California Pacific Heights Transitional Care Center
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Notable Concerns
A review of public records for Pacific Heights Transitional Care Center shows several concerns involving resident care, infection control, and staffing:
- The facility was fined $25,000 in January 2025 after a resident reportedly spent more than 13 hours in a wheelchair because he could not access his room.
- Inspectors cited the facility in 2024 after observing a nurse touch the drinking surface of a resident’s water cup during medication administration, creating a potential risk of infection.
- Some online reviewers reported concerns about limited staffing, residents not being repositioned often enough to help prevent bedsores, and improperly trained staff.
- The facility’s registered nurse turnover rate is 50%, which exceeds both the national average of 43.3% and the California average of 39.4%.
Table of Contents:
Pacific Heights Transitional Care Center Ratings and Reviews Overview
Pacific Heights Transitional Care Center, located at 2707 Pine Street in San Francisco, California, has an overall five-star Medicare rating. The facility has earned five stars for quality measures and four stars for both health inspections and staffing. It has 120 certified beds and cares for an average of about 110 residents each day.
According to Medicare’s Nursing Home Compare website, residents receive an average of four hours and seven minutes of staff care per day. That exceeds the national average but falls slightly below the state average. Meanwhile, at 50%, the registered nurse turnover rate is above the national average of 43.3% and the California average of 39.4%.
On Yelp, the facility has received an overall rating of 3.8 stars. Some reviewers report concerns about residents not being repositioned often enough to help prevent bedsores, limited staffing, and staff members who were not properly trained to assist residents with transfers to the restroom.
Violations, Deficiencies, and Penalties at Pacific Heights Transitional Care Center
Medicare’s Care Compare tool offers public access to health and complaint inspection reports from the past year. You can review older inspection reports through the nonprofit investigative journalism organization ProPublica. Below are a few notable reported concerns.
January 2025: Failure To Provide Bed and Room Access to a Resident
In January 2025, the facility received a $25,000 fine after failing to provide a resident with access to a bed or room. As a result, the resident remained seated upright in a wheelchair in the facility lobby for more than 13 hours overnight and into the following day.
According to the report, the resident was waiting for staff to take him to his room on the fifth floor when they informed him that the elevator had stopped working. Staff reportedly told him that no one could assist him to his room because he weighed more than 300 pounds and was too heavy to carry. The report also states that the chair lift was not working at the time.
August 2024: Failure to Follow Infection Control Procedures During Medication Administration
An inspection found that a registered nurse sanitized her hands, then touched the rim of a water cup with her bare hand before handing it to a resident to take medication. The resident drank from the same cup after taking the medication.
Inspectors reported
that the facility’s infection preventionist said nurses should not touch the drinking surface of a cup because doing so can increase the risk of infection. Rather, staff are expected to hold cups below the rim.July 2023: Failure to Follow Infection Prevention and Control Procedures
According to the inspection report, the facility failed to maintain an effective infection prevention and control program. Inspectors found seven wash basins, one bedpan, one measuring hat, and one urinal stored in resident bathrooms without labels or name tags identifying who they belonged to.
The report states that this practice increased the risk of spreading infections among residents, staff, and visitors. Facility policy requires that this equipment be labeled with the resident’s initials and room number, rinsed with water after each use, and stored within the resident’s bedside nightstand.
California Nursing Home Residents’ Rights: What Families Need to Know
California law protects nursing home residents by setting clear standards for care and safety. Residents have the following key rights:
- Dignity and protection from abuse:
Residents must receive respectful care free from harm, abuse, or exploitation.
- Quality care and adequate staffing:
Facilities must provide quality care and provide enough qualified staff.
- Safe and clean environment:
Residents have the right to live in a safe and sanitary environment.
- Right to report issues: Residents can file complaints without fear of punishment.
Contact Lanzone Morgan Today to Start Your Journey to Justice
We focus exclusively on nursing home abuse cases. That narrow focus allows us to offer the experience and support families need during difficult times. Our team has more than 75 years of combined experience with a strong record of holding nursing homes and other elder care facilities accountable. We have recovered over $250 million in settlements and verdicts for victims and their families.
If you are concerned about the care a loved one has received at Pacific Heights Transitional Care Center, we can help. You pay nothing up front, and there are no fees unless we win. Contact us online or call 888-887-9777 today for a free consultation with a San Francisco nursing home abuse lawyer.
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.
VIEW SOURCES
California Health and Human Services Agency, Department of Health Care Access and Information. (n.d.). Kindred Nursing and Rehabilitation – Golden Gate. https://hcai.ca.gov/facility/kindred-nursing-and-rehabilitation-golden-gate/
California Legislative Information. (n.d.). California Health and Safety Code § 1599.1. https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?lawCode=HSC§ionNum=1599.1
Code of Federal Regulations. (n.d.). 42 CFR § 483.10 – Resident rights. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-483/subpart-B/section-483.10
Code of Federal Regulations. (n.d.). 42 CFR § 483.10(j) – Grievances. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-G/part-483/subpart-B/section-483.10#:~:text=%28j%29-,Grievances,-.
Medicare.gov. (n.d.). Care Compare: Pacific Heights Transitional Care Center. https://www.medicare.gov/care-compare/details/nursing-home/056176/view-all?state=CA
ProPublica. (n.d.). Pacific Heights Transitional Care Center. https://projects.propublica.org/nursing-homes/homes/h-056176/
Yelp. (n.d.). Pacific Heights Transitional Care Center. https://www.yelp.com/biz/pacific-heights-transitional-care-center-san-francisco?rr=2
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- Wheelchair Transfer Injuries
- Elderly Wandering & Elopement
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- Urinary Tract Infections (UTIs)
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- 356 Redondo Avenue, Long Beach, CA 90814
- 888-887-9777