Your report for Peninsula Post-Acute
Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- CaliforniaAbove only 37% of peers1,154 rated homes · average 3.2★
- San Mateo CountyAbove only 31% of peers14 rated homes · average 3.6★
- United StatesAbove only 41% of peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point2★−0.8 vs CA avg
- StaffingCan add or remove a star2★−1.1 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 meansHealth inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 19% of peersCA avg2.8★U.S. avg2.8★
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.
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 turnover2★Above only 8% of peersCA avg3.1★U.S. avg2.9★
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.
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★
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.
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 staff4.85hrsAbove 81% of peersCA avg4.51Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
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 only0.76hrsAbove 79% of peersCA avg0.65Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
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 better51%Above only 15% of peersCA avg38%RN turnover65%
The share of nursing staff who left within the past year, from the same payroll data.
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
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthFeb 2020 – Oct 2024
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Oct 18, 2024Cycle 1worst F · no actual harm
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Dec 10, 2024
- F578Honor 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.Resident RightsD · isolatedCorrected Dec 10, 2024
- 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 Dec 10, 2024
- F758Implement 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.Pharmacy ServiceD · isolatedCorrected Dec 10, 2024
- Encode each residentâs assessment data and transmit these data to the State within 7 days of assessment.Resident Assessment and Care PlanningD · isolatedCorrected Dec 10, 2024
- F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceE · patternCorrected Dec 10, 2024
- F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Dec 10, 2024
- 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 Dec 10, 2024
- F802Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.Nutrition and DietaryD · isolatedCorrected Dec 10, 2024
- F803Ensure 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.Nutrition and DietaryE · patternCorrected Dec 10, 2024
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryE · patternCorrected Dec 10, 2024
- F808Ensure 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.Nutrition and DietaryD · isolatedCorrected Dec 10, 2024
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Dec 10, 2024
- F840Employ 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.AdministrationE · patternCorrected Dec 10, 2024
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Dec 10, 2024
- F836Ensure 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.AdministrationD · isolatedCorrected Dec 10, 2024
- F676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.Quality of Life and CareD · isolatedCorrected Dec 10, 2024
Apr 29, 2024Cycle 2worst D · no actual harm
- F573Let each resident or the resident's legal representative access or purchase copies of all the resident's records.Resident RightsD · isolatedCorrected May 27, 2024
Feb 27, 2024Cycle 2worst E · no actual harm
- 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 Mar 22, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Mar 22, 2024
Apr 10, 2023Cycle 3worst D · no actual harm
- F610Respond appropriately to all alleged violations.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 5, 2023
Mar 21, 2023Cycle 3worst D · no actual harm
- F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Apr 14, 2023
Feb 18, 2022Cycle 2worst G · actual harm
- F758Implement 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.Pharmacy ServiceD · isolatedCorrected Apr 8, 2022
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Apr 8, 2022
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsE · patternCorrected Apr 8, 2022
- 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 8, 2022
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationG · isolatedCorrected Apr 8, 2022
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Apr 8, 2022
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Apr 8, 2022
- 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 Apr 8, 2022
- F800Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.Nutrition and DietaryF · widespreadCorrected Apr 8, 2022
- F801Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.Nutrition and DietaryE · patternCorrected Apr 8, 2022
- F803Ensure 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.Nutrition and DietaryE · patternCorrected Apr 8, 2022
- F804Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.Nutrition and DietaryD · isolatedCorrected Apr 8, 2022
- F805Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.Nutrition and DietaryE · patternCorrected Apr 8, 2022
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Apr 8, 2022
- F908Keep all essential equipment working safely.EnvironmentalE · patternCorrected Apr 8, 2022
Feb 9, 2020Cycle 3worst F · no actual harm
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsD · isolatedCorrected Mar 6, 2020
- F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Mar 6, 2020
- 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 Mar 6, 2020
- F803Ensure 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.Nutrition and DietaryF · widespreadCorrected Mar 6, 2020
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Mar 6, 2020
- F881Implement a program that monitors antibiotic use.Infection ControlF · widespreadCorrected Mar 6, 2020
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined4.85hrs
- Registered nursesRN hours only0.76hrs
- Licensed practical nursesLPN hours1.66hrs
- Nurse aidesCNA hours2.42hrs
- Weekend nursingAll staff on Saturdays and Sundays4.12hrs
- California average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better51%Above only 15% of peersCA avg 38%
- RN turnoverRegistered nurses only65%Not ranked by CMS
- Administrators who leftIn the past year2Leadership changed
- Occupancy62 certified beds · ~59 residents a day96%Above 85% of peersCA avg 88%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $0In fines
- 0Fines
- 0Payment denials
- $26,970CA avg in fines
Actions on record
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Limited Liability company
- Chain
- Pacs Group254 facilities in the chain2.9★ chain average
- Certification
- Medicare
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
- Providence Group Nh, LLC
- Pacs Group, INC.
- Pacs Holdings, LLC
- Mark Hancock
- Jason Murray
- Frederick Apt
- Mark Hancock
- Joshua Jergensen
- John Mitchell
- Aditi Patel
- Hunter Mitchell
Person Organization
Sources & notes
Public data, updated quarterlyData 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 555856 · 1609 TROUSDALE DRIVE, BURLINGAME, CA, 94010.
- Percentiles compare this facility with every rated nursing home in California and San Mateo 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.









