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 29 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
2G
0H
0I
Potential for more than minimal harm
14D
10E
3F
Potential for minimal harm
0A
0B
0C
July 3, 2026Complaint inspection · 1 citation
- F
Post nurse staffing information every day.
Inspectors wroteBased on observation interviews and record review, the facility failed to ensure the required daily patient census and direct care service hours per patient day information was posted for 7/02/26 for a facility census of 83. Observation revealed the facility continued to display a daily patient census and direct care service hours per patient day form dated 6/30/26, rather than the current day's required posting. The facility's failure to post the required daily patient census and direct care service hours per patient day information prevented residents, residents' representatives, staff, and members of the public from having access to current staffing information as required by law. During an observation on 7/02/26 at 9:22 a.m. [...]
June 24, 2026Complaint inspection · 3 citations
- E
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview and record review, the facility failed to ensure nursing services met professional standards for one (1) of six (6) sampled residents (Resident 2) when complete neurological assessments (subjective and objective data collected through interview and detailed physical examination of the central nervous system [brain, spinal cord] and the peripheral nervous system [other body nerves] was not documented following a head injury. This failure had the potential to delay identification of neurological changes indicative of brain injury or other clinical decline. Cross reference F726). [...]
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of six sampled residents (Resident 2) from abuse when Resident 2 was struck by Resident 3 during an physical altercation on 6/06/26. This failure resulted in Resident 2 being struck on the right temple and suffering a lingering headache. A review of Resident 2's Face Sheet (a facility demographic), dated 6/10/26, indicated he was admitted to the facility on [DATE], with diagnoses including dementia (a decline in memory, reasoning, and cognitive skills severe enough to interfere with daily life), depression (a serious mood disorder characterized by persistent feelings of sadness, emptiness, and a loss of interest in activities), anxiety, and unsteadiness on feet. [...]
- D
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Inspectors wroteBased on interview and record review, the facility failed to notify the state mental health authority (Department of Health Care Services [California agency responsible for overseeing the state's required screenings to identify individuals with serious mental illness]) for two (2) of six (6) sampled residents (Resident 3 and Resident 5), who had significant changes in mental health status. This failure had the potential to result in residents not receiving appropriate mental health services based on their most current clinical needs1. [...]
April 24, 2026Standard inspection · 7 citations
- F
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Inspectors wroteThe facility failed to ensure a sufficient number of dietary staff were maintained to carry out required Food and Nutrition Services functions when dietary staff responsible for cleaning and sanitation were reassigned to cover vacant food preparation roles. This failure resulted in insufficient staffing to complete essential duties and placed a census of 78 residents who ate food from the kitchen at risk for potential foodborne illnesses.
- F
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 kitchen and maintenance staff failed to ensure food was stored, prepared and served safely in accordance with professional standards of food service when:Dietary staff did not apply hair restraints properly;Expired food and drink were found in the refrigerator;Moldy strawberries were found in the refrigerator and moldy onions found in a bin in the dry storage area;The stovetop was encrusted with hardened black residue, the backsplash was stained with grease, the side of the oven was encrusted with white and rust-colored residue and the toaster had accumulated amounts of dust in the upper vents above the serving tray. The space between the back of the stovetop, oven and wall had clumps of dust adhering to the wall, pipe and floor; and,Ice buildup was found on the inner gasket of the freezer door. [...]
- E
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation and interview, the licensed nurse failed to ensure that resident information was protected during a medication pass when Licensed Nurse 3 (LN 3) did not lock the computer screen after preparing medication for three residents (Resident 1, Resident 11, and Resident 29) of 23 sampled residents. This failure decreased the facility's potential to protect residents' personal information from the public.
- 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 licensed nurses failed to remove the following from one of two medication carts:One unlabeled bottle of eye drops,Two inhalers without open dates, andThree loose pills. In addition, one expired insulin (medication used to treat diabetes) pen was found in one of two medication storage room fridges. These failures decreased the facility's potential to safely administer medications and prevent drug diversion (the illegal redirection of prescription or controlled medication from their intended medical use to unauthorized or illicit use).
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the nursing, therapy, and maintenance staff failed to ensure infection prevention and control practices were implemented for a census of 78 residents when:Staff did not wear Personal Protective Equipment (PPE- clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) for residents three residents (Resident 25, Resident 40, and Resident 96) on Enhanced Barrier Precautions (EBP- to reduce transmission of multidrug-resistant organisms in nursing homes. EBP involves gown and glove use during high-contact resident care activities such as transferring and changing bed linen); and,12 rooms were observed without proper infection precaution signage or easily accessible PPE supply containers; and,Staff failed to maintain a clean oxygen concentrator for Resident 46. [...]
