Cycle 1
Health 2024-11-22 · Fire 2024-11-22
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Pacifica, CA
Pacifica Nursing And Rehabilitation Center
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
385 Esplanade Avenue, Pacifica, CA
(650) 993-5576
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
68
Certified beds
Average residents
63
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1970-05-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 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
1.07
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.43
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.83
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
5.34
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
2.50
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
4.78
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.79
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.59
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.86
CMS adjusted RN staffing hours
Adjusted total hours
4.28
CMS adjusted total nurse staffing hours
Case-mix index
1.71
Higher values indicate more complex resident acuity
RN turnover
13%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
21%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
213
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
77.64
Composite VBP score used to determine payment impact.
Payment multiplier
1.0253
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 17.50% · Performance 15.79% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
7.87
Baseline 5.88% · Performance 5.48% · Measure score 7.87 · Achievement 7.87 · Improvement 3.97
Total nurse turnover
8.55
Baseline 33.33% · Performance 28.75% · Measure score 8.55 · Achievement 8.55 · Improvement 4.90
Adjusted total nurse staffing
4.64
Baseline 4.96 hours · Performance 4.40 hours · Measure score 4.64 · Achievement 4.64 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.22% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 615 · Observed rate 7.97% · Lower 95% interval 8.28% |
| Discharge to community | 70.23% |
50.57%
19.7 pts better
|
Better than the National Rate · Eligible stays 650 · Observed rate 69.85% · Lower 95% interval 66.64% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.47% |
95.27%
4.2 pts better
|
Numerator 375 · Denominator 377 |
| Falls with major injury | 0.27% |
0.77%
0.5 pts better
|
Numerator 1 · Denominator 377 |
| Discharge self-care score | 81.51% |
53.69%
27.8 pts better
|
Numerator 238 · Denominator 292 |
| Discharge mobility score | 65.75% |
50.94%
14.8 pts better
|
Numerator 192 · Denominator 292 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 377 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.48% |
7.12%
1.6 pts better
|
No Different than the National Rate · Eligible stays 354 · Observed rate 3.95% · Lower 95% interval 3.75% |
| Staff COVID-19 vaccination coverage | 13.33% |
8.2%
5.1 pts better
|
Numerator 24 · Denominator 180 |
| Staff flu vaccination coverage | 71.04% |
42%
29 pts better
|
Numerator 130 · Denominator 183 |
| Discharge function score | 76.03% |
56.45%
19.6 pts better
|
Numerator 222 · Denominator 292 |
| Transfer of health information to provider | 99.44% |
95.95%
3.5 pts better
|
Numerator 357 · Denominator 359 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 46.83% |
25.2%
21.6 pts better
|
Numerator 96 · Denominator 205 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
94.0%
4.6 pts better
|
81.7%
16.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.5% · Q2 98.6% · Q3 99.2% · Q4 99.2% · 4Q avg 98.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.0% |
11.2%
3.2 pts better
|
12.0%
4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.0% · Observed 7.6% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.5%
1.2 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.3% · Q2 0.3% · Q3 0.2% · Q4 0.5% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.8% |
93.2%
2.6 pts better
|
79.7%
16.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.7% |
23.2%
0.5 pts worse
|
23.9%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.7% · Observed 22.5% · Expected 22.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-24 · Fire 2023-08-24
3 health deficiencies
Top issue: Infection Control (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2019-09-13 · Fire 2019-09-13
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-11-22
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-12-03
D · Potential for more than minimal harm
2024-11-22
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2024-12-04
E · Potential for more than minimal harm
2023-08-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-08
E · Potential for more than minimal harm
2023-08-24
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-09-08
E · Potential for more than minimal harm
2023-08-24
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-09-08
E · Potential for more than minimal harm
2023-08-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-08-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-08-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-08-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-09-08
D · Potential for more than minimal harm
2023-08-24
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-09-08
E · Potential for more than minimal harm
2019-09-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-11-25
D · Potential for more than minimal harm
2019-09-13
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2019-11-25
D · Potential for more than minimal harm
2019-09-13
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2019-11-25
D · Potential for more than minimal harm
2019-09-13
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-11-25
D · Potential for more than minimal harm
2019-09-13
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2019-11-25
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-11-22
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 2024-11-28
E · Potential for more than minimal harm
2024-11-22
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-11-28
D · Potential for more than minimal harm
2024-11-22
F661 · Resident Assessment and Care Planning Deficiencies
Health
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Corrected 2024-11-28
D · Potential for more than minimal harm
2024-06-04
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-06-28
D · Potential for more than minimal harm
2024-06-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-28
E · Potential for more than minimal harm
2023-08-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-20
E · Potential for more than minimal harm
2019-09-13
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 2019-11-18
D · Potential for more than minimal harm
2019-09-13
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2019-11-18
Penalties and ownership
What sits behind the stars
Ownership
Flagstone Healthcare North LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Beaman, Jacob
Operational/Managerial Control · Individual
Beaman, Jacob
W-2 Managing Employee · Individual
Burnam, Soon
Corporate Officer · Individual
Fitch, Craig
Corporate Officer · Individual
Monette, Cory
Corporate Officer · Individual
Willits, Adam
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Golden Pavilion Healthcare
Daly City, CA
2-star overall rating with 2-star inspections with $23,533 in total fines with 8 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Golden Heights Healthcare
Daly City, CA
4-star overall rating with 4-star inspections with 7 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#3
Ahmc Seton Medical Center
Daly City, CA
1-star overall rating with 1-star inspections with $48,836 in total fines with 17 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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