Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
MORAGA POST ACUTE
MORAGA, CA · 49 certified beds · Last Life Safety survey November 8, 2024
CMS Certification Number 055085 · first certified February 1970
Ownership
Operated by PACS GROUP · For profit - Limited Liability company
- Ownership changed June 1, 2016 (change of ownership)from RHEEM VALLEY HEALTHCARE, LLC
Position within CA
24 citations — more than 67% 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
The latest survey found 17 citations; the earlier surveys in the window averaged 3.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Past the typical window (November 2025 to April 2026). Most CA facilities have been surveyed by April 2027. This facility’s last Life Safety survey was November 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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3 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
5 of the 24 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)
3 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 24 Life Safety citations above. The Physical Environment Index
How that compares
Compared with the median facility in CA, and nationally. Surveyors differ markedly between states, so the CA figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 24 |
| Median facility in CA | 19 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| July 9, 2021 | 6 |
| November 3, 2023 | 1 |
| November 8, 2024 | 17 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0712 | Have simulated fire drills held at unexpected times. | 2 | 2024-11-08 |
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2024-11-08 |
| K-0920 | Ensure proper usage of power strips and extension cords. | 2 | 2024-11-08 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2024-11-08 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2024-11-08 |
| E-0023 | Establish policies and procedures for medical documentation. | 1 | 2021-07-09 |
| K-0347 | Properly provide smoke detection systems in areas open to corridors. | 1 | 2024-11-08 |
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | 1 | 2024-11-08 |
What the citations cover
- Smoke Deficiencies 9
- Gas, Vacuum, and Electrical Systems Deficiencies 6
- Emergency Preparedness Deficiencies 5
- Miscellaneous Deficiencies 3
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 9 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 6 |
| Emergency Preparedness Deficiencies | 5 |
| Miscellaneous Deficiencies | 3 |
| Egress Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
November 8, 2024 — 17 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0007 | Address patient/client population and determine types of services needed. | Deficient, Provider has date of correction (November 29, 2024) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (November 29, 2024) |
| E-0018 | Establish procedures for tracking staff and patients during an emergency. | Deficient, Provider has date of correction (November 29, 2024) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (November 29, 2024) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (November 29, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (November 29, 2024) |
| K-0347 | Properly provide smoke detection systems in areas open to corridors. | Deficient, Provider has date of correction (November 29, 2024) |
| K-0352 | Properly install and monitor supervisory attachments on automatic sprinkler systems. | Deficient, Provider has date of correction (November 29, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 29, 2024) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (November 29, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (November 29, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (November 29, 2024) |
| K-0781 | Have restrictions on the use of portable space heaters. | Deficient, Provider has date of correction (November 29, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (November 29, 2024) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (November 29, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (November 29, 2024) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (November 29, 2024) |
November 3, 2023 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (November 16, 2023) |
July 9, 2021 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (August 3, 2021) |
| E-0023 | Establish policies and procedures for medical documentation. | Deficient, Provider has date of correction (August 3, 2021) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (August 3, 2021) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (August 3, 2021) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (August 3, 2021) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (August 3, 2021) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.