Health inspections
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
Potential for minimal harm Potential for more than minimal harm Actual harm Immediate jeopardy Found on a complaint visit
Where its citations fall on CMS's grid
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 38 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
23D
15E
0F
Potential for minimal harm
0A
0B
0C
April 14, 2026Complaint inspection · 1 citation
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview and record review, the facility failed to ensure an allegation of abuse was reported within the required timeframe for one of four sampled residents (Resident 1), when the alleged abuse incident was reported to the Department of Public Health (CDPH) the following day. This failure of timely reporting had the potential to cause a delayed response by enforcement agencies to ensure resident safety.
March 20, 2026Standard inspection · 8 citations
- E
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on interviews and record reviews the facility failed to ensure care plans (CP, a detailed document outlining a person's healthcare needs, goals, and the specific care and support they will receive) were reviewed and revised in a timely manner, for two of 12 sampled residents (Resident 5 and Resident 2), when:Resident 5's urinary catheter (a flexible tube inserted into the bladder to drain urine into a drainage bag) care plan was not updated or revised after removal;Resident 2's urinary catheter care plan was not revised after removal; andResident 2's trazodone care plan had not been reviewed or revised after 21 days, as indicated. These failures had the potential for Resident 5 and Resident 2 to receive inaccurate care and interventions.3. [...]
- E
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services in accordance with the professional standards of nursing practice for two out of 12 sampled residents (Resident 5 and Resident 2), when the physician's orders (PO) were not updated and the care plans (CP, a personalized document outlining a person's health conditions, care goals, and necessary services to maintain quality of life) were not revised after urinary catheters (a flexible tube inserted into the bladder to drain urine into a drainage bag) had been discontinued. This failure had the potential for Resident 5 and Resident 2 to receive inadequate and unnecessary care.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications with discontinued orders were removed from facility drug supply and destroyed in a timely manner. This failure had the potential to result in medication errors and adverse events from residents receiving discontinued medications and the potential for diversion (the illegal transfer, theft, or misuse of medications) from medications not being disposed of.
- E
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food textures and preferences were accommodated for four of 12 sampled residents (Resident 2, Resident 50, Resident 51, Resident 38) when:1. Resident 2's food texture was not accommodated; 2. Resident 50 did not receive food items indicated on the daily menu;3. Resident 51's food preferences were not followed when she received food items that were identified as disliked; and,4. Resident 38's did not receive her preference of biscuit listed on the meal ticket. This failure had the potential to negatively impact Resident 2's, Resident 38's, Resident 50's, and Resident 51's nutritional status.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored and prepared in accordance with professional standards for food service safety in a census of 33 residents, when: The interior dispenser of ice machine had black, brown, and white substances on its surfaces in the facility kitchen; One kitchen staff touched the prepped food area with solid gloves after touching multiple surfaces in the kitchen;Ice buildup was found on the edge and frame of the doors of freezer in the main kitchen; andWet, dirty pans were found stored on the ready-to-use rack next to cooking area in the main kitchen. These failures had the potential risk for the spread of food-borne illnesses in a vulnerable population.
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on interview, record review, the facility failed to ensure one out of 12 sampled residents (Resident 2) was free from unnecessary psychotropic medication (drugs that affects brain activities associated with mental processes and behaviors) when Resident 2 received trazodone (an antidepressant) for insomnia without adequate indication for use and without adequate monitoring for efficacy. This failure had the potential to result in the unnecessary use of psychotropic medication and increased risk of exposure to side effects such as drowsiness, dizziness, headache, dry mouth, nausea, and lightheadedness upon standing. A review of Resident 2's medical record indicated he was admitted to the facility in February 2026 with diagnoses which included multiple lumbar fractures (a break or crack in bones of the lower back), lower back pain, lack of coordination and weakness. [...]
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a person-centered care plan (CP, a personalized document outlining a person's health conditions, care goals, and necessary services to maintain quality of life) for one of 12 sampled residents (Resident 7), when Resident 7's nutritional status CP was not individualized to meet Resident 7's specific medical needs. This failure had the potential for Resident 7 to receive inappropriate and inaccurate nutritional and dietary interventions.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Inspectors wroteBased on interview and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported to the facility irregularities related to the medication regimen for one of 12 sampled residents (Resident 2) during the medication regimen review (MRR). This failure resulted in inadequate monitoring and indication for use of psychotropic medication (drugs that affects brain activities associated with mental processes and behaviors) for Resident 2.
