Cycle 1
Health 2025-12-04 · Fire 2025-12-04
17 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
San Rafael, CA
Marin Post Acute
2-star overall rating with 2-star inspections with abuse icon flag with 15 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
234 N. San Pedro Rd, San Rafael, CA
(415) 479-3450
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
168
Certified beds
Average residents
146
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.00
Registered nurse staffing
LPN hours / resident day
0.00
Licensed practical nurse staffing
Aide hours / resident day
0.00
Nurse aide staffing
Total nurse hours
0.00
All reported nurse hours
Licensed hours
0.00
RN + LPN hours
Weekend hours
0.00
Weekend nurse staffing
Weekend RN hours
0.00
Weekend registered nurse coverage
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.00
CMS adjusted RN staffing hours
Adjusted total hours
0.00
CMS adjusted total nurse staffing hours
Case-mix index
0.00
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
11,915
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
14.72
Composite VBP score used to determine payment impact.
Payment multiplier
0.9814
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.35% · Performance 22.39% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 3.72% · Performance 8.94% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.94
Baseline 40.32% · Performance 43.48% · Measure score 4.94 · Achievement 4.94 · Improvement 0
Adjusted total nurse staffing
0.95
Baseline 3.47 hours · Performance 3.35 hours · Measure score 0.95 · Achievement 0.95 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.46% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 307 · Observed rate 7.49% · Lower 95% interval 6.77% |
| Discharge to community | 55.61% |
50.57%
5 pts better
|
No Different than the National Rate · Eligible stays 297 · Observed rate 49.83% · Lower 95% interval 50.34% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 219 · Denominator 219 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 219 |
| Discharge self-care score | 33.93% |
53.69%
19.8 pts worse
|
Numerator 38 · Denominator 112 |
| Discharge mobility score | 34.82% |
50.94%
16.1 pts worse
|
Numerator 39 · Denominator 112 |
| Pressure ulcers or injuries, new or worsened | 2.74% |
2.29%
0.5 pts worse
|
Numerator 6 · Denominator 219 · Adjusted rate 3.33% |
| Healthcare-associated infections requiring hospitalization | 8.94% |
7.12%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 179 · Observed rate 10.06% · Lower 95% interval 5.43% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 210 |
| Staff flu vaccination coverage | 17.62% |
42%
24.4 pts worse
|
Numerator 40 · Denominator 227 |
| Discharge function score | 37.5% |
56.45%
19 pts worse
|
Numerator 42 · Denominator 112 |
| Transfer of health information to provider | 98.39% |
95.95%
2.4 pts better
|
Numerator 61 · Denominator 62 |
| Transfer of health information to patient | 84.55% |
96.28%
11.7 pts worse
|
Numerator 93 · Denominator 110 |
| Resident COVID-19 vaccinations up to date | 29.37% |
25.2%
4.2 pts better
|
Numerator 37 · Denominator 126 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
2.3
0.8 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.5 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.6
0.7 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.9 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
98.5%
1 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.1% · Q3 99.1% · Q4 100.0% · 4Q avg 99.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.2% |
98.2%
8 pts worse
|
95.5%
5.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 90.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.2% |
1.6%
1.4 pts better
|
3.3%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.9% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 16.3% |
6.8%
9.5 pts worse
|
11.4%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 41.2% · Q2 8.1% · Q3 10.9% · Q4 4.0% · 4Q avg 16.3% |
| Percentage of long-stay residents who lose too much weight | 2.1% |
4.1%
2 pts better
|
5.4%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.1% · Q3 3.1% · Q4 2.2% · 4Q avg 2.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 3.3% |
13.7%
10.4 pts better
|
19.6%
16.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.1% · Q3 3.0% · Q4 4.3% · 4Q avg 3.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.5% |
14.2%
3.3 pts worse
|
16.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 20.3% · Q3 16.2% · Q4 15.9% · 4Q avg 17.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 6.3% |
11.0%
4.7 pts better
|
16.3%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 5.6% · Q3 3.3% · Q4 10.0% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.0% |
10.7%
5.7 pts better
|
14.9%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 6.5% · Q3 4.3% · Q4 3.3% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
1.0%
0.3 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 0.0% · Q4 0.9% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.2% |
1.2%
1 pts better
|
1.7%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.9% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.1% |
10.9%
7.2 pts worse
|
19.8%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.1% · Q2 22.3% · Q3 15.4% · Q4 16.6% · 4Q avg 18.1% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
