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 36 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
0G
0H
0I
Potential for more than minimal harm
17D
16E
3F
Potential for minimal harm
0A
0B
0C
May 27, 2026Complaint inspection · 1 citation
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on interview, record review, and policy review, the facility did not ensure that one of four residents sampled (Resident 1) did not get unnecessary medication when Resident 1 received a nicotine patch (a medicated adhesive patch that sticks to the skin to deliver a steady, controlled dose of nicotine into the bloodstream) when she was not a smoker. This failure caused Resident 1 to have diarrhea, be very unhappy and stressed and had an unwanted adverse effect to her physical and emotional well-being.
February 28, 2025Complaint inspection · 1 citation
- D
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Inspectors wroteBased on observation, interview and record review, the facility failed to update the responsible party (RP) for one of two sample residents, (Resident 2) when Resident 2 had a fall. This failure violated the rights of Resident 2 and the RP to for all changes to be reported immediately.
February 13, 2025Standard inspection, Complaint inspection · 5 citations
- E
Ensure medication error rates are not 5 percent or greater.
Inspectors wroteBased on observation, record review, interview, document review, and facility policy review, the facility failed to ensure a medication error rate of five percent or less. There were three errors out of 29 opportunities, which yielded a medication error rate of 10.34% for 2 (Resident #77 and Resident #75) of 4 residents observed for medication administration.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure an allegation of abuse was timely reported to the state survey that involved 2 (Resident #12 and Resident #58) of 4 sampled residents reviewed for abuse.
- D
Ensure services provided by the nursing facility meet professional standards of quality.
Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to follow the physician's order for the use of an as-needed blood pressure medication for 1 (Resident #17) of 5 sampled residents reviewed for unnecessary medications.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure there was a physician's order for the use of non-invasive mechanical ventilator for 1 (Resident #1) of 3 sampled residents reviewed for respiratory care.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff performed hand hygiene and changed their gloves during the provision of incontinence care for 1 (Resident #109) of 1 sampled resident reviewed for urinary catheter.
January 23, 2025Complaint inspection · 3 citations
- 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 facility failed to ensure food safety and sanitation requirements were met in accordance with professional standards for food service safety when: 1. Dietary Manager (DM) was not wearing a hair net in the kitchen. 2. Food was not properly covered, labeled and dated. These failures created a potential risk for exposure to foodborne illnesses in a medically vulnerable population of 110 residents who received food prepared in the kitchen.
- D
Keep residents' personal and medical records private and confidential.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the right to personal privacy for one of five sampled residents (Resident 1), when patient care was provided to Resident 1 without privacy being provided. This failure had the potential to cause distress and embarassment for Resident 1 by having other residents watching and knowing her medical problems.
- D
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control measures were adhered to when Licensed Nurse A (LN A) provided patient care in the dining room without following infection control policy and procedures. These failures had the potential to cause the spread of infection and disease to other residents in the dining room.
June 24, 2024Complaint inspection · 3 citations
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, and interview, the facility failed to clean the assistive devices used to transfer residents for five out of six mechanical lifts. This failed action had the potential for the spread of infection to clients, staff, and visitors.
- 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 ensure that one of five sampled residents (Resident 2), received assistance with activities of daily living (ADLs) to attain or maintain their independence when routine and scheduled showers and bathing were not completed. This failure had the potential to result in Resident 2 feeling depressed with poor self-esteem, and had the potential to contribute to skin breakdown, infection, and negatively impact their ability to attain or maintain their highest practicable level of well-being.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Inspectors wroteBased on interview, record review, and the facility's policy, the facility failed to complete assessments and add pertinent interventions on the care plan developed for one of three residents, (Resident 2) requiring renal (kidney) dialysis. This failure had the potential for re-hospitalization, and a negative clinical outcome.
June 14, 2024Complaint inspection · 1 citation
- E
Employ staff that are licensed, certified, or registered in accordance with state laws.
Inspectors wroteBased on interview, and record review, the facility failed to ensure professional staff were licensed in accordance with California state laws, when registered nurse (RN) 1 was employed from 11/2/23 through 1/4/2024 without a valid registered nursing license issued by the Board of Registered Nursing This failure had the potential to result in substandard quality of care to all the residents in the facility and negatively impact their quality of life and ability to attain or maintain their highest practicable level of physical, emotional, and psychosocial well-being.