January 9, 2025Standard inspection · 11 citations
- E
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store medications for three residents (Resident 14, Resident 148, and Resident 149) of a census of 33, when three opened inhalers were not dated with open and discard dates. This failure decreased the facility's potential to properly store residents' medications and ensure medication potency.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nutritive values of food were conserved during preparation for a census of 33 residents, when [NAME] 1 prepared quiche (an entrée for lunch) without measuring the ingredients and following the recipe. This failure decreased the facility's potential to meet the residents' nutritional needs.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored and prepared in accordance with professional standards for a census of 33 residents, when; 1. Unlabeled, expired, incorrectly dated, and soiled food items were found stored in the ready-to-cook area in the main kitchen; 2. Wet, dirty, and damaged cooking pans were found stored on the ready-to-use rack next to cooking area in the main kitchen; 3. A can-opener was found dirty, ready-to-use, and attached to the kitchen counter in the main kitchen; 4. The interior dispenser of ice machine had black, brown, and white substances on its surfaces in Skilled Nursing Facility (SNF) kitchen; 5. One kitchen staff touched the clean cutting board and knife with soiled gloved hands after touching multiple surfaces in the main kitchen; and 6. [...]
- E
Keep all essential equipment working safely.
Inspectors wroteBased on observation, interview, and record review, the facility failed to safely operate the dryer for a census of 33 residents, when the dryer's lint compartment was not cleaned accordingly. This failure decreased the facility's potential to prevent a fire hazard.
- D
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.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment for one of 22 sampled residents (Resident 248), when the light switch behind Resident 248's bed was broken and kept in a non-operational drawer. This failure had the potential to negatively impact Resident 248's psychosocial well-being, ability to read, and access to personal belongings.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a person-centered care plan for one of 22 sampled residents (Resident 148), when Resident 148's care plan did not indicate he was receiving oxygen therapy. This failure decreased the facility's potential to meet Resident 148's care needs.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services according to professional standards of quality for one of 22 sampled residents (Resident 198), when Licensed Nurse 1 (LN 1) prepared a medication for Resident 198 taken from another resident's medication supply. This failure decreased the facility's potential to safely administer medications to residents.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate assistance with activities of daily living (ADLs- activities such as bathing, dressing and toileting a person performs daily) for one of 22 sampled residents (Resident 248), when Resident 248 was not offered or given showers as scheduled. This failure had the potential to negatively impact Resident 248's cleanliness, discomfort, and psychosocial well-being.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safety measures were in place for one of 22 sampled residents (Resident 15), when Resident 15 fell to the floor during transfer and sustained a blunt head injury (when the head hit a hard object or surface without breaking the skull) and a scalp abrasion (cut of the scalp). This failure decreased the facility's potential to prevent Resident 15's fall and injury.
- D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food preferences were accommodated to one of 22 sampled residents (Resident 15), when Resident 15's meal ticket did not match with lunch's meal tray. This failure had the potential to negatively impact the resident's nutritional status.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices for a census of 33 residents, when Certified Nursing Assistant 3 (CNA 3) did not use gown and gloves in an isolation (separation of residents with an infection from residents without an infection) room. This failure had the potential to increase the spread of infection among residents.
July 3, 2024Complaint inspection · 1 citation
- D
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Inspectors wroteBased on interview and record review, the facility failed to ensure the rights of one of three sampled residents (Resident 1) when a medication was discontinued without informing the resident. This failure resulted in Resident 1 not being able to have input into decisions regarding her plan of care.
May 1, 2024Complaint inspection · 1 citation
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on interview and record review, the facility failed to manage one of three sampled residents (Resident 1's) pain timely when Licensed Nurse (LN) delayed administration of the breakthrough pain medication for the resident. This failure resulted in Resident 1 being in pain, feeling ignored and mistreated.
February 29, 2024Standard inspection · 16 citations
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Inspectors wroteBased on interview and record review, the facility failed to maintain a complete record of controlled drugs' receipt and disposition for a census of 21, when the Director of Nursing (DON) did not sign the facility's Discontinued Narcotic Drug and Disposition Log upon receiving controlled drugs. This failure decreased the facility's potential to safely destroy the residents'-controlled drugs.
