Burlingame, CA

Peninsula Post-Acute

3-star overall rating with 2-star inspections with 16 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle

1609 Trousdale Drive, Burlingame, CA

(650) 652-3969

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

5 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Pacs Group

Operator or chain grouping

Approved since

2008-12-22

CMS approved date

Coverage

Medicare

Participation flags

Chain footprint

264 facilities

Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars

Changed ownership

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

0.76

Registered nurse staffing · state 0.65 · national 0.68

LPN hours / resident day

1.66

Licensed practical nurse staffing · state 1.22 · national 0.87

Aide hours / resident day

2.42

Nurse aide staffing · state 2.64 · national 2.35

Total nurse hours

4.85

All reported nurse hours · state 4.51 · national 3.89

Licensed hours

2.43

RN + LPN hours · state 1.87 · national 1.54

Weekend hours

4.12

Weekend nurse staffing · state 4.08 · national 3.43

Weekend RN hours

0.47

Weekend registered nurse coverage · state 0.50 · national 0.47

Physical therapist

0.29

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.52

CMS adjusted RN staffing hours

Adjusted total hours

3.30

CMS adjusted total nurse staffing hours

Case-mix index

2.01

Higher values indicate more complex resident acuity

RN turnover

65%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

51%

Annual nurse turnover · state 38% · national 46%

SNF VBP

Value-based purchasing

Program rank

12,694

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

11.01

Composite VBP score used to determine payment impact.

Payment multiplier

0.9810

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 22.48% · Performance 24.47% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

Baseline 6.79% · Performance 8.76% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

3.48

Baseline 45.45% · Performance 49.46% · Measure score 3.48 · Achievement 3.48 · Improvement 0

Adjusted total nurse staffing

0.92

Baseline 4.06 hours · Performance 3.34 hours · Measure score 0.92 · Achievement 0.92 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.11%	10.72% 1.6 pts better	No Different than the National Rate · Eligible stays 524 · Observed rate 7.44% · Lower 95% interval 7.07%
Discharge to community	68.12%	50.57% 17.6 pts better	Better than the National Rate · Eligible stays 587 · Observed rate 63.88% · Lower 95% interval 64.1%
Medicare spending per beneficiary	1.24	1.02 0.2 pts worse
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 351 · Denominator 351
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 351
Discharge self-care score	76.02%	53.69% 22.3 pts better	Numerator 168 · Denominator 221
Discharge mobility score	73.76%	50.94% 22.8 pts better	Numerator 163 · Denominator 221
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 351 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	8.76%	7.12% 1.6 pts worse	No Different than the National Rate · Eligible stays 368 · Observed rate 8.7% · Lower 95% interval 5.93%
Staff COVID-19 vaccination coverage	40%	8.2% 31.8 pts better	Numerator 22 · Denominator 55
Staff flu vaccination coverage	48.45%	42% 6.5 pts better	Numerator 78 · Denominator 161
Discharge function score	84.62%	56.45% 28.2 pts better	Numerator 187 · Denominator 221
Transfer of health information to provider	99.27%	95.95% 3.3 pts better	Numerator 136 · Denominator 137
Transfer of health information to patient	97.13%	96.28% 0.8 pts better	Numerator 203 · Denominator 209
Resident COVID-19 vaccinations up to date	54.91%	25.2% 29.7 pts better	Numerator 95 · Denominator 173

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	100.0%	94.0% 6 pts better	81.7% 18.3 pts better	Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of short-stay residents who had an outpatient emergency department visit	16.4%	11.2% 5.2 pts worse	12.0% 4.4 pts worse	Short Stay · 20240701-20250630 · Adjusted 16.4% · Observed 15.6% · Expected 10.6% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.2%	1.5% 1.3 pts better	1.6% 1.4 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.3% · Q4 0.4% · 4Q avg 0.2% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	98.3%	93.2% 5.1 pts better	79.7% 18.6 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 98.3%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	34.4%	23.2% 11.2 pts worse	23.9% 10.5 pts worse	Short Stay · 20240701-20250630 · Adjusted 34.4% · Observed 30.9% · Expected 21.4% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-10-18 · Fire 2024-10-18

16 health deficiencies

Top issue: Nutrition and Dietary (5 deficiencies)

