Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
MARIN POST ACUTE
SAN RAFAEL, CA · 168 certified beds · Last Life Safety survey December 4, 2025
CMS Certification Number 055310 · first certified January 1967
Ownership
Operated by PACS GROUP · For profit - Limited Liability company
- Ownership changed March 1, 2017 (change of ownership)from RAFAEL CONVALESCENT HOSPITAL
Position within CA
44 citations — more than 98% 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 12 citations; the earlier surveys in the window averaged 10.7. With 4 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens December 2026 — about 2 months from now. This facility’s last Life Safety survey was December 2025. 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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6 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
10 of the 44 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)
8 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 44 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0584 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.
- F-0880 Provide and implement an infection prevention and control program.
- F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 | 44 |
| Median facility in CA | 19 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| May 7, 2021 | 11 |
| February 15, 2024 | 20 |
| November 5, 2024 | 1 |
| December 4, 2025 | 12 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 4 | 2025-12-04 |
| K-0712 | Have simulated fire drills held at unexpected times. | 3 | 2025-12-04 |
| K-0363 | Install corridor and hallway doors that block smoke. | 3 | 2025-12-04 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2025-12-04 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 3 | 2025-12-04 |
| E-0026 | Establish roles under a Waiver declared by secretary. | 2 | 2025-12-04 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 2 | 2025-12-04 |
| K-0324 | Provide properly protected cooking facilities. | 2 | 2025-12-04 |
What the citations cover
- Smoke Deficiencies 14
- Emergency Preparedness Deficiencies 10
- Gas, Vacuum, and Electrical Systems Deficiencies 9
- Miscellaneous Deficiencies 5
- Other 6
| Category | Citations |
|---|---|
| Smoke Deficiencies | 14 |
| Emergency Preparedness Deficiencies | 10 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 9 |
| Miscellaneous Deficiencies | 5 |
| Egress Deficiencies | 5 |
| Construction Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
December 4, 2025 — 12 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (December 22, 2025) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (January 8, 2026) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (January 8, 2026) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (January 9, 2026) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (December 22, 2025) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (January 8, 2026) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (December 22, 2025) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (December 23, 2025) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (December 23, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has plan of correction (December 31, 2026) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (January 9, 2026) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (December 28, 2025) |
November 5, 2024 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (December 10, 2024) |
February 15, 2024 — 20 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (April 30, 2024) |
| E-0023 | Establish policies and procedures for medical documentation. | Deficient, Provider has date of correction (April 30, 2024) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (April 30, 2024) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (April 30, 2024) |
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (April 30, 2024) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (April 30, 2024) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (April 30, 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 (April 30, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (April 30, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (April 30, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (April 30, 2024) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (April 30, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (April 30, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (April 30, 2024) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (April 30, 2024) |
| K-0781 | Have restrictions on the use of portable space heaters. | Deficient, Provider has date of correction (April 30, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (April 30, 2024) |
| K-0919 | Meet requirements for the use of electrical equipment. | Deficient, Provider has date of correction (April 30, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (April 30, 2024) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (April 30, 2024) |
May 7, 2021 — 11 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (June 29, 2021) |
| E-0007 | Address patient/client population and determine types of services needed. | Deficient, Provider has date of correction (June 29, 2021) |
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (June 29, 2021) |
| E-0041 | Implement emergency and standby power systems. | Deficient, Provider has date of correction (June 29, 2021) |
| K-0161 | Use approved construction type or materials. | Deficient, Provider has date of correction (June 29, 2021) |
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (June 29, 2021) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (June 29, 2021) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (June 29, 2021) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (June 29, 2021) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (June 29, 2021) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (June 29, 2021) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.