- E
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.
Inspectors wroteThe facility failed to ensure that recipes were used and followed during meal preparation. This failure had the potential to alter the nutrient content of the meals and to affect the health status of the 3 residents (Resident 13, 14 and 185) out of 21 receiving the Consistent Carbohydrate diet to control blood sugar.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteThe facility failed to serve food at a safe and appetizing temperature for five out of 21 residents (Residents 8, 9, 84, 186, and 236). This failure had the potential of leading to poor food intake, nutrient deficits, and undesirable weight loss for residents eating facility prepared meals.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Inspectors wroteThe facility failed to provide food storage and preparation in accordance with professional standards for food service safety when: 1) Hair and beard nets not used as required; 2) Kitchen surfaces found discolored or rusted; 3) Food products not labeled and/or dated; 4) Fans found with whitish/gray build-up; 5) Food packages left open and/or uncovered; 6) Floor in dry storage found with missing linoleum; 7) Worn equipment not discarded and replaced such as can opener, cutting boards, and fry pan; 8) Moldy bread was not discarded; 9) Kitchen floors, oven, heating element of large kettle, and wire rack found with dark build-up and/or debris; and, 10) Reach-in ice cream dipping cabinet found with ice build-up and discoloration on sides of cabinet. These concerns had the potential to lead to food borne illness for the 21 residents eating facility provided foods.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices for four out of 14 sampled residents (Resident 14, Resident 234, Resident 235 and Resident 237) when: 1. Staff did not disinfect vital sign equipment before and after use; 2. A Housekeeper (HK) did not apply the proper Personal Protective Equipment (PPE, gloves, gown, and/or goggles/face shield if risk of splash or spray) while cleaning Resident 234's room; and, 3. Resident 14, Resident 235 and Resident 237 were not assisted or offered to wash their hands before meals. These failures had the potential to spread infection in the facility.
- E
Keep all essential equipment working safely.
Inspectors wroteThe facility failed to maintain equipment in safe operating condition when: 1) ALU (assisted living unit) walk-in freezer found with ice build-up on ceiling and racks indicating potential temperature changes; 2) Ice machine filter found leaking clear fluid on to the main kitchen floor in cook's work area; and, 3) Sandwich bar not holding food temperature in safe food zone (below 41 degrees Fahrenheit-a unit of measurement). These issues had the potential of leading to food borne illness for the 21 residents eating facility prepared meals, as well as staff injury.
- D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Inspectors wroteBased on observation, interview, and record review, the facility failed to notify the resident of a bed hold upon transfer to the hospital for one of 14 sampled resident (Resident 85). This failure had the potential for Resident 85 not knowing the duration of the bed hold period and not able to exercise the resident's right of returning to the facility.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview and record review, the facility failed to accurately assess four of 14 sampled residents (Resident 4, Resident 234, Resident 235, and Resident 25), when the Minimum Data Set (MDS; an assessment tool) inaccurately indicated: 1. The change in Resident 4's skin condition; 2. Resident 234's Continuous Positive Airway Pressure (CPAP, a machine that uses mild air pressure to keep breathing airways open while sleeping); 3. Resident 235's urinary catheter; and, 4. Resident 25's MDS discharge assessment date. These failures decreased the facility's potential to identify residents' care needs.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on interview and record review, the facility failed to follow its own policy and procedure for Baseline Care Plan (BCP, a care plan that identifies resident's care needs upon admission) for one of 14 sampled residents (Resident 14) when Resident 14 was not provided a written summary of her BCP within 48 hours of admission. This failure had the potential to increase Resident 14's risk of not being aware of her plan of care.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Inspectors wroteBased on interview and record review, the facility failed to develop and/or implement a person-centered care plan for three of 14 sampled residents (Resident 84, Resident 14, and Resident 234) when: 1. There was no care plan for a coccyx (tail bone) wound for Resident 84; 2. There was no care plan for a wedge pillow for Resident 14; and, 3. There was no care plan for a continuous positive airway pressure (CPAP, a machine that uses mild air pressure to keep breathing airways open while sleeping) machine for Resident 234. These failures had the potential for Resident 84, Resident 14, and Resident 234 to not receive the appropriate care, services, and treatment.
