Map showing the location of CENTRAL GARDENS POST ACUTE in SAN FRANCISCO, California
1355 ELLIS STREET, SAN FRANCISCO, CA, 94115

Overall Score

CMS Five-Star Quality Rating
5/5Much above averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • CaliforniaAbove 76% of peers1,154 rated homes · average 3.2★
  • San Francisco CountyAbove only 31% of peers17 rated homes · average 4.4★
  • United StatesAbove 80% of peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point4★+1.2 vs CA avg
  • StaffingCan add or remove a star4★+0.9 vs CA avg
  • Quality measuresCan add or remove a star5★+0.9 vs CA avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles4★Above 66% of peersCA avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover4★Above 60% of peersCA avg3.1★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments5★Above 57% of peersCA avg4.1★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff3.92hrsAbove only 17% of peersCA avg4.51Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.80hrsAbove 81% of peersCA avg0.65Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better29%Above 76% of peersCA avg38%RN turnover53%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$0Above only 45% of peersCA avg$26,970Fines · denials0 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
34citations
9inspection dates
0actual harm (G–I)
0immediate jeopardy (J–L)
Feb 20, 2025most recent

Citations by monthOct 2019 – Feb 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

Feb 20, 20253 citationsCycle 1worst D · no actual harm
  1. F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningD · isolatedCorrected Mar 13, 2025
  2. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Mar 13, 2025
  3. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Mar 13, 2025
Apr 25, 20242 citationsCycle 2worst E · no actual harm
  1. F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningE · patternCorrected May 31, 2024
  2. F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationE · patternCorrected May 31, 2024
Jan 27, 20241 citationCycle 3worst D · no actual harm
  1. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected May 1, 2024
May 26, 20238 citationsCycle 2worst E · no actual harm
  1. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected Jun 24, 2023
  2. F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningD · isolatedCorrected Jun 24, 2023
  3. F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Pharmacy ServiceD · isolatedCorrected Jun 24, 2023
  4. F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Nutrition and DietaryD · isolatedCorrected Jun 24, 2023
  5. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Jun 24, 2023
  6. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Jun 24, 2023
  7. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Jun 24, 2023
  8. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceE · patternCorrected Jun 24, 2023
May 19, 20232 citationsCycle 3worst D · no actual harm
  1. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jun 6, 2023
  2. F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Jun 6, 2023
Mar 15, 20231 citationCycle 3worst D · no actual harm
  1. F908Keep all essential equipment working safely.EnvironmentalD · isolatedCorrected Mar 30, 2023
Mar 14, 20233 citationsCycle 3worst E · no actual harm
  1. F584Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.Resident RightsE · patternCorrected Apr 4, 2023
  2. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningE · patternCorrected Apr 4, 2023
  3. F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Apr 4, 2023
Mar 13, 20232 citationsCycle 3worst E · no actual harm
  1. F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Mar 30, 2023
  2. F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.EnvironmentalE · patternCorrected Mar 30, 2023
Oct 4, 201912 citationsCycle 3worst F · no actual harm
  1. F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Nov 12, 2019
  2. F554Allow residents to self-administer drugs if determined clinically appropriate.Resident RightsD · isolatedCorrected Nov 12, 2019
  3. F582Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.Resident RightsE · patternCorrected Nov 12, 2019
  4. F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Quality of Life and CareD · isolatedCorrected Nov 12, 2019
  5. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Nov 12, 2019
  6. F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician ServicesE · patternCorrected Nov 12, 2019
  7. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceE · patternCorrected Nov 12, 2019
  8. F760Ensure that residents are free from significant medication errors.Pharmacy ServiceE · patternCorrected Nov 12, 2019
  9. F761Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.Pharmacy ServiceE · patternCorrected Nov 12, 2019
  10. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Nov 12, 2019
  11. F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Nov 12, 2019
  12. F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Nov 12, 2019

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined3.92hrsAbove only 17% of peers−0.59 vs CA avg
  • Registered nursesRN hours only0.80hrsAbove 81% of peers+0.15 vs CA avg
  • Licensed practical nursesLPN hours0.74hrs
  • Nurse aidesCNA hours2.38hrs
  • Weekend nursingAll staff on Saturdays and Sundays3.56hrs
  • California average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better29%Above 76% of peersCA avg 38%
  • RN turnoverRegistered nurses only53%Not ranked by CMS
  • Administrators who leftIn the past year0Stable leadership
  • Occupancy92 certified beds · ~87 residents a day94%Above 73% of peersCA avg 88%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $0In fines
  • 0Fines
  • 0Payment denials
  • $26,970CA avg in fines
Above only 45% of peersFewer fines than 45% of rated homes in California

Actions on record

No fines or payment denialsNothing on record in the current reporting window. California facilities average 1.3 penalties.

Ownership

As filed with CMS

Structure

Ownership type
For profit - Limited Liability company
Chain
Pacs Group254 facilities in the chain2.9★ chain average
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Providence Group INC
Indirect owners (5%+)
  • Pacs Group, INC.
  • Pacs Holdings, LLC
  • Mark Hancock
  • Jason Murray
Corporate officers
  • Frederick Apt
  • Joshua Jergensen
  • John Mitchell
Contracted managers
  • David Portier
Managing employees
  • Matthew Russell

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 055280 · 1355 ELLIS STREET, SAN FRANCISCO, CA, 94115.
  • Percentiles compare this facility with every rated nursing home in California and San Francisco County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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