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| Deficiency Category | Inspection Date: 7/26/24 Complaint Reporting Period: 3/1/24 - 2/28/25 | Inspection Date: 7/16/21 Complaint Reporting Period: 3/1/23 - 2/29/24 | Inspection Date: 11/26/19 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: | 7/26/24Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 3/1/24 - 2/28/25 | 11/27/24Read the full report (PDF) 10/23/24Read the full report (PDF) 9/23/24Read the full report (PDF) 9/20/24Read the full report (PDF) 8/22/24Read the full report (PDF) 5/28/24Read 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) |
|---|---|---|---|---|
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | 9/20/24 | 10/11/24 | 2 - Minimal harm or potential for actual harm | Many |
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | 9/20/24 | 10/11/24 | 4 - Immediate jeopardy to resident health or safety | Few |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. | 7/26/24 | 8/18/24 | 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. | 5/28/24 | 6/27/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide medically-related social services to help each resident achieve the highest possible quality of life. | 5/28/24 | 6/27/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide safe, appropriate pain management for a resident who requires such services. | 7/26/24 | 8/18/24 | 2 - Minimal harm or potential for actual harm | Some |
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. | 7/26/24 | 8/18/24 | 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. | 11/27/24 | 12/2/24 | 3 - Actual harm | Few |
| No Infection Control 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) |
|---|---|---|---|---|
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 9/20/24 | 10/11/24 | 3 - 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. | 10/23/24 | 11/6/24 | 2 - Minimal harm or potential for actual harm | Few |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | 7/26/24 | 8/18/24 | 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 nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | 7/26/24 | 8/18/24 | 2 - Minimal harm or potential for actual harm | Many |
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. | 9/3/24 | 9/20/24 | 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. | 11/27/24 | 12/2/24 | 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) |
|---|---|---|---|---|
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | 9/20/24 | 10/11/24 | 3 - Actual harm | Few |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | 5/28/24 | 6/27/24 | 2 - Minimal harm or potential for actual harm | Few |
Reasonably accommodate the needs and preferences of each resident. | 7/26/24 | 8/18/24 | 2 - Minimal harm or potential for actual 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. | 9/23/24 | 10/3/24 | 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. | 7/26/24 | 8/18/24 | 2 - Minimal harm or potential for actual harm | Many |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
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. | 8/22/24 | 9/15/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure each resident’s drug regimen must be free from unnecessary drugs. | 7/26/24 | 8/18/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | 8/8/24 | 8/30/24 | 2 - Minimal harm or potential for actual harm | Some |
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | 7/26/24 | 8/18/24 | 2 - Minimal harm or potential for actual harm | Few |
Ensure that residents are free from significant medication errors. | 8/8/24 | 8/30/24 | 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. | 7/26/24 | 8/18/24 | 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) |
|---|---|---|---|---|
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | 5/28/24 | 6/27/24 | 2 - Minimal harm or potential for actual harm | Some |
Keep all essential equipment working safely. | 11/27/24 | 12/2/24 | 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) |
|---|---|---|---|---|
Have a plan that describes the process for conducting QAPI and QAA activities. | 9/20/24 | 10/11/24 | 2 - Minimal harm or potential for actual harm | Many |
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | 7/26/24 | 8/18/24 | 2 - Minimal harm or potential for actual harm | Few |
| Date of last standard health inspection: | 7/16/21Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 3/1/23 - 2/29/24 | 10/26/23Read the full report (PDF) 9/25/23Read the full report (PDF) 9/15/23Read the full report (PDF) 8/24/23Read the full report (PDF) 5/11/23Read the full report (PDF) 4/14/23Read the full report (PDF) |
| Date(s) of infection control inspection(s) between 3/1/23 - 2/29/24 | 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: |
| Inspectors determined that the nursing home failed to: | Inspection Date | Date of Correction | Level of Harm (Least to most) | Residents Affected (Few, Some, Many) |
|---|---|---|---|---|
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 10/26/23 | 10/27/23 | 2 - Minimal harm or potential for actual harm | Few |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 8/24/23 | 9/20/23 | 2 - Minimal harm or potential for actual harm | Few |
Respond appropriately to all alleged violations. | 8/24/23 | 9/20/23 | 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 care or services that was trauma informed and/or culturally competent. | 2/1/24 | 2/23/24 | 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. | 7/16/21 | 8/12/21 | 2 - Minimal harm or potential for actual harm | Few |
Provide enough food/fluids to maintain a resident's health. | 7/16/21 | 8/12/21 | 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. | 5/11/23 | 6/11/23 | 3 - Actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 9/15/23 | 10/12/23 | 3 - Actual harm | Few |
Provide safe, appropriate pain management for a resident who requires such services. | 7/16/21 | 8/12/21 | 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 and implement an infection prevention and control program. | 10/26/23 | 10/27/23 | 2 - Minimal harm or potential for actual harm | Some |
Provide and implement an infection prevention and control program. | 6/7/23 | 7/3/23 | 2 - Minimal harm or potential for actual harm | Some |
Provide and implement an infection prevention and control program. | 7/16/21 | 8/12/21 | 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 each resident receives an accurate assessment. | 7/16/21 | 8/12/21 | 2 - Minimal harm or potential for actual harm | Some |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | 7/16/21 | 8/12/21 | 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) |
|---|---|---|---|---|
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. | 7/16/21 | 8/12/21 | 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) |