4.7%
1.7 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 3.2% · Q3 1.9% · Q4 4.9% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.5% |
94.0%
2.5 pts better
|
81.7%
14.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 95.7% · Q3 94.5% · Q4 97.3% · 4Q avg 96.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.1% |
11.2%
5.1 pts better
|
12.0%
5.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.1% · Observed 6.0% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 1.2% · Q3 1.2% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.6% |
93.2%
4.6 pts worse
|
79.7%
8.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.6% |
23.2%
2.4 pts worse
|
23.9%
1.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.6% · Observed 23.7% · Expected 22.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-15 · Fire 2024-02-15
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
21 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Cycle 3
Health 2021-05-07 · Fire 2021-05-07
23 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-04
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2025-12-22
F · Potential for more than minimal harm
2025-12-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-12-31
E · Potential for more than minimal harm
2025-12-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-12-22
E · Potential for more than minimal harm
2025-12-04
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-12-28
D · Potential for more than minimal harm
2025-12-04
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2026-01-08
D · Potential for more than minimal harm
2025-12-04
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2026-01-08
D · Potential for more than minimal harm
2025-12-04
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2026-01-09
D · Potential for more than minimal harm
2025-12-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-12-22
D · Potential for more than minimal harm
2025-12-04
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2026-01-08
D · Potential for more than minimal harm
2025-12-04
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-12-23
D · Potential for more than minimal harm
2025-12-04
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2026-01-09
C · Minimal harm
2025-12-04
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-12-23
F · Potential for more than minimal harm
2024-11-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-10
F · Potential for more than minimal harm
2024-02-15
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2024-04-30
F · Potential for more than minimal harm
2024-02-15
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-04-30
F · Potential for more than minimal harm
2024-02-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-30
F · Potential for more than minimal harm
2024-02-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-30
F · Potential for more than minimal harm
2024-02-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-30
F · Potential for more than minimal harm
2024-02-15
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-30
E · Potential for more than minimal harm
2024-02-15
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-04-30
E · Potential for more than minimal harm
2024-02-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-02-15
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-02-15
E23 · Emergency Preparedness Deficiencies
Fire Safety
Establish policies and procedures for medical documentation.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-02-15
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-02-15
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-02-15
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-02-15
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-02-15
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-02-15
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-02-15
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-02-15
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-02-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-04-30
D · Potential for more than minimal harm
2024-02-15
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-04-30
E · Potential for more than minimal harm
2021-05-07
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2021-06-29
E · Potential for more than minimal harm
2021-05-07
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2021-06-29
E · Potential for more than minimal harm
2021-05-07
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2021-06-29
E · Potential for more than minimal harm
2021-05-07
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2021-06-29
E · Potential for more than minimal harm
2021-05-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-06-29
D · Potential for more than minimal harm
2021-05-07
E26 · Emergency Preparedness Deficiencies
Fire Safety
Establish roles under a Waiver declared by secretary.
Corrected 2021-06-29
D · Potential for more than minimal harm
2021-05-07
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2021-06-29
D · Potential for more than minimal harm
2021-05-07
E7 · Emergency Preparedness Deficiencies
Fire Safety
Address patient/client population and determine types of services needed.
