Deficiencies (last 4 years)
Deficiencies (over 4 years)
11 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
175% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 19, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to recognize and appropriately act on the clinical change in condition of a resident (Resident 1), which led to avoidable emergency hospital transport and serious health consequences.
Complaint Details
The complaint investigation was substantiated. The facility failed to notify the physician on 9/12/25 and 9/13/25 of abnormal lab results and low blood pressure for Resident 1. Nursing staff did not recognize or act on Resident 1's clinical decline on 9/14/25, leading to emergency hospital admission with sepsis and acute kidney injury. The resident's grandson reported concerns and requested 911 multiple times before emergency services were called.
Findings
The facility failed to notify the physician of abnormal lab results and vital signs for Resident 1, resulting in delayed medical intervention. Resident 1 experienced clinical decline including altered mental status, low oxygen saturation, and was subsequently hospitalized with sepsis and acute kidney injury.
Deficiencies (1)
Failure to immediately notify the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Report Facts
Vital signs: 91
Vital signs: 116
Lab result: 17.93
Oxygen saturation: 75
Hospitalization duration: 19
BUN: 62
Creatinine: 1.89
BIMS score: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 1 | Registered Nurse | Assigned nurse on 9/12/25 who did not complete daily assessment or notify physician of elevated WBC |
| LVN 1 | Licensed Vocational Nurse | Provided care on 9/14/25, assessed Resident 1's low oxygen saturation and clinical decline |
| DON | Director of Nursing | Confirmed failure to notify physician and incomplete resident assessments |
| CNA 2 | Certified Nursing Assistant | Observed Resident 1's decline and reported family concerns on 9/14/25 |
| CNA 3 | Certified Nursing Assistant | Provided care on 9/14/25 and reported Resident 1's complaints of pain |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Aug 14, 2025
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in the nursing facility, specifically focusing on medication administration and related care practices.
Findings
The facility failed to provide services meeting professional standards for two residents when their medications were unavailable and the licensed nurse did not notify the physician. This failure posed a risk of worsening health conditions and delayed medical response for the affected residents.
Deficiencies (1)
Failure to notify the physician when medications were unavailable and not administered to residents, risking worsening chronic conditions.
Report Facts
Residents affected: 2
Medication doses not administered: 4
Medication doses held: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Stated licensed nurse should have notified physician when medications were unavailable and not given |
| Licensed Vocational Nurse | Licensed Vocational Nurse | Interviewed regarding medication administration and notification procedures |
| Registered Nurse | Registered Nurse | Interviewed regarding medication administration and documentation procedures |
Inspection Report
Deficiencies: 1
Date: Jun 12, 2025
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality in medication administration following a failure to administer prescribed medications to a resident as ordered by the physician.
Findings
The facility failed to administer medications as ordered to one resident on 5/23/25 due to medication unavailability and did not notify the prescribing physician as required. This failure posed a risk of worsening chronic conditions, health deterioration, rehospitalization, or death. The licensed nurse did not follow facility policies and procedures for missed medication doses.
Deficiencies (1)
Failure to administer prescribed medications to Resident 1 on 5/23/25 due to medication unavailability and failure to notify the physician.
Report Facts
Residents Affected: 4
Residents Affected: Few
BIMS score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse (LVN 2) | Interviewed regarding medication administration and facility policy | |
| Director of Staff Development (DSD) | Interviewed regarding medication administration and facility policy |
Inspection Report
Routine
Deficiencies: 9
Date: Dec 10, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident dignity, medication administration, infection control, food safety, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to ensure resident privacy during care, improper medication administration practices, inadequate personal hygiene assistance, expired medications in emergency kits, unsafe medication storage and labeling, unsanitary kitchen conditions, lack of infection prevention program implementation, improper oxygen equipment handling, overcrowded resident rooms, and call lights not within residents' reach.
Deficiencies (9)
Failure to ensure residents were treated with dignity and respect by not providing privacy during blood sugar checks, blood pressure checks, and medication administration.
Allowed Resident 14 to self-administer inhalers without proper assessment, physician order, or care plan.
