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 13 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
10D
3E
0F
Potential for minimal harm
0A
0B
0C
April 24, 2026Standard inspection, Complaint inspection · 8 citations
- 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 service safety and sanitation requirements were followed when:1. A 7-pound can of cherry pie filling was observed to have a dent near the top of the can and was stored alongside regular cans outside the designated dented can area.2. A cheese grater, hung up with clean food preparation items, was found with a broken red plastic rim.3. A green cutting board, stored with clean food preparation items, was found with yellow debris and was marred (surface with deep gouges) on one side. These failures had the potential to cause food borne illness among vulnerable residents.
- D
Allow residents to self-administer drugs if determined clinically appropriate.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure for one of 34 sampled residents (Resident 44) when a comprehensive assessment for self-medication administration was not completed prior to Resident 44 self-administering medications. This failure resulted in unmonitored medication use and had the potential to result in medication overuse and errors.
- 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 report an allegation of abuse to the California Department of Public Health (CDPH) within 2 hours for two of 34 residents (Resident 5 and Resident 223). This failure had the potential to result in serious adverse physical, psychosocial, and emotional harm for Resident 5 and Resident 223.
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Inspectors wroteBased on interview and record review, the facility failed to provide a written bed hold notification to one of 34 sampled residents (Resident 142) and/or his representative upon Resident 142's transfer to an acute care hospital on 1/21/2026. This failure resulted in Resident 142 and/or his representative not informed of his rights to return to the facility following his hospitalization.
- 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 update the nursing care plan (an individualized plan that provides direction for a resident's medical care) for one of 34 sampled residents (Resident 95). This failure had the potential to affect the provision of care for Resident 95.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on observation, interviews and record review, the facility failed to implement physician orders for two of 34 sampled Residents (Resident 2 and Resident 135) when:1. A STAT (immediate) X-ray (medical imaging test to take pictures of the inside body) was not implemented timely per physician order, when the contract vendor did not show up to the facility and the facility failed to follow up with the vendor. This resulted in Resident 2 being transferred to an outside hospital for an X-ray, obtained approximately 28 hours later. 2. Resident 135' s PRN (as needed) pain medication was not administered according to physician's orders. These failures resulted in delayed treatment for Resident 2 and the potential to result in inadequate pain relief for Resident 135.
- 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 ensure: 1. A set of keys for a treatment cart (a cart with wound care medications and supplies), were left unattended, unsecured and not kept with the licensed nurses. This failure had the potential for unauthorized staff to have access to the treatment cart. 2. Self-administration medications, such as Vitamin D (essential nutrients that work together) were not stored in a locked compartment for one of 34 sample residents (Resident 44). In addition the following additional medications for Resident 44, Biotin (nutrient the body needs in small amounts), Vitamin K (essential nutrients that work together), Vitamin E (nutrient the body needs in small amounts), and Magnesium Glycinate (dietary supplement), were stored in an open shelf in Resident 44's shared room. [...]
- D
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 two of 34 sampled residents (Resident 150 and Resident 8) when:1. A Maintenance Assistant (MA 1) and a Certified Nursing Assistant (CNA 1) did not wear personal protective equipment (PPE, specialized clothing or equipment worn by individuals to minimize exposure to hazards that cause serious workplace injuries or illnesses), in Resident 150's room, who was on contact precautions (series of procedures designed to minimize the transmission of infectious organisms by direct or indirect contact with an infected person or his/her surrounding environment).2. [...]
March 27, 2025Standard inspection · 2 citations
- 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 a clean environment, within standards for safety when: 1) Ice Machine floor drain was not maintained clean; 2) Food items stored in the refrigerator had expired with past use by dates; 3) Food items in the refrigerator did not have use by and expiration dates; 4) Food items in the pantry not labelled and stored properly; 5) Kitchenware (including pans, cutting boards, cooking utensils, ergo silverware, strainers, blender, food processor) were in poor condition; 6) The two-part sink, on the left side of sink, was being used for washing potatoes and the right side of the sink with a large cleaning bucket filled with rags, water and cleaning solution; 7) Drawers used to store cooking utensils were not maintained clean; [...]
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Inspectors wroteBased on observation, interview, and record review, the facility failed to verify gastrointestinal tube (GT - digestive tract and related organs) placement for one of five residents (Resident 10) prior to medication administration. This failure had the potential for medications not to be safely and effectively delivered into the stomach and may lead to serious complications such as aspiration pneumonia.
April 25, 2024Standard inspection · 3 citations
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation, interviews, document review, and facility policy review, the facility failed to follow the recipe when they prepared pureed chopped beef steak for 11 (Residents #10, #13, #41, #60, #67, #69, #74, #82, #84, #104, and #111) of 11 residents who received pureed diets from the kitchen.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Inspectors wroteBased interviews, record review, and facility policy review, the facility failed to ensure a resident's use/need for hearing aids were included on the baseline care plan for 1 (Resident # 180) of 3 sampled residents reviewed for communication/sensory.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to ensure a fall intervention was implemented as documented on the resident care plan for 1 (Resident #19) of 3 sampled residents reviewed for accidents.
Fire safety inspections
18 fire safety citations on file: 3 on April 24, 2026, 5 on March 27, 2025, 10 on April 25, 2024.
Every fire safety citation18 citations
- F
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · April 24, 2026 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · April 24, 2026 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · April 24, 2026 · Corrected (the home has a date of correction)
- F
Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.
K 926 · March 27, 2025 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · March 27, 2025 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 27, 2025 · Corrected (the home has a date of correction)
- D
Meet requirements for the use of electrical equipment.
K 919 · March 27, 2025 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · March 27, 2025 · Corrected (the home has a date of correction)
- E
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · April 25, 2024 · Corrected (the home has a date of correction)
- D
Provide emergency officials' contact information.
E 31 · April 25, 2024 · Corrected (the home has a date of correction)
- D
Provide primary/alternate means for communication.
E 32 · April 25, 2024 · Corrected (the home has a date of correction)
- D
Use approved construction type or materials.
K 161 · April 25, 2024 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · April 25, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · April 25, 2024 · Corrected (the home has a date of correction)
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
K 372 · April 25, 2024 · Corrected (the home has a date of correction)
- D
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · April 25, 2024 · Corrected (the home has a date of correction)
- D
Meet requirements for the use of electrical equipment.
K 919 · April 25, 2024 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · April 25, 2024 · Corrected (the home has a date of correction)