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| Deficiency Category | Inspection Date: 10/4/24 Complaint Reporting Period: 3/1/24 - 2/28/25 | Inspection Date: 10/15/23 Complaint Reporting Period: 3/1/23 - 2/29/24 | Inspection Date: 12/17/21 Complaint Reporting Period: 3/1/22 - 2/28/23 |
|---|---|---|---|
| Freedom from Abuse, Neglect, and Exploitation Deficiencies | |||
| Quality of Life and Care Deficiencies | |||
| Infection Control Deficiencies | |||
| Resident Assessment and Care Planning Deficiencies | |||
| Nursing and Physician Services Deficiencies | |||
| Resident Rights Deficiencies | |||
| Nutrition and Dietary Deficiencies | |||
| Pharmacy Service Deficiencies | |||
| Environmental Deficiencies | |||
| Administration Deficiencies |
| Date of last standard health inspection: | 10/4/24Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 3/1/24 - 2/28/25 | 8/26/24Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 3/1/24 - 2/28/25 | No infection control inspections |
| Total number of Health Deficiencies for this nursing home: | |
| Average number of Health Deficiencies in California: | |
| Average number of Health Deficiencies in the United States: |
| No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide safe and appropriate respiratory care for a resident when needed. | 8/26/24 | 9/6/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide safe and appropriate respiratory care for a resident when needed. | 10/4/24 | 10/30/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide enough food/fluids to maintain a resident's health. | 10/4/24 | 10/30/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 10/4/24 | 10/30/24 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide and implement an infection prevention and control program. | 10/4/24 | 10/30/24 | 2 - Minimal harm or potential for actual harm | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 10/4/24 | 10/30/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure each resident receives an accurate assessment. | 10/4/24 | 10/30/24 | 1 - Potential for minimal harm | Some |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | 10/4/24 | 10/30/24 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Post nurse staffing information every day. | 10/4/24 | 10/30/24 | 1 - Potential for minimal harm | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | 10/4/24 | 10/30/24 | 2 - Minimal harm or potential for actual harm | Few |
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | 10/4/24 | 10/30/24 | 1 - Potential for minimal harm | Some |
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. | 8/26/24 | 9/6/24 | 2 - Minimal harm or potential for actual harm | Few |
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. | 10/4/24 | 10/30/24 | 2 - Minimal harm or potential for actual harm | Few |
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. | 10/4/24 | 10/30/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | 10/4/24 | 10/30/24 | 2 - Minimal harm or potential for actual harm | Few |
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | 8/26/24 | 9/6/24 | 2 - Minimal harm or potential for actual harm | Few |
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. | 10/4/24 | 10/30/24 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 10/4/24 | 10/30/24 | 2 - Minimal harm or potential for actual harm | Some |
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. | 10/4/24 | 10/30/24 | 2 - Minimal harm or potential for actual harm | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure medication error rates are not 5 percent or greater. | 10/4/24 | 10/30/24 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | 10/4/24 | 10/30/24 | 4 - Immediate jeopardy to resident health or safety | Few |
Ensure each resident’s drug regimen must be free from unnecessary drugs. | 10/4/24 | 10/30/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that residents are free from significant medication errors. | 10/4/24 | 10/30/24 | 2 - Minimal harm or potential for actual harm | Some |
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. | 10/4/24 | 10/30/24 | 2 - Minimal harm or potential for actual harm | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | 10/4/24 | 10/30/24 | 1 - Potential for minimal harm | Some |
| No Administration Deficiencies were found during this inspection period. |
| Date of last standard health inspection: | 10/15/23Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 3/1/23 - 2/29/24 | 1/11/24Read the full report (PDF) 9/25/23Read the full report (PDF) 8/21/23Read the full report (PDF) 7/18/23Read the full report (PDF) 3/13/23Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 3/1/23 - 2/29/24 | 3/13/23Read the full report (PDF) |
| Total number of Health Deficiencies for this nursing home: | |
| Average number of Health Deficiencies in California: | |
| Average number of Health Deficiencies in the United States: |
| No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 6/8/23 | 6/24/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide enough food/fluids to maintain a resident's health. | 10/15/23 | 11/7/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | 10/15/23 | 11/7/23 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide and implement an infection prevention and control program. | 3/13/23 | 4/7/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide and implement an infection prevention and control program. | 10/15/23 | 11/7/23 | 2 - Minimal harm or potential for actual harm | Few |
Implement a program that monitors antibiotic use. | 10/15/23 | 11/7/23 | 2 - Minimal harm or potential for actual harm | Some |
Provide and implement an infection prevention and control program. | 1/11/24 | 1/24/24 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | 10/15/23 | 11/7/23 | 2 - Minimal harm or potential for actual harm | Few |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 10/15/23 | 11/7/23 | 2 - Minimal harm or potential for actual harm | Some |
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. | 10/15/23 | 11/7/23 | 2 - Minimal harm or potential for actual harm | Few |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 9/25/23 | 10/19/23 | 1 - Potential for minimal harm | Some |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 10/15/23 | 11/7/23 | 2 - Minimal harm or potential for actual harm | Few |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 6/8/23 | 6/24/23 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Post nurse staffing information every day. | 3/13/23 | 4/7/23 | 2 - Minimal harm or potential for actual harm | Few |
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | 8/21/23 | 9/15/23 | 2 - Minimal harm or potential for actual harm | Some |
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. | 7/18/23 | 7/28/23 | 2 - Minimal harm or potential for actual harm | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | 10/15/23 | 11/7/23 | 2 - Minimal harm or potential for actual harm | Few |
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. | 10/15/23 | 11/7/23 | 2 - Minimal harm or potential for actual harm | Some |
