Nursing home report card · San Francisco, CA
Victorian Post Acute
2121 Pine Street, San Francisco, CA 94115
Call this home: (415) 922-5085
View this home on Medicare.gov ↗
Quick summary
Review the ratings and inspection history below
Use the star ratings as a quick grade, then read what inspectors actually wrote. Numbers alone do not tell the whole story for any one resident.
Our summary of public Medicare records. It does not establish that this home harmed a particular resident. About this summary.
How recent is this information?
- Medicare file prepared
- Aug 1, 2026
- Our record last updated
- Oct 15, 2026
- Last routine health inspection
- Feb 20, 2025
These dates mean different things. A new file can include older inspections and staffing figures. Read about the dates.
Medicare ratings
One star is the lowest rating. Five stars is the highest. Ratings are a starting point—read the inspection findings too.
Combines inspection, staffing, and care measures.
Among the highest Medicare ratings
Based on problems found during health inspections.
Above average
Based on staffing levels and related measures.
About average for U.S. nursing homes
Based on reported health and care results.
Among the highest Medicare ratings
What do the ratings and warnings mean?
- Medicare ratings
- One star is the lowest rating. Five stars is the highest. These are government ratings, not family reviews.
- Inspection problems
- Inspectors found that a home did not meet a care or safety rule. The official term is “deficiency.”
- Abuse warning
- Medicare has flagged the home because of abuse-related inspection findings. Read the findings and dates.
- Nursing staff time
- Average staff hours for each resident per day. This does not mean each resident gets that much one-to-one care.
At a glance
These numbers come from the records we have. Inspection problems are rules the home did not meet. The dates covered can differ.
Care, safety, and resident-rights issues on recent inspections
Building, alarms, exits, and related safety citations
Total fine amounts in the imported penalty records
Medicare home ID: 055848
Inspection findings to read first
Start with these past findings. We show the most serious first, then the most recent. They do not describe the home’s condition today.
Caused actual harm · isolated case
Aug 23, 2019 · Inspection rule 0745
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Caused actual harm · isolated case
Aug 23, 2019 · Inspection rule 0697
Provide safe, appropriate pain management for a resident who requires such services.
Could have caused harm · isolated case
Feb 20, 2025 · Inspection rule 0880
Provide and implement an infection prevention and control program.
Nursing staff time
These are average staff hours for each resident per day. They are not one-to-one bedside care. The file does not give the reporting period for each figure.
about 27 minutes per resident per day
about 3 hr 49 min per resident per day
about 20 minutes per resident per day
Latest inspection summary
A summary of the most recent routine inspections. You can open the dated findings below.
We do not have a routine inspection summary for this home. Check the dated findings below and the Medicare.gov record.
How this home compares
Compared with state and national averages. The numbers may cover different periods.
- Overall CMS rating: 5 stars
- Health inspection rating: 4 stars
- Staffing rating: 3 stars
- Registered nurse time per resident: 0.46 hours/day
- Total nurse time per resident: 3.82 hours/day
See the dates used for these averages
Medicare file dates: this home Aug 1, 2026; California averages Unavailable; U.S. averages Oct 1, 2026.
Other concerns in the records
These points may be worth asking about. They do not establish what happened to a particular resident. See our Terms of Use.
- Recent citations include infection-control problems
- Inspectors have listed an unusually high number of problems
How serious were the problems?
Inspectors rate each problem by how much harm it caused or could cause. We group the CMS letter codes into plain language.
- Caused actual harm2 citations
- Could have caused harm34 citations
Why inspectors showed up
Routine checks happen on a schedule. Complaint visits happen when someone reports a concern.
- Complaints
- 0
- Routine
- 36
- Fire safety
- 0
- Other
- 0
Who owns it
Names CMS lists as owners or managers · reported as For profit - Corporation.
- We do not have individual owner names for this home.
Other homes in this group: All Pacs Group nursing homes
Inspection history
Open a date to read what inspectors found. The harm labels explain how serious the problem was at the time.