Corrected 2021-06-29
D · Potential for more than minimal harm
2021-05-07
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2021-06-29
D · Potential for more than minimal harm
2021-05-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-06-29
D · Potential for more than minimal harm
2021-05-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2021-06-29
Inspection history
Recent health citations
G · Actual harm
2026-01-08
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Not marked corrected
D · Potential for more than minimal harm
2026-01-08
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Not marked corrected
D · Potential for more than minimal harm
2026-01-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Not marked corrected
E · Potential for more than minimal harm
2025-12-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-12-17
D · Potential for more than minimal harm
2025-12-16
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-12-17
D · Potential for more than minimal harm
2025-12-16
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-12-17
E · Potential for more than minimal harm
2025-12-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-12-04
F584 · Resident Rights Deficiencies
Health
Honor 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.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-12-04
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-12-04
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-12-04
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-12-26
D · Potential for more than minimal harm
2025-08-12
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-08-22
E · Potential for more than minimal harm
2025-05-05
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2025-05-29
D · Potential for more than minimal harm
2025-05-05
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-05-29
D · Potential for more than minimal harm
2025-05-05
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-05-29
D · Potential for more than minimal harm
2025-05-05
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-05-29
F · Potential for more than minimal harm
2025-03-13
F850 · Administration Deficiencies
Health
Hire a qualified full-time social worker in a facility with more than 120 beds.
Corrected 2025-03-27
D · Potential for more than minimal harm
2024-02-15
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-15
F585 · Resident Rights Deficiencies
Health
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.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-15
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-15
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-15
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-15
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-03-15
D · Potential for more than minimal harm
2023-12-20
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2024-02-01
F · Potential for more than minimal harm
2023-06-01
F836 · Administration Deficiencies
Health
Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-06-01
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-06-01
F839 · Administration Deficiencies
Health
Employ staff that are licensed, certified, or registered in accordance with state laws.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-04-12
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-05-12
E · Potential for more than minimal harm
2023-03-02
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-04-02
G · Actual harm
2021-05-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-07-02
G · Actual harm
2021-05-07
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2021-07-02
E · Potential for more than minimal harm
2021-05-07
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-07-02
E · Potential for more than minimal harm
2021-05-07
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2021-06-30
E · Potential for more than minimal harm
2021-05-07
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2021-06-30
E · Potential for more than minimal harm
2021-05-07
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2021-06-30
E · Potential for more than minimal harm
2021-05-07
F688 · Quality of Life and Care Deficiencies
Health
Provide 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.
Corrected 2021-06-30
E · Potential for more than minimal harm
2021-05-07
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2021-06-30
E · Potential for more than minimal harm
2021-05-07
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-06-30
E · Potential for more than minimal harm
2021-05-07
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2021-06-30
E · Potential for more than minimal harm
2021-05-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-06-30
E · Potential for more than minimal harm
2021-05-07
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2021-06-30
E · Potential for more than minimal harm
2021-05-07
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2021-06-30
D · Potential for more than minimal harm
2021-05-07
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2021-06-30
D · Potential for more than minimal harm
2021-05-07
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2021-06-30
D · Potential for more than minimal harm
2021-05-07
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2021-07-07
D · Potential for more than minimal harm
2021-05-07
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2021-06-30
Penalties and ownership
What sits behind the stars
Ownership
Providence Group North LLC
5% Or Greater Direct Ownership Interest · Organization
Apt, Frederick
Corporate Officer · Individual
Flake, Ethan
W-2 Managing Employee · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Hancock, Mark
Corporate Officer · Individual
Jergensen, Joshua
Corporate Officer · Individual
Mitchell, John
Corporate Officer · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Picetti, Dominic
Contracted Managing Employee · Individual
Providence Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Northgate Postacute Care
San Rafael, CA
2-star overall rating with 2-star inspections with $129,101 in total fines with 19 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
Pine Ridge Care Center
San Rafael, CA
4-star overall rating with 2-star inspections with $7,542 in total fines with 19 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
Professional Post Acute Center
San Rafael, CA
2-star overall rating with 1-star inspections with $283,454 in total fines with 6 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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