Medicare flags this nursing home for abuse. Medicare adds this flag when a home was cited for abuse that harmed a resident, or for potential abuse more than once. Ask the home what changed.
Inspection citations
15’21
6’24
18’25
3’26
42 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Feb 12, 2026 | E · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Feb 12, 2026 | D · potential | Ensure each resident receives an accurate assessment. | Complaint |
| Jan 8, 2026 | D · potential | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Complaint |
| Dec 5, 2025 | E · potential | Honor 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. | Routine |
| Dec 5, 2025 | D · potential | Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge. | Complaint |
| Dec 5, 2025 | D · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Dec 5, 2025 | E · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Routine |
| Dec 5, 2025 | D · potential | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Routine |
| Dec 5, 2025 | D · potential | Provide care or services that was trauma informed and/or culturally competent. | Routine |
| Dec 5, 2025 | F · potential | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Routine |
| Dec 5, 2025 | E · potential | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Routine |
| Dec 5, 2025 | E · potential | Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Routine |
| Dec 5, 2025 | F · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Dec 5, 2025 | D · potential | Provide and implement an infection prevention and control program. | Routine |
| Sep 8, 2025 | D · potential | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Complaint |
| Aug 4, 2025 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| Aug 4, 2025 | D · potential | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Complaint |
| Aug 4, 2025 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Jul 16, 2025 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Apr 17, 2025 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Apr 17, 2025 | E · potential | Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. | Complaint |
| Dec 12, 2024 | D · potential | Assure that each resident’s assessment is updated at least once every 3 months. | Routine |
| Dec 12, 2024 | D · potential | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Routine |
| Dec 12, 2024 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Dec 12, 2024 | D · potential | Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Routine |
| May 28, 2024 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Mar 19, 2024 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Aug 12, 2021 | F · potential | Ensure residents have reasonable access to and privacy in their use of communication methods. | Routine |
| Aug 12, 2021 | E · potential | Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Routine |
| Aug 12, 2021 | E · potential | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Routine |
| Aug 12, 2021 | E · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Aug 12, 2021 | E · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Aug 12, 2021 | E · potential | Provide enough food/fluids to maintain a resident's health. | Routine |
| Aug 12, 2021 | E · potential | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Routine |
| Aug 12, 2021 | E · potential | Implement 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. | Routine |
| Aug 12, 2021 | E · potential | Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Routine |
| Aug 12, 2021 | E · potential | Ensure 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. | Routine |
| Aug 12, 2021 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Aug 12, 2021 | E · potential | Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Routine |
| Aug 12, 2021 | E · potential | Have a plan that describes the process for conducting QAPI and QAA activities. | Routine |
| Aug 12, 2021 | E · potential | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Routine |
| Aug 12, 2021 | E · potential | Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Routine |
Medicare's severity letters: A–C minimal harm, D–F potential for more than minimal harm, G–L actual harm or immediate danger. Source: CMS health deficiencies file, processed October 1, 2026.
Questions to ask on a visit
Pine Ridge Care Center
45 Professional Center Pkwy, San Rafael, CA 94903 · (415) 479-3610
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 055850
- Certified beds
- 101
- Legal owner
- San Rafael Operating Company LP
- Part of
- Mariner Health Care
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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