- D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Inspectors wroteBased on interview and record review, the facility failed to revise in a timely manner the care plan interventions following a significant change assessment for one of 14 sampled residents (Resident 4), when Resident 4 developed a facility-acquired sacral pressure injury. This failure decreased the facility's potential to provide Resident 4 with a person-centered care plan and evaluate its effectiveness.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services according to professional standards of quality for one of 14 sampled residents (Resident 235), when Resident 235's omeprazole (medication used to treat excess stomach acid) was not administered as indicated in physician's order. This failure decreased the facility's potential to safely follow the physician's orders.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interview, and record review the facility failed to follow and implement a physician's order for one of 14 sampled residents (Resident 14) when a prescribed hip-ankle wedge pillow was not provided as ordered for Resident 14. This failure had the potential to delay the healing of Resident 14's ankle related to improper positioning and alignment.
- D
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Inspectors wroteBased on interview and record review, the facility failed to provide pressure injury preventative care plan interventions for one of 14 sampled residents (Resident 4), when: 1. The certified nursing assistants (CNAs) did not consistently check Resident 4's skin during routine care for impairments; 2. Resident 4 was not frequently repositioned until 12/1/23; and, 3. A pressure reducing mattress was not applied until 11/27/23. These failures increased Resident 4's potential to develop a facility-acquired pressure injury.
- D
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to remove from use one expired medication for a census of 21, when miconazole nitrate cream (used to treat skin infections) was stored in the residents' treatment cart after its expiration date. This failure increased the facility's potential to administer expired medications to residents.
- D
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Inspectors wroteBased on interview and record review, the facility failed to complete its abuse and neglect training and dementia in-services (a professional training or staff development effort) for two out of five staff members. This failure had the potential to place the residents at risk for elder abuse.
Fire safety inspections
26 fire safety citations on file: 4 on March 20, 2026, 8 on January 9, 2025, 14 on February 29, 2024.
Every fire safety citation26 citations
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · March 20, 2026 · Corrected (the home has a date of correction)
- D
Have properly installed hallway dispensers for alcohol-based hand rub.
K 325 · March 20, 2026 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · March 20, 2026 · Corrected (the home has a date of correction)
- C
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 20, 2026 · Corrected (the home has a date of correction)
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · January 9, 2025 · Corrected (the home has a date of correction)
- D
Use approved construction type or materials.
K 161 · January 9, 2025 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · January 9, 2025 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · January 9, 2025 · Corrected (the home has a date of correction)
- D
Meet requirements for the use of electrical equipment.
K 919 · January 9, 2025 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · January 9, 2025 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · January 9, 2025 · Corrected (the home has a date of correction)
- C
Inspect, test, and maintain automatic sprinkler systems.
K 353 · January 9, 2025 · Corrected (the home has a date of correction)
- F
Establish staff and initial training requirements.
E 37 · February 29, 2024 · Corrected (the home has a date of correction)
- F
Have properly located and lighted "Exit" signs.
K 293 · February 29, 2024 · Corrected (the home has a date of correction)
- F
Provide properly protected cooking facilities.
K 324 · February 29, 2024 · Corrected (the home has a date of correction)
- F
Properly provide smoke detection systems in areas open to corridors.
K 347 · February 29, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · February 29, 2024 · Corrected (the home has a date of correction)
- F
Install smoke barrier doors that can resist smoke for at least 20 minutes.
K 374 · February 29, 2024 · Corrected (the home has a date of correction)
- F
Have simulated fire drills held at unexpected times.
K 712 · February 29, 2024 · Corrected (the home has a date of correction)
- E
Develop and maintain an Emergency Preparedness Program (EP).
E 4 · February 29, 2024 · Corrected (the home has a date of correction)
- E
Develop Emergency Preparedness policies and procedures.
E 13 · February 29, 2024 · Corrected (the home has a date of correction)
- E
Develop a communication plan.
E 29 · February 29, 2024 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 29, 2024 · Corrected (the home has a date of correction)
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · February 29, 2024 · Corrected (the home has a date of correction)
- D
Use approved construction type or materials.
K 161 · February 29, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · February 29, 2024 · Corrected (the home has a date of correction)