Victorian Post Acute
- Reviewed By
Anthony C. Lanzone, Founding Partner
If you are searching for information on San Francisco’s Victorian Post Acute nursing home facility, a review of federal and state inspection data, Medicare ratings, and staffing records reveals an alarming pattern of health and safety concerns that families deserve to know about. Here is what the public record actually shows:
ProPublica
has reported that inspectors found 36 recent deficiencies at Victorian Post Acute. These include violations involving medication errors and failures to follow proper protocols for infection control, pain management, and the protection of residents’ rights.While Victorian Post Acute advertises a five-star Medicare rating on its website, that number reflects quality measures only. Medicare’s health inspection rating for this facility is two stars, which alarmingly falls well below the average.
Federal regulators fined Victorian Post Acute $36,774 following a complaint inspection in January 2022.
State inspectors found that staff failed to promptly notify residents, family members, and treating physicians when a resident’s condition changed, a delay that can have serious medical consequences.
It was found that VPA provides 3.87 nurse hours per resident per day. California’s state average is 4.5 hours, meaning each resident receives considerably less hands-on, individual care than the state average.
Victorian Post Acute’s Ratings and Reviews
Victorian Post Acute, located on Pine Street in San Francisco, is a for-profit corporation under the PACS Group. It currently offers 90 beds and accepts both Medicare and Medicaid.
Although the facility’s website showcases a five-star overall Medicare rating, the true number averages three very different scores, with one warranting a much closer look.
Medicare scores nursing homes across the following three areas:
- Health inspections
- Staffing
- Quality measures
The following scores were derived from what state inspectors physically observe during unannounced visits to the facility. What the inspectors unfortunately found at Victorian Post Acute after several recent inspections is documented below.
Staffing
According to Pro Publica, Victorian Post Acute provides 3.87 nurse hours per resident per day, while California’s state average is 4.5 hours. Beyond the raw numbers, some data sources report the facility has a 75% annual registered nurse turnover rate, far above the state average of roughly 47%. These registered nurses are responsible for supervising aides, catching medication errors before they occur, and recognizing when a resident’s condition is changing. When three out of four RNs leave within a year, continuity of care invariably breaks down, leaving the facility’s residents to bear the consequences.
Victorian Post Acute’s Reviews
Reviews of Victorian Post Acute are genuinely mixed. Many people speak highly of the therapy staff and the short-term rehabilitation experience. However, what experienced state surveyors documented through their recurring inspections is independent of online reviews and documents ongoing problems with medication safety, infection prevention, and the facility’s obligations to keep families informed.
Victorian Post Acute’s Deficiencies and Violations
February 2025 Inspection
The most recent standard inspection, performed on February 20, 2025, produced two citations. It was found that staff failed to protect residents from significant and dangerous medication errors. It was also discovered that the facility failed to implement adequate infection-prevention measures or to establish an effective infection-control program. Sadly, this was not the first infection control citation in Victorian Post Acute’s inspection history.
2024 Complaint Inspections
Two complaint inspections in March of 2024 resulted in citations. On March 8, inspectors found that staff had not promptly informed a resident, their physician, and family members about a notable change in the resident’s condition. On March 7, the facility was cited for failing to provide a resident with safe and appropriate pain management.
It is completely unacceptable for a nursing home resident, who cannot adequately advocate for themselves, to suffer in constant pain unnecessarily. Though, sadly, the facility did nothing to stop it.
April 2023 Inspection
- Food safety violations related to improper food storage and disposal.
- The failure to provide safe dialysis care to residents who depended on it
- Multiple pharmacy or medication violations, including medication error rates exceeding the maximum allotted 5% threshold
- Repeated failures to complete and update required resident assessments
- Inadequate bed sore prevention and care
- The failure to provide social services
- Resident rights violations, including suppression of grievances
- Providing residents with rooms below the minimum square footage requirements
Inadequate pest control remediation
2019 Inspection
The 2019 inspection of Victorian Post Acute resulted in 12 citations, including two in which actual harm had occurred. One resident suffered actual harm because the facility failed to manage their pain appropriately. A second resident experienced true harm because the medically related social services to which they were entitled were never provided.
Federal Fine
Federal regulators fined San Francisco’s Victorian Post Acute nursing home facility $36,774 following a January 2022 complaint inspection. These fines are imposed when a nursing home is found to have committed a serious health violation or failed to correct a previously cited deficiency within the required time frame.
What to Do If You Suspect Nursing Home Abuse or Neglect
As a family member, you will notice something is wrong before anyone else does. You do not need proof before acting. Consider taking the following steps if you suspect nursing home abuse or neglect:
- Document what you observe. Write down dates, times, and specific concerns. Photograph anything you believe is relevant. Detailed written records prove critical if a formal investigation follows.
- File a complaint with the California Department of Public Health. Call (800) 554-0354. The CDPH can send inspectors who will implement strict measures to compel Victorian Post Acute to address any problems.
- Contact the Long-Term Care Ombudsman at (800) 231-4024. The local ombudsman will visit your loved one, investigate your concerns, and advocate on their behalf at no cost to your family.
- Consult with Lanzone Morgan, LLP, as soon as possible. Our team will move quickly to perform a deep dive into any and all concerns you have, preserve all evidence, and fight relentlessly to hold Victorian Post Acute accountable.
Fight for the Justice You and Your Loved One Deserve
If you trusted a nursing home to care for someone you love, and that trust was broken, you should not have to face what comes next alone.
Lanzone Morgan, LLP, exclusively handles nursing home and elder abuse cases. Our attorneys have more than 75 years of combined experience, have recovered over $250 million for victims and their families, and secured some of the largest nursing home abuse settlements in recent California history. Beyond the courtroom, through our relentless passion and dedication in seeking justice for those who can’t fight for themselves, our San Francisco nursing home abuse attorneys have shaped California’s nursing home and elder abuse legislation. For decades, we have tirelessly worked with key lawmakers and advocacy organizations to strengthen protections for residents statewide.
When a California nursing home’s defense team sees our name, they take it seriously.
If your loved one was harmed at Victorian Post Acute or anywhere else in California, call us at (888) 887-9777 or contact us online for a free, confidential consultation.
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
Victorian Post Acute. (n.d.). ProPublica. Retrieved June 25, 2026, from https://projects.propublica.org/nursing-homes/homes/h-055848
Victorian Post Acute. (n.d.). Medicare.gov. Retrieved June 25, 2026, from medicare.gov/care-compare/details/nursing-home/055848/view-all/?state=CA
- 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
Victorian Post Acute. (n.d.). ProPublica. Retrieved June 25, 2026, from https://projects.propublica.org/nursing-homes/homes/h-055848
Victorian Post Acute. (n.d.). Medicare.gov. Retrieved June 25, 2026, from medicare.gov/care-compare/details/nursing-home/055848/view-all/?state=CA