March 10, 2023Standard inspection · 20 citations
- 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 facility failed to ensure professional food safety and sanitation practices were in place when: 1. Inappropriate use of hats and hairnets were observed for three dietary staff members. 2. Four out of four chicken breasts were not stored and handled according to professional standards of practice. 3. Chlorine test strips were not available to all staff, two out of two staff used the wrong test strip, and chlorine test strip results were incorrectly. 4a. The walk-in freezer floor, dry storage rice bin, prep area drawers, stationary and non-stationary fans, reach-in refrigerator, and the ice machine were not clean. b. The stove, oven, tray line, stationary can opener, and sheet pans were non cleanable due to a black residue build up and grime. c. [...]
- F
Keep all essential equipment working safely.
Inspectors wroteBased on observation, interview and record review, the facility failed to maintain resident food in safe storage when the facility's walk-in freezer had severe ice buildup and was not maintained in a safe operating condition. This had the potential for equipment failure.
- E
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure individualized needs were met for two of 18 residents when: 1. Resident 70's call light device was not within his reach or his line of sight. This failure had the potential for the resident's needs not being met promptly and an increase in accidents and injury. 2. Resident 85 was not provided a trained and competent language translator for his communication with facility staff. This failure had the potential for the resident's needs not being met and psychosocial harm.
- E
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 ensure four of four sampled residents (Resident 50, 7, 25 and 16), and five of six confidential resident interviewed, were not protected from loss when the facility had no system to return lost clothing items to residents. This failure resulted in residents feeling angry and frustrated because they did not have their own clothes to wear.
- E
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 comprehensive care plans for five of 18 sampled residents (Resident 2, 38, 68, 72, and 73) when: 1. Resident 2 for potential risk of choking hazards during mealtimes (Refer F689); 2. Resident 68 for impaired visual function ; 3. Resident 38 for severe depression; 4. Resident 73 wandering around the facility and; 5. Resident 72 the use of arm brace. These failures had the potential for care plans to inaccurately reflect the care needed, being provided, or resident care needs to go unmet or the conditions to worsen.
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
Inspectors wrote3. Review of Resident 38 medical record revealed that the resident was admitted to the facility on [DATE], with diagnoses that included diabetes, heart failure, muscle weakness and bilateral (both sides) groin wounds. During a review of the the facility's policy and procedure titled, Activities of Daily Living (ADL), revised March 2018, indicated that a resident's ability to perform ADLs will be measured using clinical tools, including the MDS. During record review of Resident 38's MDS dated [DATE], indicated he required staff assistance with all ADLs. During record review of shower/bath schedule dated 2/8/23-3/8/23, Resident 38 was scheduled for baths on Sundays and Wednesdays. He missed 4 out of 10 bed baths scheduled. No record of nail care performed was found. [...]
- E
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 a plan of care to address the safety of two of 18 residents when: 1. Resident 2 did not have assistance during meals. 2. Resident 73 was wandering into other resident rooms frequently without supervision. This resulted a choking hazard and had the potential to put all residents at risk for falls and resident to resident altercations.
- E
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure nursing staff had appropriate competencies and skills sets for developing and implementing plan of care for 18 sampled residents when: 1. Resident 2 did not have the direct care staff supervision for safety during meals. 2. Direct care staff did not ensure Resident 68 had eye glasses available for use. 3. Direct care staff did not provide necessary grooming, nail care, and bed bath services for three of seven dependent residents (Residents 8, 38 and 70). 4. Nursing staff did not develop and implement a plan of care for severe depression for Resident 38. 5. Resident 73 had no interventions in place to mitigate his wandering behavior. This had the potential to put all residents at risk for accidents and hazards and decreased quality of care and life.
- 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 interview, observation and record review, the facility failed to ensure safe medication storage in two out of three medication rooms (a locked room storing the drugs and supplies) and three out of six medication carts (a secure mobile cart storing resident's medications) when: 1. Medication refrigerators (a locked temperature-controlled unit for medication storage) were frosted where vaccines, and insulin (Medicine for blood sugar or diabetic disease) products were stored. 2. Multi dose containers (a bulk container that can be used more than once) of medication and supplies were not dated when first opened and not stored per manufacturer labeling (the drug maker's label on how to store or use the product). 3. [...]