- D
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.
Inspectors wroteBased on interview and record review, the facility's admissions or social service staff failed to ensure residents were asked about their Advanced Directives (a legal document indicating resident preference on end-of-life treatment decisions), for one resident (Resident 20) of eight sampled residents when there was no documented evidence in Resident 20's medical record that a discussion was had about an Advanced Directive. This failure decreased the facility's potential to ensure Resident 20's wishes were carried out during an emergency.
- 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 licensed nurses and social service staff failed to provide written summaries of resident baseline care plans to communicate the initial goals of care for two residents (Resident 8 and Resident 14) of three sampled residents. This failure decreased the facility's potential to safeguard against adverse events right after admission to the facility by ensuring continuity of care and communication of residents' care needs.
February 11, 2026Complaint inspection · 1 citation
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Inspectors wroteBased on interview and record review, Licensed Nurses (LNs) and Certified Nursing Assistants (CNAs) failed to provide urinary catheter care for one resident (Resident 1) out of three sampled residents when Resident 1 developed a facility acquired mucosal membrane skin injury (damage to the skin and/or underlying soft tissue caused by pressure from a medical device used for therapeutic purposes) and urinary tract infection (UTI- an infection of the bladder/urinary tract) from an indwelling urinary catheter (flexible tube remaining in the bladder to continuously drain urine into an external bag). [...]
February 5, 2026Complaint inspection · 2 citations
- E
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a baseline care plan (BCP, a document created within 48 hours of a resident's admission to a nursing home, outlining the initial care needed to ensure residents' safety and well-being, focusing on basic needs and resident-specific information) was completed timely, for two out of two sampled residents (Resident 1 and Resident 2), when neither BCPs were completed within 48 hours of admission and Resident 1's BCP did not address her Pressure Ulcers (PUs, a localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) for nearly one month after admission. These failures had the potential to result in newly admitted residents receiving unsafe care and put Resident 1 at an increased risk for further skin breakdown and worsening of PUs.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure professional standards of quality were provided, for one out of two sampled residents (Resident 3), when:1. Resident 3 administered a nebulizer (a machine that turns liquid medication into a fine mist that is inhaled into the lungs through a mouthpiece or mask) treatment herself without physician order or assessment for self-medication administration,2. LN B inaccurately documented in Resident 3's Electronic Medication Administration Record (EMAR, a digital system used to track and document the administration of medications, ensuring accuracy and timeliness in medication delivery) polyethylene glycol (a laxative/stool softener use to treat occasional constipation [stool that is hard, dry, or difficult and painful to pass]) had been given. [...]
January 28, 2026Complaint inspection · 1 citation
- D
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Inspectors wroteBased on interview and record review, the facility failed to implement their abuse policy for one resident (Resident 1) of nine sampled residents when licensed nurses did not document an assessment, a Change of Condition (COC), notification of the incident to the physician (MD), and 72-hour monitoring for Resident 1 immediately after an alleged abuse incident. This failure decreased the facility's potential to ensure Resident 1's needs were met after his involvement in an altercation.
January 8, 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 facility record review, the facility did not ensure an allegation of verbal abuse involving one resident (Resident 1) was reported to the California Department of Public Health (the Department) within the required timeframe of the incident. This failure delayed the Department from investigating the allegation of abuse to ensure resident safety.
November 25, 2025Complaint inspection · 1 citation
- G
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interviews and record reviews, the facility failed to provide services for one resident (Resident 1) when licensed nurses did not provide care for Resident 1's surgical drains (tubes placed in the body after surgery to remove excess blood, pus, or other fluids from a wound or cavity, preventing buildup that could slow healing or cause infections) upon admission to the facility. This failure resulted in Resident 1 having to be readmitted to the hospital for care of a preventable infection.
August 6, 2025Complaint inspection · 1 citation
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on observation, interview, and record review, the facility nursing staff failed to follow professional standards when one licensed nurse gave a dose of one of four sampled residents, Resident 1's, prescription medications to a staff member who was experiencing symptoms of anxiety. This failure resulted in the potential misuse of Resident 1's medication when the nurse, who was entrusted with full access to the medication cart, gave the medication to someone to whom it was not prescribed, and resulted in the loss of a dose of Resident 1's medication when the dose was thrown away. During an observation on 8/6/25 at 9:45 a.m., two medication carts were parked next to the nurses' station. Two security cameras were noted mounted on the ceiling pointed at the nurses' station. [...]
