Central Gardens Post Acute
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Central Gardens Post Acute is a skilled nursing facility in San Francisco. Public records highlight the following areas of concern if you’re considering placing a loved one in this facility:
- Residents at Central Gardens Post Acute receive significantly fewer hours of nursing care than the California average, and registered nurse turnover is also alarmingly high.
- The facility has a 3.3-star Yelp rating, with negative reviews highlighting inattentive care, medication issues, poor living conditions, and concerns of abuse by staff members.
- In 2025, inspectors observed multiple medication errors, including a nurse attempting to administer ear drops into a resident’s nostril. The facility’s medication error rate was 6.67%, which exceeded the federal maximum of 5%.
- A 2023 inspection found that a resident identified as a high fall risk had five falls at the facility, and staff failed to implement the resident’s fall-prevention care plan.
- In 2020, Central Gardens Post Acute was the site of San Francisco’s largest nursing home COVID-19 outbreak at the time, and the facility faced scrutiny for its early handling of the pandemic. By April, the outbreak had contributed to four resident deaths.
Central Gardens Post Acute Ratings and Reviews
Medicare currently gives Central Gardens Post Acute an overall rating of five out of five stars. However, a closer look at the data reveals concerning details about staffing levels and resident outcomes.
Residents at the facility receive an average of just 3.85 hours of nursing care per day, significantly below California’s average of 4.5 hours. Registered nurse turnover is also high at 52.6%—compared to the state average of 39.5%—meaning more than half of all RNs left the facility within a 12-month period.
Several quality measures also fall below state averages. According to Medicare data, 21.6% of long-stay residents develop new or worsening bowel or bladder incontinence, compared to the California average of 10.7%. Additionally, 22.8% of long-stay residents experience symptoms of depression, which is more than 3 times higher than the statewide average of 7%.
Central Gardens Post Acute has a 3.3-star rating on Yelp. Negative reviews from residents and loved ones describe concerns about delayed staff responses to residents’ needs, poor hygiene care, medication-related issues, difficulty reaching physicians, poor food quality, and physical or emotional mistreatment by staff members.
Care Deficiencies at Central Gardens Post Acute
Federal regulators have issued three health citations to Central Gardens Post Acute in recent years. Inspections of the facility have made alarming findings regarding medication errors, infection-control failures, and other resident-safety concerns.
February 2025 Inspection Findings
A February 2025 inspection identified multiple medication administration errors. Surveyors observed a nurse prepare the wrong dose of a medication for treating bipolar disorder. The same nurse then placed a bottle of Debrox ear drops into a resident’s nostril instead of the ear canal. Overall, the facility’s medication error rate was reportedly 6.67%, exceeding the federal maximum of 5%.
In another incident, inspectors observed a nurse caring for a resident with a feeding tube without wearing the required protective gown. This failure posed a risk of transmitting germs between residents and staff.
May 2023 Inspection Findings
In a May 2023 inspection, surveyors noted failures in the care of a resident identified as high risk for falls at admission. The resident experienced five falls while living at the facility, but staff repeatedly failed to make changes to the resident’s care. After the fourth fall, the care plan finally called for a fall mat, but no mat had been placed by the time of the inspection. Some staff members were also unaware that the resident was considered a high fall risk.
Inspectors also identified several infection control concerns. According to the document, staff moved between resident rooms without sanitizing their hands and used blood pressure cuffs on multiple residents without cleaning in between uses.
The inspection further uncovered medication-related issues. A nurse crushed a delayed-release seizure medication, a resident’s respiratory medication was unavailable because staff hadn’t ordered it in time, and staff documented a pain patch as administered when it was never actually applied. Surveyors also found controlled substances left unsecured and oxycodone tablets missing from inventory.
April 2020 COVID-19 Outbreak
In April 2020, Central Gardens Post Acute became the target of controversy regarding its early handling of the COVID-19 pandemic
. The facility was reportedly the site of San Francisco’s largest nursing home COVID-19 outbreak at the time, with 65 confirmed infections among residents and staff and four resident deaths.
A former resident alleged that she was discharged from the facility without being informed of the outbreak and that staff did not offer her a COVID-19 test before she left. Additionally, staff members reportedly requested universal testing of residents and employees early in the outbreak, but management allegedly limited testing to people with fevers. Many infected individuals were later found to be asymptomatic, which could have allowed the virus to spread undetected throughout the facility.
How To Protect Your Loved One From Nursing Home Abuse or Neglect
- Visit your loved one regularly, and pay attention to changes in their physical condition or behavior.
- Ask facility officials questions about falls, infections, or other significant changes in your loved one’s health.
- Document any concerns about your loved one’s care. Take photos, write down your observations, and keep a copy of all communications with staff members.
- Report your concerns in writing to administrators. You can also contact the California Department of Public Health at (800) 554-0354.
- To report abuse or neglect currently occurring in a nursing home, contact the California Department of Aging Long-Term Care Ombudsman CRISIS Line at (800) 231-4024.
Get Trusted Help From Our California Nursing Home Abuse Lawyers Today
If you believe your loved one has suffered preventable harm at Central Gardens Post Acute or another California nursing home facility, you have an ally in Lanzone Morgan, LLP.
Our team is singularly focused on protecting the rights of vulnerable adults, and we’ve earned a reputation as one of the leading elder abuse law firms in the United States. With more than 75 years of combined experience and over $250 million recovered for victims of nursing home abuse and neglect, we have the knowledge and resources necessary to stand up to negligent care providers.
Our San Francisco nursing home abuse lawyers are available 24/7 to provide compassionate guidance during this difficult time. Call 888-887-9777 or complete our online contact form for a free, confidential consultation about your rights and next steps.
Disclaimer: The inspection information provided above comes from public sources. Lanzone Morgan, LLP, cannot ensure that this page reflects the most current data or complete findings. For the latest information, visit https://projects.propublica.org/ or medicare.gov. Deficiencies listed may have been corrected since the inspection date and the time of publication. This page is a legal advertisement and information resource. It is not endorsed by the named facility or any government agency. Lanzone Morgan, LLP, is not affiliated with the facility discussed.
- Fact-Checked
This content has been legally reviewed and approved by nursing home abuse attorney, Anthony Lanzone. Anthony holds notable memberships with professional organizations including the American Association for Justice and Consumer Attorneys of California.
VIEW SOURCES
- Central Gardens Post Acute. (n.d.). Medicare.gov. https://www.medicare.gov/care-compare/details/nursing-home/055280/view-all?state=CA
- Central Gardens Post Acute in California. (n.d.). ProPublica. https://projects.propublica.org/nursing-homes/homes/h-055280/
- Eskenazi, J. (2020, April 23). Former resident at Central Gardens, site of city’s deadliest COVID-19 outbreak, says she was discharged without any warning. Mission Local. https://missionlocal.org/2020/04/former-resident-at-central-gardens-site-of-citys-deadliest-covid-19-outbreak-says-she-was-discharged-without-any-warning/
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