- E
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Inspectors wroteBased on interview and record review, the facility failed to ensure the qualifications, competencies, and skill sets of the Registered Dietitian (RD) and the Dietary Manager (DM) were in place and supported to carry out the functions of the food and nutrition service when: 1. A qualified dietician or other clinically qualified nutrition professional was not employed at the facility full time. 2a. The RD did not monitor or implement weekly weights for three out of three residents: Resident 4 2b. Resident 59 2c. Resident 85 3. The DM did not meet the minimum qualifications. 4. The DM did not evaluate new staff for competencies. (Refer to F802) These failures had the potential to result in foodborne illness, compromise nutritional status, weight loss, ineffective resident care interventions and decreased quality of life impacting 89 residents who lived in the facility.
- E
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff were competent to perform food safety processes according to professional standards when: 1. Equipment was not cleaned according to professional standards of practice. (Refer to F812) 2. Four out of four chicken breasts were thawing at room temperature. (Refer to F812) 3. Staff used the wrong test strips and documented incorrect results when testing the dishwasher's chlorine level. (Refer to F812) 4. Dietary Manager (DM) did not evaluate new staff for competencies. Failure to ensure staff were competent in food safety processes had the potential to result in foodborne illness for 89 residents consuming food from the facility.
- 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 wroteBased on observation, interview and record review, the facility failed to provide two out of two residents (Residents 85 and 4) with plant-based (vegetarian) meals that met the nutritive needs of the residents when: 1. Planned vegetarian menus, prepared in advance, that included a nutrient analysis and alternates (a meal substitute provided when the served menu item was not wanted by the resident) for Resident 85 and Resident 4, were not followed, and were not available for residents or staff. 2. Alternate menu food items did not have a recipe. These failures created the potential for vegetarian residents to receive food that did not meet their nutrient needs and or provide the variety in foods and flavors needed to encourage meal intakes, enhance resident's quality of life, and had the potential to contribute to weight loss.
- E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Inspectors wroteBased on observation and interview, the facility failed to ensure food was served at an appetizing temperature when four out of four residents (Resident 4, 19, 38, and 59) stated the food was cold. This failure had the potential for a decrease in meal intake and could contribute to weight loss resulting in compromised nutritional status.
- E
Have a plan that describes the process for conducting QAPI and QAA activities.
Inspectors wroteBased on observation, interview and record review, the facility failed to implement and maintain an effective, comprehensive Quality Assurance and Performance Improvement (QAPI) program that addressed the full range of services the facility provided when: 1. A qualified Registered Dietician (RD) or other clinically qualified nutritional professional were not employed at the facility full time who was responsible to carry out the functions of the food and nutrition service and that their Dietary Manager (DM) did not meet the minimum qualifications. 2. Licensed Nursing staff did not develop and implement a plan of care for five of 18 sampled residents (Resident 2, 38, 68, 72, and 73). 3. Certified Nursing Assistants (CNA)s had the skills and competencies to assist dependent residents with their Activities of Daily Living (ADL). [...]
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe infection control practices when: 1. Licensed nurses (LNs) did not sanitize their hands upon entering or exiting five resident's rooms when direct care was provided. 2. Licensed nurse did not sanitize the shared glucometer (a device used to measure blood sugar) in between resident care for Resident 80, Resident 19, and Resident 7. 3. Licensed nurse did not sanitize the shared blood pressure device (or BP device that measured the pressure of blood pushing against the walls of the arteries) in between resident care provided for Resident 80 and Resident 19. These failed practices may result in spread of infection in the facility.
- D
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Inspectors wroteBased on interview and record review, the facility failed to issue complete and timely Beneficiary (a person who received Medicare insurance benefits) Notifications to three of 18 sampled residents (Residents 48, 50, and 77). This failure had the potential to prevent the residents from making informed decisions about their care which could have threatened their health and well-being.