May 8, 2025Complaint inspection · 1 citation
- G
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 implement a fall risk care plan to meet the medical, nursing, mental, and psychosocial needs for one (Resident 1) of three sampled residents. This deficient practice resulted in Resident 1 experiencing injury and pain secondary to an unwitnessed fall on 4/26/25.
August 2, 2024Standard inspection · 2 citations
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure they referred the resident to the appropriate state-designated authority for a Level II preadmission and resident review (PASARR) when the resident was diagnoses with a new mental illness diagnosis for 1 (Resident #11) of 1 sampled resident reviewed for PASARR.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to implement enhanced barrier precautions (EBP) during wound care for 1 (Resident #64) of 1 sampled resident reviewed for pressure ulcer/injury.
January 8, 2024Complaint inspection · 1 citation
- D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two (2) of four (4) residents (Resident 1 and Resident 4) were treated with respect and dignity when Resident 1 had to wait 20 minutes to be assisted to the toilet, and Resident 4 was not provided appropriate size adult diapers, not assisted to the toilet, and not changed and left to lie in bed in her wet adult diaper, clothes and linen. These failures made Resident 1 feel like she was not important and Resident 4 often wet and smelling of urine.
June 11, 2021Standard inspection · 7 citations
- E
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Inspectors wroteBased on observation and interview, the facility failed to ensure three residents (Resident 39, 2 and 261) were provided services to improve and maintain grooming. This failure resulted in: 1. Resident 39 and 2 not getting haircuts in the facility, and 2.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wroteBased on interview and record review, the facility failed to provide scheduled showers for two dependent residents (Resident 113 and Resident 261). This had the potential to result in discomfort, unpleasant body odor, and skin infections to the residents involved.
- 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: 1. Ensure that expired medications were removed from medication carts. This failure had the potential for expired, and therefore less effective or ineffective, medications to be given to residents, which could impact the residents' health.
- E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Inspectors wroteBased on interview and record review, the facility failed to ensure documentation for Activities of Daily Living (ADLs-Basic tasks of daily life) was complete for two of five sampled residents (Resident 17 and Resident 40). The records had missing documentation for personal hygiene and toileting, among other categories. This failure had the potential to result in inability for staff to respond to the status and needs of the residents, and lack of availability of information to facilitate communication among the interdisciplinary team.
- 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 principles when: 1. A facility staff did not disinfect a thermometer per facility's policy during visitor screening, 2. Facility staff did not wear appropriate PPE (Personal Protective Equipment- Protective clothing or equipment designed to protect the wearer's body from injury or infection) in the Yellow Zone (Area on quarantine for housing newly admitted residents)of the facility, and; 3. The facility did not follow their mitigation plan when they did not quarantine residents who were exposed to a confirmed COVID-19 positive staff. These findings had the potential to result in spread of infections, including COVID-19, among staff and residents at the facility.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview and record review, the facility failed to accurately assess one resident's (Resident 21) hearing ability. This failure resulted in the facility not providing necessary treatment to improve Resident 21's activities of daily living due to impaired hearing.
- D
Provide safe, appropriate pain management for a resident who requires such services.
Inspectors wroteBased on interview and record review, the facility failed to assess and document pain levels accurately for one of five sampled residents (Resident 29). In addition, the facility failed to ensure physician orders for pain medication were followed as prescribed. This failure could have resulted in increased pain levels and decreased quality of life and suffering to Resident 29.
Fire safety inspections
10 fire safety citations on file: 5 on April 24, 2026, 3 on August 2, 2024, 2 on June 11, 2021.
Every fire safety citation10 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 24, 2026 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · April 24, 2026 · Corrected (the home has a date of correction)
- F
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
K 521 · April 24, 2026 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · April 24, 2026 · Corrected (the home has a date of correction)
- D
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
K 342 · April 24, 2026 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · August 2, 2024 · Corrected (the home has a date of correction)
- F
Inspect, test, and maintain automatic sprinkler systems.
K 353 · August 2, 2024 · Corrected (the home has a date of correction)
- D
Provide a written emergency evacuation plan.
K 711 · August 2, 2024 · Corrected (the home has a date of correction)
- E
Ensure proper usage of power strips and extension cords.
K 920 · June 11, 2021 · Corrected (the home has a date of correction)
- D
Meet requirements for the use of electrical equipment.
K 919 · June 11, 2021 · Corrected (the home has a date of correction)