Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

DANVILLE POST-ACUTE REHAB

DANVILLE, CA · 54 certified beds · Last Life Safety survey October 11, 2024

CMS Certification Number 555376 · first certified May 1989

Ownership

Operated by THE ENSIGN GROUP · For profit - Corporation

Ownership changed February 1, 2023 (change of ownership)to DANVILLE POST ACUTE REHABILITATION from DANVILLE LONG-TERM CARE INC

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within CA

17 citations — more than 38% of the 1,165 certified nursing homes in CA. Compared within CA rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Holding steadyabout the same at the latest survey as at its earlier surveys in the window.

The latest survey found 6 citations; the earlier surveys in the window averaged 5.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Past the typical window (October 2025 to April 2026). Most CA facilities have been surveyed by March 2027. This facility’s last Life Safety survey was October 2024. Facilities in CA are typically surveyed 12–18 months after the last one (median 14), measured over 1,766 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

4 of the 17 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 17 Life Safety citations above. The Physical Environment Index

F-0880 Provide and implement an infection prevention and control program.
F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

How that compares

Citations on file over three years

Compared with the median facility in CA, and nationally. Surveyors differ markedly between states, so the CA figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	17
Median facility in CA	19
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
February 13, 2019	7
November 4, 2022	4
October 11, 2024	6

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0363	Install corridor and hallway doors that block smoke.	2	2022-11-04
K-0324	Provide properly protected cooking facilities.	2	2024-10-11
E-0026	Establish roles under a Waiver declared by secretary.	1	2019-02-13
E-0030	List the names and contact information of those in the facility.	1	2024-10-11
E-0032	Provide primary/alternate means for communication.	1	2024-10-11
K-0161	Use approved construction type or materials.	1	2022-11-04
K-0353	Inspect, test, and maintain automatic sprinkler systems.	1	2024-10-11
K-0919	Meet requirements for the use of electrical equipment.	1	2024-10-11

What the citations cover

Citations by CMS category

Smoke Deficiencies 8
Emergency Preparedness Deficiencies 4
Miscellaneous Deficiencies 2
Gas, Vacuum, and Electrical Systems Deficiencies 2
Other 1

Citations by CMS category
Category	Citations
Smoke Deficiencies	8
Emergency Preparedness Deficiencies	4
Miscellaneous Deficiencies	2
Gas, Vacuum, and Electrical Systems Deficiencies	2
Construction Deficiencies	1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

October 11, 2024 — 6 citations

Citations issued on October 11, 2024
Tag	What the surveyor checks	Status
E-0030	List the names and contact information of those in the facility.	Deficient, Provider has date of correction (November 13, 2024)
E-0032	Provide primary/alternate means for communication.	Deficient, Provider has date of correction (November 13, 2024)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (November 13, 2024)
K-0347	Properly provide smoke detection systems in areas open to corridors.	Deficient, Provider has date of correction (November 13, 2024)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (November 13, 2024)
K-0919	Meet requirements for the use of electrical equipment.	Deficient, Provider has date of correction (November 13, 2024)

November 4, 2022 — 4 citations

Citations issued on November 4, 2022
Tag	What the surveyor checks	Status
E-0018	Establish procedures for tracking staff and patients during an emergency.	Deficient, Provider has date of correction (November 28, 2022)
K-0161	Use approved construction type or materials.	Deficient, Provider has date of correction (November 28, 2022)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (November 28, 2022)
K-0920	Ensure proper usage of power strips and extension cords.	Deficient, Provider has date of correction (November 28, 2022)

February 13, 2019 — 7 citations

Citations issued on February 13, 2019
Tag	What the surveyor checks	Status
E-0026	Establish roles under a Waiver declared by secretary.	Deficient, Provider has date of correction (May 20, 2019)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (May 20, 2019)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (May 20, 2019)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (May 20, 2019)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (May 20, 2019)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (May 20, 2019)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (May 20, 2019)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.