|---|---|---|---|---|
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | 4/14/23 | 5/2/23 | 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. | 7/6/23 | 7/21/23 | 2 - Minimal harm or potential for actual harm | Few |
Honor the resident's right to organize and participate in resident/family groups in the facility. | 7/16/21 | 8/12/21 | 2 - Minimal harm or potential for actual harm | Some |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | 7/16/21 | 8/12/21 | 2 - Minimal harm or potential for actual harm | Some |
Reasonably accommodate the needs and preferences of each resident. | 7/16/21 | 8/12/21 | 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. | 7/16/21 | 8/12/21 | 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) |
|---|---|---|---|---|
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. | 7/16/21 | 8/12/21 | 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. | 7/16/21 | 8/12/21 | 2 - Minimal harm or potential for actual harm | Some |
Ensure medication error rates are not 5 percent or greater. | 7/16/21 | 8/12/21 | 2 - Minimal harm or potential for actual harm | Some |
Ensure each resident’s drug regimen must be free from unnecessary drugs. | 7/16/21 | 8/12/21 | 2 - Minimal harm or potential for actual harm | Few |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | 9/25/23 | 10/25/23 | 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. | 7/16/21 | 8/12/21 | 2 - Minimal harm or potential for actual harm | Few |
| No Environmental 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) |
|---|---|---|---|---|
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | 7/16/21 | 8/12/21 | 2 - Minimal harm or potential for actual harm | Some |
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | 7/6/23 | 7/21/23 | 2 - Minimal harm or potential for actual harm | Few |
| Date of last standard health inspection: | 11/26/19Read the full report (PDF) |
| Date(s) of complaint inspection(s) between 3/1/22 - 2/28/23 | No complaint inspections |
| Date(s) of infection control inspection(s) between 3/1/22 - 2/28/23 | 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. |
| No Quality of Life and Care 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 and implement an infection prevention and control program. | 11/26/19 | 1/2/20 | 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 each resident receives an accurate assessment. | 11/26/19 | 1/2/20 | 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 that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | 11/26/19 | 1/2/20 | 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) |
|---|---|---|---|---|
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | 11/26/19 | 1/2/20 | 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) |
|---|---|---|---|---|
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | 11/26/19 | 1/2/20 | 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. | 11/26/19 | 1/2/20 | 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 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. | 11/26/19 | 1/2/20 | 2 - Minimal harm or potential for actual harm | Few |
| No Environmental Deficiencies were found during this inspection period. |
| 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) |
|---|---|---|---|---|
Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents. | 9/20/24 | 10/11/24 | 2 - Minimal harm or potential for actual harm | Many |
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | 9/20/24 | 10/11/24 | 4 - Immediate jeopardy to resident health or safety | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 5/28/24 | 6/27/24 | 2 - Minimal harm or potential for actual harm | Some |
Provide medically-related social services to help each resident achieve the highest possible quality of life. | 5/28/24 | 6/27/24 | 2 - Minimal harm or potential for actual harm | Some |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 11/27/24 | 12/2/24 | 3 - 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. | 9/20/24 | 10/11/24 | 3 - 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. | 10/23/24 | 11/6/24 | 2 - Minimal harm or potential for actual harm | Few |
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. | 9/3/24 | 9/20/24 | 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. | 11/27/24 | 12/2/24 | 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. | 9/20/24 | 10/11/24 | 3 - Actual harm | Few |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | 5/28/24 | 6/27/24 | 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. | 9/23/24 | 10/3/24 | 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. | 8/22/24 | 9/15/24 | 2 - Minimal harm or potential for actual harm | Few |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | 8/8/24 | 8/30/24 | 2 - Minimal harm or potential for actual harm | Some |
Ensure that residents are free from significant medication errors. | 8/8/24 | 8/30/24 | 2 - Minimal harm or potential for actual harm | Some |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | 5/28/24 | 6/27/24 | 2 - Minimal harm or potential for actual harm | Some |
Keep all essential equipment working safely. | 11/27/24 | 12/2/24 | 2 - Minimal harm or potential for actual harm | Few |
Have a plan that describes the process for conducting QAPI and QAA activities. | 9/20/24 | 10/11/24 | 2 - Minimal harm or potential for actual harm | Many |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 10/26/23 | 10/27/23 | 2 - Minimal harm or potential for actual harm | Few |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | 8/24/23 | 9/20/23 | 2 - Minimal harm or potential for actual harm | Few |
Respond appropriately to all alleged violations. | 8/24/23 | 9/20/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide care or services that was trauma informed and/or culturally competent. | 2/1/24 | 2/23/24 | 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. | 5/11/23 | 6/11/23 | 3 - Actual harm | Few |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | 9/15/23 | 10/12/23 | 3 - Actual harm | Few |
Provide and implement an infection prevention and control program. | 10/26/23 | 10/27/23 | 2 - Minimal harm or potential for actual harm | Some |
Provide and implement an infection prevention and control program. | 6/7/23 | 7/3/23 | 2 - Minimal harm or potential for actual harm | Some |
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | 4/14/23 | 5/2/23 | 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. | 7/6/23 | 7/21/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | 9/25/23 | 10/25/23 | 2 - Minimal harm or potential for actual harm | Few |
Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | 7/6/23 | 7/21/23 | 2 - Minimal harm or potential for actual harm | Few |
| This nursing home has not had any infection control inspections in the past 3 years. |