14 fire-safety deficiencies

Top issue: Smoke (6 deficiencies)

Cycle 2 Health 2022-02-18 · Fire 2022-02-18

17 health deficiencies

Top issue: Nutrition and Dietary (6 deficiencies)

8 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Cycle 3 Health 2020-02-09 · Fire 2020-02-09

10 health deficiencies

Top issue: Nutrition and Dietary (2 deficiencies)

2 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2024-10-18

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-11-07

D · Potential for more than minimal harm 2024-10-18

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2024-11-07

D · Potential for more than minimal harm 2024-10-18

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2024-11-07

D · Potential for more than minimal harm 2024-10-18

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-11-07

D · Potential for more than minimal harm 2024-10-18

K342 · Smoke Deficiencies

Fire Safety

Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.

Corrected 2024-11-07

D · Potential for more than minimal harm 2024-10-18

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-11-07

D · Potential for more than minimal harm 2024-10-18

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2024-11-07

D · Potential for more than minimal harm 2024-10-18

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-11-07

C · Minimal harm 2024-10-18

E13 · Emergency Preparedness Deficiencies

Fire Safety

Develop Emergency Preparedness policies and procedures.

Corrected 2024-11-07

C · Minimal harm 2024-10-18

E29 · Emergency Preparedness Deficiencies

Fire Safety

Develop a communication plan.

Corrected 2024-11-07

C · Minimal harm 2024-10-18

E36 · Emergency Preparedness Deficiencies

Fire Safety

Establish emergency prep training and testing.

Corrected 2024-11-07

C · Minimal harm 2024-10-18

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2024-11-07

C · Minimal harm 2024-10-18

K346 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the fire alarm was out of service for more than 4 hours.

Corrected 2024-11-07

C · Minimal harm 2024-10-18

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2024-11-07

E · Potential for more than minimal harm 2022-02-18

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2022-03-14

D · Potential for more than minimal harm 2022-02-18

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2022-03-14

D · Potential for more than minimal harm 2022-02-18

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2022-03-14

D · Potential for more than minimal harm 2022-02-18

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2022-03-14

D · Potential for more than minimal harm 2022-02-18

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2022-03-14

D · Potential for more than minimal harm 2022-02-18

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2022-03-14

C · Minimal harm 2022-02-18

K346 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the fire alarm was out of service for more than 4 hours.

Corrected 2022-03-14

C · Minimal harm 2022-02-18

K354 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Corrected 2022-03-14

E · Potential for more than minimal harm 2020-02-09

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2020-08-13

D · Potential for more than minimal harm 2020-02-09

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2020-08-13

Inspection history

Recent health citations

F · Potential for more than minimal harm 2024-10-18

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 2024-12-10

E · Potential for more than minimal harm 2024-10-18

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2024-12-10

E · Potential for more than minimal harm 2024-10-18

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 2024-12-10

E · Potential for more than minimal harm 2024-10-18

F803 · Nutrition and Dietary Deficiencies

Health

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected 2024-12-10

E · Potential for more than minimal harm 2024-10-18

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2024-12-10

E · Potential for more than minimal harm 2024-10-18

F840 · Administration Deficiencies

Health

Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.

Corrected 2024-12-10

D · Potential for more than minimal harm 2024-10-18

F578 · Resident Rights Deficiencies

Health

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Corrected 2024-12-10

D · Potential for more than minimal harm 2024-10-18

F640 · Resident Assessment and Care Planning Deficiencies

Health

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Corrected 2024-12-10

D · Potential for more than minimal harm 2024-10-18

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 2024-12-10

D · Potential for more than minimal harm 2024-10-18

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2024-12-10

D · Potential for more than minimal harm 2024-10-18

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 2024-12-10

D · Potential for more than minimal harm 2024-10-18

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2024-12-10

D · Potential for more than minimal harm 2024-10-18

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2024-12-10

D · Potential for more than minimal harm 2024-10-18

F802 · Nutrition and Dietary Deficiencies

Health

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Corrected 2024-12-10

D · Potential for more than minimal harm 2024-10-18

F808 · Nutrition and Dietary Deficiencies

Health

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.

