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 32 health citations on file.
Severity
Isolated
Pattern
Widespread
Immediate jeopardy
0J
0K
0L
Actual harm
1G
0H
0I
Potential for more than minimal harm
21D
9E
1F
Potential for minimal harm
0A
0B
0C
December 15, 2025Standard inspection · 7 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 safety and sanitation were observed in he kitchen when:1. Multiple ham and cheese sandwiches found undated in the kitchen and at Station 2 Clean utility room refrigerators;2. A plastic container of ketchup was found in the kitchen refrigerator with the corner of the lid open to air;3. Two packages of meat were found in the freezer undated;4. Multiple food items were found in the Clean Utility Room of Station 3 refrigerator not labeled and undated;5. A small amount of orange colored residue was found on a plastic piece of the ice machine in the Clean Utility Room of Station 2; 6. A large tomato sauce can was placed on a tray with parchment paper that was going to be used to cook the lunchtime garlic bread and;7. [...]
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to ensure care and treatment was provided, for two of 32 sampled residents (Residents 163 and 8) when: 1. For Resident 163, hydralazine (medication used to treat high blood pressure) was not administered according to the physician's order; and 2. For Resident 8, blood sugar was not closely monitored related to use of long-acting insulin. These failures had the potential for a delay in care and treatment and could cause a decline in the residents' overall health condition.
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to implement required infection control interventions, use appropriate personal protective equipment (PPE - specialized gear like gloves, gowns, masks, and goggles used by healthcare workers to create a physical barrier against infectious agents, protecting them from blood, body fluids, and germs, ensuring safety during patient care by preventing transmission pathways) and follow Centers for Disease Control and Prevention (CDC) guidance, for two of 78 sampled residents when: 1. [...]
- D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Inspectors wroteBased on interview and record review, the facility failed to ensure, for one of five sampled residents (Resident 16) was free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when Resident 16 was administered lorazepam (used to treat anxiety) without adequate behavioral monitoring during the use of lorazepam. This failure had the potential to result in unnecessary use of medications for Resident 16 which increased the potential for medication interactions, adverse reactions, and unidentified risks associated with the use of lorazepam that included but not limited to sedation, dizziness, unsteadiness, and difficulty concentrating.
- D
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, for one of two IV (intravenous, into the vein) Medication Emergency Kits (E-kit; a kit/box containing medications and supplies for immediate use during a medical emergency) was replaced timely after being opened in accordance with the facility's policy and procedure. This failure resulted in the potential for emergency medications to be unavailable when needed, and the potential for not meeting the residents' therapeutic needs or worsening of their medical conditions.
- 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 observation, interview, and record review, the facility failed to ensure the Consultant Pharmacist (CP) recommendation were acted upon, for two of seven residents reviewed for unnecessary medications (Residents 7 and 8) when:1. For Resident 7, the duration of heparin (an anticoagulant [blood thinner] solution used to prevent and treat blood clots in various medical conditions and procedures) therapy was not indicated. This failure had the potential for Resident 7 to be exposed to unnecessary medication and placed the resident at risk for adverse effects; and2. For Resident 8, episodes of blood sugar levels above 300 mg/dl (milligram/deciliter - unit of measurement)was not evaluated by the physician. This failure had the potential for the medications not being optimized for best possible health outcome for Resident 8.
- D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents were free from unnecessary medications, for one of seven residents (Resident 7), when the use of heparin (an anticoagulant [blood thinner] solution used to prevent and treat blood clots in various medical conditions and procedures) was not evaluated for the continued use. This failure has the potential to cause Resident 7 to develop adverse reactions from unnecessary medications.
June 23, 2025Complaint inspection · 1 citation
- E
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 ensure a copy of the notice of transfer/discharge was provided to the State Long-Term Care Ombudsman (assists with conflict resolution and protection of resident rights) prior to the planned discharge, for three of three sampled residents (Resident 1, 2, and 3). This failure had the potential to violate the resident's rights to appeal their discharge.
April 29, 2025Complaint inspection · 1 citation
- D
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.