Failed to provide assistance with activities of daily living for Resident 22, resulting in poor personal hygiene.
Expired lorazepam medication found in emergency kit, not replaced by pharmacist.
Treatment cart left unlocked and unsupervised; medications including inhalers and nasal sprays lacked open and expiration dates; discontinued medications improperly stored without labels.
Unsanitary kitchen conditions including debris on vents, shelves, food carts, toaster, and freezer with freezer-burned beef roast.
Failure to implement Water Management Program to reduce risk of Legionella; oxygen nasal cannulas found on floor risking cross contamination; inhalers not sanitized after use.
Resident bedrooms exceeded maximum occupancy of four residents per room.
Call lights not within reach of residents in multiple rooms, posing risk of inability to summon assistance.
Report Facts
Residents affected: 9
Residents affected: 1
Residents affected: 1
Residents affected: 54
Residents affected: 3
Residents per room: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Named in privacy violation during blood sugar check |
| LVN 3 | Licensed Vocational Nurse | Named in privacy violation during blood pressure check and medication administration |
| LVN 2 | Licensed Vocational Nurse | Named in self-administration medication deficiency and medication administration practices |
| Director of Nursing | Director of Nursing | Provided statements on privacy, medication administration, and call light expectations |
| Infection Preventionist | Infection Preventionist | Provided statements on privacy, medication administration, infection control, and water management |
| Dietary Manager | Dietary Manager | Provided statements on kitchen sanitation deficiencies |
| Maintenance Director | Maintenance Director | Provided statements on water management and kitchen sanitation |
| Registered Dietician | Registered Dietician | Provided statements on kitchen sanitation and food safety |
| LVN 5 | Licensed Vocational Nurse | Named in call light deficiency |
| Certified Nursing Assistant 2 | Certified Nursing Assistant | Named in call light deficiency and ADL care |
| Certified Nursing Assistant 3 | Certified Nursing Assistant | Named in call light deficiency and ADL care |
Inspection Report
Routine
Deficiencies: 15
Date: Nov 9, 2023
Visit Reason
The inspection was conducted to evaluate compliance with federal regulations related to resident rights, care planning, medication administration, food and nutrition services, infection control, safety, and facility environment.
Findings
The facility was found deficient in multiple areas including failure to provide written notification prior to room changes, incomplete care plans for anticoagulant use and weight loss monitoring, failure to follow physician orders for weekly weights, inadequate pain assessment for cognitively impaired resident, incomplete dialysis post-weight documentation, expired medication storage, improper food preparation and sanitation practices, unsanitary conditions in resident shower rooms, uncovered linen carts, pest presence in shower, and overcrowding in resident rooms.
Deficiencies (15)
Failed to provide written notification before room changes for three residents.
Failed to develop and implement comprehensive care plans for anticoagulant use and weight loss monitoring for three residents.
Failed to ensure weekly weights were done as ordered for one resident, resulting in unmonitored weight loss.
Failed to monitor effectiveness of nutrition interventions for one resident with severe weight loss.
Failed to provide appropriate pain management for a cognitively impaired resident by using an incorrect pain assessment tool.
Failed to ensure post-dialysis weight assessments were documented for one resident on multiple dates.
Expired stool softener medication was stored and available for use in medication cart.
Dietary staff failed to properly calibrate thermometers and follow sanitizer test strip instructions; improper food portioning and texture preparation for residents on special diets; exposed hair during meal preparation.
Failed to ensure menus met nutritional needs and were followed for pureed diet residents.
Failed to maintain sanitary kitchen environment including lack of air gap in 3-compartment sink, debris on walls and equipment, chipped paint on refrigerator shelves, holes under ice machine, dirty microwaves, and uncovered hair of dietary staff.
Facility dumpsters were left uncovered and overfilled with trash and landscaping debris.
Failed to implement effective infection prevention and control program including failure of licensed nurse to perform hand hygiene during medication administration, uncovered linen cart with soiled tissue, open clean linen room door, and unsanitary shower room conditions.
Resident rooms 11, 12, and 14 each housed 8 residents exceeding the maximum of 4 residents per room without adequate privacy waiver.