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on observation, interview and record review, the facility failed to provide an accurate and complete assessment for one of five sampled residents (Resident 68) when an assessment dated [DATE] documented that vision was adequate and no activity assessment after admission. These failures had the potential for staff to not be fully informed of his health status, to determine the need for further assessment and interventions that could result in delays in care and decline in resident's condition.
- 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 ensure accurate documentation with specific psychiatric (mental health illness) diagnosis for the use of mind-altering drug called quetiapine (also known as Seroquel, a medication used to treat mental illness) in one out of 18 sampled residents (Resident 40). This failure may pose unsafe medications use in the facility with inconsistent diagnosis.
- D
Plan the resident's discharge to meet the resident's goals and needs.
Inspectors wroteBased on interview and record review, the facility failed to develop a complete Discharge Plan for one of 18 sampled residents (Resident 77). This failure had the potential to prevent a smooth and safe transition for Resident 77 from the facility to the community.
- 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 interview and record review, the facility failed to accommodate one out of one resident (Resident 85) with preferred food preferences that met cultural needs when dietary staff did not update Resident 85's medical record with preferences. This failure created the potential for a lack of the variety in foods and flavors needed to encourage meal intakes, enhance resident's quality of life, and had the potential to contribute to weight loss.
September 5, 2019Standard inspection · 2 citations
- 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, review of the facility's document and review of the facility's policy, the facility failed to ensure one of 21 sampled residents (Resident (R) R58) was assisted with her meal in the dining room in a dignified manner.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of 21 sampled residents (Resident (R) R64) received oxygen (O2) therapy as prescribed by the physician.
Fire safety inspections
29 fire safety citations on file: 11 on February 13, 2025, 10 on March 10, 2023, 8 on September 5, 2019.
Every fire safety citation29 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · February 13, 2025 · 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 · February 13, 2025 · Corrected (the home has a date of correction)
- E
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
K 741 · February 13, 2025 · Corrected (the home has a date of correction)
- D
Use approved construction type or materials.
K 161 · February 13, 2025 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · February 13, 2025 · Corrected (the home has a date of correction)
- D
Provide a written emergency evacuation plan.
K 711 · February 13, 2025 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · February 13, 2025 · Corrected (the home has a date of correction)
- D
Meet requirements for the use of electrical equipment.
K 919 · February 13, 2025 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · February 13, 2025 · Corrected (the home has a date of correction)
- D
Have proper medical gas storage and administration areas.
K 923 · February 13, 2025 · Corrected (the home has a date of correction)
- C
Have simulated fire drills held at unexpected times.
K 712 · February 13, 2025 · Corrected (the home has a date of correction)
- F
Conduct testing and exercise requirements.
E 39 · March 10, 2023 · Corrected (the home has a date of correction)
- F
Have properly installed hallway dispensers for alcohol-based hand rub.
K 325 · March 10, 2023 · Corrected (the home has a date of correction)
- E
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
K 342 · March 10, 2023 · Corrected (the home has a date of correction)
- D
Provide primary/alternate means for communication.
E 32 · March 10, 2023 · Corrected (the home has a date of correction)
- D
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · March 10, 2023 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · March 10, 2023 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · March 10, 2023 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · March 10, 2023 · Corrected (the home has a date of correction)
- D
Meet requirements for the use of electrical equipment.
K 919 · March 10, 2023 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · March 10, 2023 · Corrected (the home has a date of correction)
- E
Install emergency lighting that can last at least 1 1/2 hours.
K 291 · September 5, 2019 · Corrected (the home has a date of correction)
- E
Have properly located and lighted "Exit" signs.
K 293 · September 5, 2019 · Corrected (the home has a date of correction)
- E
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · September 5, 2019 · Corrected (the home has a date of correction)
- E
Properly provide smoke detection systems in areas open to corridors.
K 347 · September 5, 2019 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · September 5, 2019 · Corrected (the home has a date of correction)
- D
Properly select, install, inspect, or maintain portable fire extinguishes.
K 355 · September 5, 2019 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · September 5, 2019 · Corrected (the home has a date of correction)
- D
Have generator or other power source capable of supplying service within 10 seconds.
K 918 · September 5, 2019 · Corrected (the home has a date of correction)