Corrected 2024-12-10

D · Potential for more than minimal harm 2024-10-18

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 2024-12-10

D · Potential for more than minimal harm 2024-10-18

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-12-10

D · Potential for more than minimal harm 2024-04-29

F573 · Resident Rights Deficiencies

Health

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

Corrected 2024-05-27

E · Potential for more than minimal harm 2024-02-27

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 2024-03-22

D · Potential for more than minimal harm 2024-02-27

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 2024-03-22

D · Potential for more than minimal harm 2023-04-10

F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Respond appropriately to all alleged violations.

Corrected 2023-05-05

D · Potential for more than minimal harm 2023-03-21

F558 · Resident Rights Deficiencies

Health

Reasonably accommodate the needs and preferences of each resident.

Corrected 2023-04-14

G · Actual harm 2022-02-18

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 2022-04-08

F · Potential for more than minimal harm 2022-02-18

F800 · Nutrition and Dietary Deficiencies

Health

Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

Corrected 2022-04-08

F · Potential for more than minimal harm 2022-02-18

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 2022-04-08

E · Potential for more than minimal harm 2022-02-18

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 2022-04-08

E · Potential for more than minimal harm 2022-02-18

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 2022-04-08

E · Potential for more than minimal harm 2022-02-18

F801 · Nutrition and Dietary Deficiencies

Health

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Corrected 2022-04-08

E · Potential for more than minimal harm 2022-02-18

F803 · Nutrition and Dietary Deficiencies

Health

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected 2022-04-08

E · Potential for more than minimal harm 2022-02-18

F805 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Corrected 2022-04-08

E · Potential for more than minimal harm 2022-02-18

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-04-08

E · Potential for more than minimal harm 2022-02-18

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2022-04-08

D · Potential for more than minimal harm 2022-02-18

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 2022-04-08

D · Potential for more than minimal harm 2022-02-18

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2022-04-08

D · Potential for more than minimal harm 2022-02-18

F758 · Pharmacy Service Deficiencies

Health

Corrected 2022-04-08

D · Potential for more than minimal harm 2022-02-18

F761 · Pharmacy Service Deficiencies

Health

Corrected 2022-04-08

D · Potential for more than minimal harm 2022-02-18

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2022-04-08

F · Potential for more than minimal harm 2020-02-09

F803 · Nutrition and Dietary Deficiencies

Health

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected 2020-03-06

F · Potential for more than minimal harm 2020-02-09

F881 · Infection Control Deficiencies

Health

Implement a program that monitors antibiotic use.

Corrected 2020-03-06

E · Potential for more than minimal harm 2020-02-09

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 2020-03-06

D · Potential for more than minimal harm 2020-02-09

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2020-03-06

D · Potential for more than minimal harm 2020-02-09

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2020-03-06

D · Potential for more than minimal harm 2020-02-09

F761 · Pharmacy Service Deficiencies

Health

Corrected 2020-03-06

Penalties and ownership

What sits behind the stars

Ownership

Providence Group Nh, LLC

5% Or Greater Direct Ownership Interest · Organization

100% 168 facilities 2023-06-30

Apt, Frederick

Corporate Officer · Individual

0% 252 facilities 2024-01-01

Hancock, Mark

5% Or Greater Indirect Ownership Interest · Individual

0% 253 facilities 2024-04-15

Hancock, Mark

Corporate Officer · Individual

0% 253 facilities 2024-01-01

Jergensen, Joshua

Corporate Officer · Individual

0% 237 facilities 2024-01-01

Mitchell, Hunter

W-2 Managing Employee · Individual

0% 2 facilities 2023-04-01

Mitchell, John

Corporate Officer · Individual

0% 254 facilities 2024-01-01

Murray, Jason

5% Or Greater Indirect Ownership Interest · Individual

0% 250 facilities 2024-04-15

Pacs Group, Inc.

5% Or Greater Indirect Ownership Interest · Organization

0% 239 facilities 2023-06-30

Pacs Holdings, LLC

5% Or Greater Indirect Ownership Interest · Organization

0% 238 facilities 2023-06-30

Patel, Aditi

Contracted Managing Employee · Individual

0% 1 facilities 2015-10-01

Nearby options

Other facilities in reach

Millbrae Care Center

Millbrae, CA

2-star overall rating with 2-star inspections with $7,045 in total fines with 10 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle

Overall: 2 / 5
Health: 2 / 5
Staffing: 3 / 5
Fines: $7,045