February 20, 20252 findings
- Infection Control problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0880 · code D
Provide and implement an infection prevention and control program.
- Pharmacy Service problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0760 · code D
Ensure that residents are free from significant medication errors.
March 8, 20241 finding
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0580 · code D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
March 7, 20241 finding
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0697 · code D
Provide safe, appropriate pain management for a resident who requires such services.
April 21, 202320 findings
- Nutrition and Dietary problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0813 · code E
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0582 · code D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
- Resident Rights problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0585 · code D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
- Resident Assessment and Care Planning problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0636 · code D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
- Resident Assessment and Care Planning problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0637 · code D
Assess the resident when there is a significant change in condition
- Resident Assessment and Care Planning problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0638 · code D
Assure that each resident’s assessment is updated at least once every 3 months.
- Resident Assessment and Care Planning problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0641 · code D
Ensure each resident receives an accurate assessment.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0684 · code D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0686 · code D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0699 · code D
Provide care or services that was trauma informed and/or culturally competent.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0745 · code D
Provide medically-related social services to help each resident achieve the highest possible quality of life.
- Pharmacy Service problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0755 · code D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- Pharmacy Service problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0759 · code D
Ensure medication error rates are not 5 percent or greater.
- Pharmacy Service problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0761 · code D
Ensure 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.
- Environmental problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0912 · code D
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
- Environmental problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0925 · code D
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- Infection Control problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0880 · code D
Provide and implement an infection prevention and control program.
- Nutrition and Dietary problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0812 · code F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Nutrition and Dietary problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0814 · code F
Dispose of garbage and refuse properly.
- Quality of Life and Care problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0698 · code E
Provide safe, appropriate dialysis care/services for a resident who requires such services.
August 23, 201912 findings
- Quality of Life and Care problemsCaused actual harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0697 · code G
Provide safe, appropriate pain management for a resident who requires such services.
- Quality of Life and Care problemsCaused actual harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0745 · code G
Provide medically-related social services to help each resident achieve the highest possible quality of life.
- Nursing and Physician Services problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0732 · code F
Post nurse staffing information every day.
- Nutrition and Dietary problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0812 · code F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Environmental problemsCould have caused harm · widespread case
Inspection type and official rule codes
Routine health inspection · CMS tag 0912 · code F
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
- Resident Rights problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0623 · code E
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
- Nutrition and Dietary problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0806 · code E
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
- Nutrition and Dietary problemsCould have caused harm · pattern case
Inspection type and official rule codes
Routine health inspection · CMS tag 0808 · code E
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
- Freedom from Abuse, Neglect, and Exploitation problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0609 · code D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- Resident Assessment and Care Planning problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0657 · code D
Develop 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 Planning problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0661 · code D
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
- Quality of Life and Care problemsCould have caused harm · isolated case
Inspection type and official rule codes
Routine health inspection · CMS tag 0825 · code D
Provide or get specialized rehabilitative services as required for a resident.
Fines & penalties
These fines appear in Medicare’s records. A listed amount does not tell us whether it has been paid.
- No fines or penalties appear in the records we have.
Other homes in this chain
Pacs Group · other locations in California
- Napa Post Acute · Napa1 of 5 · 51 problems
- Sunnyvale Post-Acute Center · Sunnyvale1 of 5 · 68 problems
- Kennedy Care Center · Los Angeles1 of 5 · 110 problems
- Visalia Post Acute · Visalia1 of 5 · 72 problems
- Beachwood Post-Acute & Rehab · Santa Monica1 of 5 · 112 problems
- Bakersfield Post Acute · Bakersfield1 of 5 · 113 problems
- Artesia Palms Care Center · Artesia1 of 5 · 62 problems
- San Diego Post-Acute Center · EL Cajon1 of 5 · 95 problems
Related topics
Questions about Victorian Post Acute
What is Victorian Post Acute's Medicare star rating?
Has Victorian Post Acute been fined?
Does Victorian Post Acute have a Medicare abuse warning?
How does Victorian Post Acute compare with other nursing homes in California?
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