Inspectors wroteBased on interview and record review, the facility failed to ensure monitoring for one of three sampled residents (Resident 1), of the following: 1. Behavior of anxiety (feeling of fear, dread, and uneasiness); 2. Psychotic behavior (refers to the observable actions, thoughts, and expression of a person experiencing psychosis [mental state or condition itself, describing a range of symptoms including those that manifest as psychotic behavior]); and 3. Side effects for use of psychotropic medications (drugs that affect the brain and nervous system, primarily used to treat mental health conditions). This failure had the potential for unnecessary medication use.
January 29, 2025Complaint inspection · 2 citations
- 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 interview and record review, the facility failed to notify Resident 3 ' s Responsible Person (RP- person designated as being responsible for another person's medical and/or financial decisions) as well as other emergency contacts, of Resident 3 ' s change of condition (COC) and subsequent transfer to the general acute care hospital (GACH) on January 17, 2025. This resulted in the RP and emergency contacts being uninformed and unaware of Resident 3 ' s COC and transfer to the GACH.
- D
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 accurately document the Responsible Person (RP) notification of one of three residents' (Resident 3) transfer to the general acute care hospital (GACH) on January 17, 2025. This failure resulted in inaccurate documentation of events in relation to Resident 3 ' s transfer process.
January 21, 2025Complaint 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 ensure pain medications were administered as ordered by the physician, for one of three residents (Resident A). This failure had the potential for Resident A's pain not be managed and affect overall health condition.
August 8, 2024Complaint inspection · 1 citation
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Inspectors wroteBased on interview and record review, the facility failed to ensure the resident receive the necessary care and treatment to prevent and treat allergic reactions, for one of four residents reviewed (Resident A) when: 1. Resident A's allergy to aspirin (medication to treat pain, fever, headache, and inflammation. It can also reduce the risk of heart attack) was not listed in the allergy list. Aspirin was administered to Resident A from June 3 to 17, 2024, and June 19 to 22, 2024 (total of 19 days); and 2. Resident A did not receive medication to treat signs and symptoms of allergic reaction. These failures resulted in Resident A to be transferred to the general acute hospital and acquired toxic epidermal necrolysis (a rare, life-threatening skin reaction, usually caused by a medication. [...]
July 3, 2024Standard inspection · 2 citations
- D
Ensure each resident receives an accurate assessment.
Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure Minimum Data Set (MDS) assessments accurately reflected the status of 1 (Resident #91) of 3 sampled residents reviewed for nutrition and 1 (Resident #101) of 1 sampled resident reviewed for dementia care. Specifically, the MDS assessments inaccurately indicated Resident #91's weight-loss was due to a physician-prescribed weight-loss regimen and did not reflect Resident #101's use of bed and wander/elopement alarms.
- 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 ensure staff properly donned personal protective equipment (PPE) prior to entering the room of 1 (Resident #268) of 4 residents reviewed for transmission-based precautions.
April 15, 2024Complaint inspection · 3 citations
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Inspectors wroteBased on interview and record review, the facility failed to ensure for one three residents (Resident A) was free from verbal abuse when a Certified Nursing Assistant (CNA) was witnessed to have used explicit words towards Resident A in the hallway. This failure resulted in a verbal abuse from CNA towards Resident A and had the potential to have a negative effect on the psychological, behavioral, or psychosocial outcomes to maintain or improve resident's overall well-being.
- 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 for one three residents (Resident A), an incident of verbal abuse from a Certified Nursing Assistant (CNA) towards Resident A was reported to California Department of Public Health (CDPH) within two hours. This failure resulted to a delay in the reporting and investigation of a verbal abuse and potentially placed Resident A and/or other residents at risk for further abuse.
- D
Respond appropriately to all alleged violations.
Inspectors wroteBased on interview and record review, facility failed to ensure for one three residents (Resident A), was free from any further abuse, when Certified Nursing Assistant (CNA) was not removed from all patient care after being witnessed by other staff to have verbally abused Resident A in the hallway. This failure had the potential to placed Resident A and/or other residents at risk for further abuse.
