |
| LVN 1 | Licensed Vocational Nurse | Observed medication storage and feeding tube dressing, expressed regret about errors |
| RN 1 | Registered Nurse | Filed incident report and communicated with physician and family regarding feeding formula error |
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