Allow residents to self-administer drugs if determined clinically appropriate. | 10/15/23 | 11/7/23 | 2 - Minimal harm or potential for actual harm | Few |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | 10/15/23 | 11/7/23 | 2 - Minimal harm or potential for actual harm | Few |
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. | 10/15/23 | 11/7/23 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Have a policy regarding use and storage of foods brought to residents by family and other visitors. | 10/15/23 | 11/7/23 | 2 - Minimal harm or potential for actual harm | Few |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | 10/15/23 | 11/7/23 | 2 - Minimal harm or potential for actual harm | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | 7/18/23 | 7/28/23 | 2 - Minimal harm or potential for actual harm | Some |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | 10/15/23 | 11/7/23 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that residents are free from significant medication errors. | 10/15/23 | 11/7/23 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | 10/15/23 | 11/7/23 | 1 - Potential for minimal harm | Some |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | 10/15/23 | 11/7/23 | 2 - Minimal harm or potential for actual harm | Few |
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | 8/21/23 | 9/15/23 | 2 - Minimal harm or potential for actual harm | Few |
| Date of last standard health inspection: | 12/17/21Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 3/1/22 - 2/28/23 | 12/5/22Read the full report (PDF) 11/28/22Read the full report (PDF) 9/21/22Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 3/1/22 - 2/28/23 | 1/29/23Read the full report (PDF) |
| Total number of Health Deficiencies for this nursing home: | |
| Average number of Health Deficiencies in California: | |
| Average number of Health Deficiencies in the United States: |
| No Freedom from Abuse, Neglect, and Exploitation Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 12/17/21 | 1/14/22 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide and implement an infection prevention and control program. | 12/5/22 | 12/15/22 | 2 - Minimal harm or potential for actual harm | Few |
Implement a program that monitors antibiotic use. | 12/17/21 | 1/14/22 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 11/28/22 | 12/14/22 | 2 - Minimal harm or potential for actual harm | Few |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 8/4/22 | 8/12/22 | 2 - Minimal harm or potential for actual harm | Few |
Ensure services provided by the nursing facility meet professional standards of quality. | 12/17/21 | 1/14/22 | 2 - Minimal harm or potential for actual harm | Few |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 12/17/21 | 1/14/22 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Post nurse staffing information every day. | 9/21/22 | 10/20/22 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | 11/28/22 | 12/14/22 | 2 - Minimal harm or potential for actual harm | Few |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | 8/4/22 | 8/12/22 | 2 - Minimal harm or potential for actual harm | Few |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | 12/17/21 | 1/14/22 | 2 - Minimal harm or potential for actual harm | Few |
Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | 8/4/22 | 8/12/22 | 2 - Minimal harm or potential for actual harm | Few |
| No Nutrition and Dietary Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | 12/17/21 | 1/14/22 | 2 - Minimal harm or potential for actual harm | Some |
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. | 9/21/22 | 10/20/22 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that residents are free from significant medication errors. | 12/17/21 | 1/14/22 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | 12/17/21 | 4/15/22 | 1 - Potential for minimal harm | Some |
| No Administration Deficiencies were found during this inspection period. |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide safe and appropriate respiratory care for a resident when needed. | 8/26/24 | 9/6/24 | 2 - Minimal harm or potential for actual harm | Few |
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. | 8/26/24 | 9/6/24 | 2 - Minimal harm or potential for actual harm | Few |
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | 8/26/24 | 9/6/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 6/8/23 | 6/24/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide and implement an infection prevention and control program. | 3/13/23 | 4/7/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide and implement an infection prevention and control program. | 1/11/24 | 1/24/24 | 2 - Minimal harm or potential for actual harm | Few |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 9/25/23 | 10/19/23 | 1 - Potential for minimal harm | Some |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 6/8/23 | 6/24/23 | 2 - Minimal harm or potential for actual harm | Few |
Post nurse staffing information every day. | 3/13/23 | 4/7/23 | 2 - Minimal harm or potential for actual harm | Few |
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | 8/21/23 | 9/15/23 | 2 - Minimal harm or potential for actual harm | Some |
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. | 7/18/23 | 7/28/23 | 2 - Minimal harm or potential for actual harm | Some |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | 7/18/23 | 7/28/23 | 2 - Minimal harm or potential for actual harm | Some |
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | 8/21/23 | 9/15/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide and implement an infection prevention and control program. | 12/5/22 | 12/15/22 | 2 - Minimal harm or potential for actual harm | Few |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 11/28/22 | 12/14/22 | 2 - Minimal harm or potential for actual harm | Few |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | 8/4/22 | 8/12/22 | 2 - Minimal harm or potential for actual harm | Few |
Post nurse staffing information every day. | 9/21/22 | 10/20/22 | 2 - Minimal harm or potential for actual harm | Few |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | 11/28/22 | 12/14/22 | 2 - Minimal harm or potential for actual harm | Few |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | 8/4/22 | 8/12/22 | 2 - Minimal harm or potential for actual harm | Few |
Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | 8/4/22 | 8/12/22 | 2 - Minimal harm or potential for actual harm | Few |
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. | 9/21/22 | 10/20/22 | 2 - Minimal harm or potential for actual harm | Few |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Provide and implement an infection prevention and control program. | 3/13/23 | 4/7/23 | 2 - Minimal harm or potential for actual harm | Few |
Post nurse staffing information every day. | 3/13/23 | 4/7/23 | 2 - Minimal harm or potential for actual harm | Few |