November 21, 2023Complaint inspection · 1 citation
- G
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, the facility failed to provide appropriate care and treatment services to prevent recurrent urinary tract infection (UTI- an infection in any part of the urinary system which include the kidneys, ureters, bladder, and urethra) to a resident with an indwelling catheter (IC - a flexible tube passed into the bladder to allow urine to drain), for one of three residents reviewed (Resident A). This failure resulted in Resident A to have recurrent episodes of UTIs on April 15, May 18, June 2, August 4, and August 25, 2023. In addition, Resident A was transferred to the acute hospital on August 26, 2023, due to a change of condition secondary to UTI and Resident A expired after three days at the acute hospital due to sepsis (bacteria spread through blood).
November 8, 2023Complaint inspection · 1 citation
- 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 home medications were destructed or disposed according to the facility's policy and procedure when: 1. Multiple Dilaudid (narcotic medication for pain) tablets were destructed together with non-narcotic medications; and 2. Multiple Zofran (medication to treat nausea) tablets and a tube of antifungal cream (medication to treat fungal skin infection) were destructed without verification of the physician orders for the medication. These failures had the potential administration error, inaccurate reconciliation, and drug diversion (illegal distribution or abuse of prescription drugs or their unintended purposes) of narcotic and non-narcotic medications.
October 4, 2023Complaint inspection · 1 citation
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to report a scabies (a parasitic infestation of the skin caused by an itch mite) outbreak to the California Department of Health (CDPH), within 24 hours according to the facility's policy and procedure and CDPH scabies outbreak reporting timeframe guidelines. This failure had the potential to interfere with facility operations and agencies ability to respond to outbreak as needed.
August 23, 2021Standard inspection · 11 citations
- E
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 provide necessary care and treatment when: 1. The facility failed to assess changes in skin condition for three of eight residents (Residents 70, 73, and 88) reviewed for skin conditions. The facility failed to assess Residents 70 and 88's skin discolorations and Resident 73's open skin. These failures had the potential to result in delayed treatment, which could cause worsening of Residents 70, 73, and 88's, skin conditions; and 2. The facility failed for one of five residents (Resident 66) reviewed for dialysis (the process of removing waste or fluid from the blood with the use of a machine) to obtain a physician order for monitoring, care, and treatment of Resident 66's right upper chest Quinton catheter site (a central venous catheter inserted thru a large vein into the heart). [...]
- 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 ensure medications were stored, according to the facility's policy and regulatory requirements when: 1. For Resident 49, one albuterol inhaler (medication to treat shortness of breath) was found unsecured on top of Resident 49's bedside table; 2. For Resident 5, one bottle of nystatin powder (medication to treat fungal infection) was found unsecured on top of Resident 5's bedside table; 3. For Resident 230, one small tub of Eucerin cream (medicated cream) was found unsecured on top of Resident 230's bedside table; 4. For Resident 88, one-unit dose of albuterol (medication to treat shortness of breath) was found unsecured on top of Resident 88's drawer; and 5. For Resident 66, two small packets of hydrocortisone cream (medication to treat a skin condition) were found unsecured on top of Resident 66's bedside table. [...]
- E
Provide and implement an infection prevention and control program.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were observed, when: 1. One staff member unvaccinated for COVID-19 (a highly contagious respiratory disease spread from person to person) did not wear a respirator mask when inside of the facility; 2. Inside the bathroom of resident room [ROOM NUMBER], one unlabeled bedpan was stored between the wall and the handrail; 3. Resident 88's suction tubing with a Yankauer tip (a type of device used to remove oral secretions) and nebulizer tubing with a chamber (a container to hold a liquid medication for breathing treatments) were observed stored together inside a plastic bag and were undated; 4. [...]
- E
Perform COVID19 testing on residents and staff.
Inspectors wroteBased on interview and record review, the facility failed to follow their infection control program to prevent the spread of COVID-19 (a highly contagious respiratory illness caused by a corona virus that can be spread from person to person) when the facility did not conduct daily COVID-19 testing for facility staff according to their policy and procedure. This failure had the potential to result in the spread of COVID-19 infection among healthcare personnel and residents, which could result in an outbreak affecting the vulnerable facility residents.
