Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pacifica Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to follow proper dishwashing procedures by stacking wet swirl bowls in the kitchen. During an observation, it was found that the bowls were not air-dried as required by the facility's policy. The DFNS confirmed the issue, acknowledging that the bowls should be dry before stacking to prevent mold growth.
The facility failed to ensure that licensed staff initialed and dated lidocaine patches after application for two residents. An LVN did not initial or date a new patch on a resident's lower back, and another LVN failed to do so for a patch on a resident's knee, despite being aware of the facility's policy. The oversight was attributed to forgetfulness and distraction.
A resident was discharged with an inaccurate summary and incorrect medications, including drugs for conditions she did not have. The discharge instructions were not reviewed with her, leading to a failure in providing coordinated care. The ADON noted that discharge instructions were faxed by the case manager, and the nurse on duty failed to properly review them.
A resident with multiple fractures and an LVAD experienced severe chest pain due to a bump, but the facility failed to accurately document the redness on his chest. Despite complaints from the resident and his daughter, the condition was not consistently recorded in the Daily Skilled Notes, leading to a deficiency in care.
A facility failed to monitor a resident's small raised area with redness on the chest, reported by the resident and his daughter, from one PM shift to another over several days. Despite the facility's policy requiring documentation of changes in condition, no monitoring was recorded, potentially delaying the identification of infection symptoms. The resident, who had multiple fractures and an LVAD, later died from sepsis and LVAD infection.
Improper Dishwashing Procedures in Kitchen
Penalty
Summary
The facility failed to ensure safe operations in the kitchen by not adhering to proper dishwashing procedures. During an observation and interview, it was noted that clear bowls, specifically swirl bowls, were stacked while still wet on the inside. The Dietary Aide stated that tableware should be dried before stacking, but the observation showed otherwise. The Director of Food and Nutrition Services confirmed the presence of six wet swirl bowls stacked together and acknowledged that they should be dry before stacking to prevent mold growth. The facility's policy on dishwashing, dated 2023, clearly indicates that dishes are to be air-dried in racks before stacking and storing, which was not followed in this instance.
Failure to Initial and Date Lidocaine Patches
Penalty
Summary
The facility failed to ensure that licensed staff initialed and dated lidocaine patches after applying them to affected areas for two residents. During an observation and record review, it was noted that a licensed vocational nurse (LVN) did not initial or date a new lidocaine patch applied to a resident's lower back. The Assistant Director of Nursing (ADON) confirmed that the facility's policy and procedure require the new patch to be initialed and dated by the nurse. However, the LVN admitted to forgetting to do so despite being aware of the policy. In another instance, a lidocaine patch applied to a resident's right knee was also not initialed or dated. The LVN involved acknowledged awareness of the facility's policy but attributed the oversight to being distracted by the resident. The physician's orders for both residents specified the application of lidocaine patches for pain management, and the facility's policy outlined the requirement for labeling the patch with the date and nurse's initials.
Discharge Summary and Medication Reconciliation Errors
Penalty
Summary
The facility failed to ensure that a resident's discharge summary included an accurate recapitulation of stay and reconciliation of medications. This deficiency was identified for one of the three sampled residents. The resident, who was admitted with multiple fractures and required assistance with personal care, was discharged with a summary that contained incorrect medical history and medication information. The discharge summary inaccurately listed conditions such as hypertension and fractures that the resident did not have. During the discharge process, the resident received medications that were not prescribed to her, including metoprolol, pantoprazole, and metformin, which belonged to another resident. The resident did not have conditions such as hypertension, acid reflux, or diabetes, which these medications are typically used to treat. The discharge instructions were not reviewed with the resident, and she was simply asked to sign the forms without a proper explanation. The Assistant Director of Nursing stated that the case manager was responsible for providing discharge instructions, which were then faxed to the facility. The nurse on duty was supposed to review these instructions with the resident, but this did not occur. The Licensed Vocational Nurse involved admitted to not thoroughly checking the medications, leading to the resident receiving incorrect medications. This oversight resulted in a failure to provide continuous and coordinated care for the resident.
Inaccurate Assessment of Resident's Condition
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's condition, specifically regarding redness on the resident's right chest. The resident, who was cognitively intact, had been admitted for rehabilitation following multiple fractures and had a Left Ventricular Assist Device (LVAD) due to end-stage heart failure. Despite complaints from the resident and his daughter about a bump on his chest causing severe pain, the facility's documentation did not accurately reflect the resident's condition over several dates. The redness was noted by a nurse but was not consistently documented in the resident's Daily Skilled Notes, leading to a lack of appropriate treatment and services. Interviews and record reviews revealed that the redness was not documented accurately on multiple occasions, and the facility's policy on charting and documentation was not followed. The resident's daughter had repeatedly contacted the facility to address the issue, but the documentation remained inconsistent. The facility's policy required all changes in a resident's condition to be documented, but this was not adhered to, resulting in a deficiency in the resident's care.
Failure to Monitor Resident's Condition
Penalty
Summary
The facility failed to provide care in accordance with professional standards of practice for one resident, who was admitted for rehabilitation after a hospital stay due to multiple fractures and had a Left Ventricular Assist Device (LVAD) since 2021. The resident developed a small raised area with redness on the right side of the chest, which was reported by the resident to his daughter and subsequently to the nursing staff. Despite this, there was no evidence of monitoring the area from the PM shift on September 1 to the PM shift on September 5, 2023, which could have delayed the identification of symptoms of infection. Interviews and record reviews revealed that the redness was noted in the resident's Daily Skilled Note, but no specific monitoring was documented during the specified period. The facility's policy required documentation of changes in the resident's condition, which was not adhered to in this case. The resident's death certificate later indicated sepsis and LVAD infection as causes of death, highlighting the potential impact of the facility's failure to monitor the resident's condition adequately.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Pacifica
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Golden Pavilion Healthcare | 1.7 mi | ★★★★★ | 2 | 0 |
| Golden Heights Healthcare | 1.7 mi | ★★★★★ | 0 | 0 |
| Ahmc Seton Medical Center | 2.4 mi | ★★★★★ | 34 | 0 |
| San Bruno Skilled Nursing | 4.1 mi | ★★★★★ | 18 | 0 |
| Linda Mar Care Center | 4.4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.