- D
Reasonably accommodate the needs and preferences of each resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the need of one resident (Resident 91), when the facility did not provide batteries for the hearing aids used by Resident 91. This failure resulted in Resident 91 to not be able to hear properly and communicate effectively.
- 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 interview and record review, the facility failed to inform the Responsible Party (RP) when there was a change of condition (COC) in one of five residents (Resident 95) reviewed for skin condition. This failure resulted in Resident 95's RP not being notified of Resident 95's change of condition on the right and left buttocks on July 29, 2021.
- D
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Inspectors wroteBased on interview and record review, the facility failed to notify the Responsible Party (RP) for one of three residents (Resident 95) reviewed for closed records, when Resident 95 was transferred to the hospital due to a change of condition. This failure resulted in Resident 95's RP not being notified of Resident 95's transfer to the acute hospital on August 3, 2021.
- 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 observation, interview, and record review, the facility failed to develop a baseline (an initial) care plan to address the care and treatment of an unused Quinton catheter - a central line catheter used temporarily for hemodialysis (a procedure where a dialysis machine and special filter are used to clean the blood) for one of five residents reviewed (Resident 66). This failure resulted in Resident 66 not receiving the necessary care and treatment of the unused Quinton catheter from July 2, 2021 to August 17, 2021.
- D
Honor each resident's preferences, choices, values and beliefs.
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident 73) received care and services necessary to maintain the highest level of physical and psychosocial well-being when Resident 73 did not receive an oral care. This failure increased the potential for Resident 73 to develop tooth cavities, gum infections, and cause emotional distress.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's orders when the facility did not administer oxygen as ordered for two of six residents (Resident 331 and 108) reviewed for oxygen therapy. These failures had the potential for Resident 331 and 108 to experience respiratory problems and a decline in their health condition due to ineffective oxygen therapy.
- D
Provide routine and 24-hour emergency dental care for each resident.
Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary dental services for one of two residents (Resident 68) reviewed for dental service, when there was no follow up dental service provided for Resident 68 to address broken dentures. This failure had the potential to decrease Resident 68's food intake which could result in a decline in the resident's nutritional condition, weight loss, and decreased self-esteem.
Fire safety inspections
16 fire safety citations on file: 2 on December 15, 2025, 5 on July 3, 2024, 9 on August 23, 2021.
Every fire safety citation16 citations
- F
Have approved installation, maintenance and testing program for fire alarm systems.
K 345 · December 15, 2025 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · December 15, 2025 · Corrected (the home has a date of correction)
- F
Provide emergency officials' contact information.
E 31 · July 3, 2024 · Corrected (the home has a date of correction)
- D
Keep aisles, corridors, and exits free of obstruction in case of emergency.
K 211 · July 3, 2024 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · July 3, 2024 · Corrected (the home has a date of correction)
- D
Inspect, test, and maintain automatic sprinkler systems.
K 353 · July 3, 2024 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · July 3, 2024 · Corrected (the home has a date of correction)
- E
Install an approved automatic sprinkler system.
K 351 · August 23, 2021 · Corrected (the home has a date of correction)
- D
Address subsistence needs for staff and patients.
E 15 · August 23, 2021 · Corrected (the home has a date of correction)
- D
List the names and contact information of those in the facility.
E 30 · August 23, 2021 · Corrected (the home has a date of correction)
- D
Provide emergency officials' contact information.
E 31 · August 23, 2021 · Corrected (the home has a date of correction)
- D
Provide primary/alternate means for communication.
E 32 · August 23, 2021 · Corrected (the home has a date of correction)
- D
Use approved construction type or materials.
K 161 · August 23, 2021 · Corrected (the home has a date of correction)
- D
Provide properly protected cooking facilities.
K 324 · August 23, 2021 · Corrected (the home has a date of correction)
- D
Install corridor and hallway doors that block smoke.
K 363 · August 23, 2021 · Corrected (the home has a date of correction)
- D
Ensure proper usage of power strips and extension cords.
K 920 · August 23, 2021 · Corrected (the home has a date of correction)