Unsanitary conditions in resident shower rooms including black mold and dirt on floors and walls, missing grout, dirty call light pull cords with black and pink substances, and presence of winged bugs.
Electrical fan in resident room had plastic packaging on cord touching outlet creating fire hazard.
Report Facts
Residents per room: 8
Weight loss: 54
Weight loss: 33
Pureed meat portion: 3
Thermometer calibration temperature: 32
Quat sanitizer dip time: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Failed to perform hand hygiene during medication administration to Resident 51 |
| LVN 3 | Licensed Vocational Nurse | Used incorrect pain assessment tool for Resident 2 |
| LVN 4 | Licensed Vocational Nurse | Reported incomplete dialysis post-weight documentation for Resident 307 |
| RN 1 | Registered Nurse | Acknowledged expectation for mechanical soft diet vegetables to be chopped |
| CK 1 | Cook | Did not follow portion size for pureed meat and served chunky pureed chicken |
| CK 2 | Cook | Failed to properly calibrate thermometer and did not follow sanitizer test strip instructions; exposed hair during meal prep |
| DOM | Director of Maintenance | Acknowledged missing grout in showers, dirty call light cords, and fire hazard from fan cord plastic |
| RD | Registered Dietitian | Reported multiple dietary deficiencies including improper food texture, thermometer calibration, and sanitation issues |
| IP | Infection Preventionist | Reported failure of hand hygiene, uncovered linen cart, unsanitary shower rooms, and pest presence |
| DON | Director of Nursing | Reported failure of hand hygiene, incomplete dialysis documentation, unsanitary shower rooms, and pest presence |
| ADM | Administrator | Acknowledged fire hazard from fan cord plastic and expectation for pest-free environment |
Inspection Report
Routine
Deficiencies: 3
Date: Sep 13, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning and infection prevention and control requirements, specifically regarding the use and care of oxygen therapy equipment for sampled residents.
Findings
The facility failed to develop comprehensive care plans for three sampled residents regarding the use of supplemental oxygen and nebulizer machines, and failed to maintain proper infection prevention practices for oxygen therapy equipment, placing residents at risk for respiratory infections due to cross contamination.
Deficiencies (3)
Failure to develop a comprehensive care plan for supplemental oxygen use including proper replacement and storage of nasal cannula for Resident 2.
Failure to develop comprehensive care plans for nebulizer machine use including proper replacement and storage of nebulizer masks for Residents 1 and 3.
Failure to maintain an effective infection prevention and control program related to oxygen therapy equipment, including improper storage and lack of dating of nasal cannula and nebulizer masks for Residents 1, 2, and 3.
Report Facts
Residents sampled: 5
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 1 | LVN | Interviewed regarding improper storage and replacement of Resident 2's nasal cannula. |
| Licensed Vocational Nurse 2 | LVN | Interviewed regarding care plans and infection control for Residents 1, 2, and 3. |
| Certified Nursing Assistant 1 | CNA | Interviewed regarding improper storage and dating of nebulizer mask for Resident 3. |
| Infection Preventionist | IP | Interviewed regarding infection prevention practices and reviewed physician orders. |
| Administrator | ADM | Interviewed regarding facility expectations for licensed nurses on oxygen therapy equipment care. |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Feb 24, 2023
Visit Reason
The inspection was conducted to assess compliance with professional standards of quality in the nursing facility, specifically regarding the implementation of physician orders for resident care.
Findings
The facility failed to provide services meeting professional standards for one resident when a physician's order for a floor mat to reduce fall injury risk was not implemented. Licensed nurses did not follow the physician's order, increasing the resident's risk of injury from falls.
Deficiencies (1)
Failure to implement physician order for floor mat to reduce fall injury risk for Resident 1.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Validated absence of floor mat in Resident 1's room and confirmed resident was a fall risk. |
| Licensed Vocational Nurse 1 | Licensed Vocational Nurse | Observed absence of floor mat during medication pass and stated responsibility to follow physician orders. |
| Minimum Data Set Coordinator | Minimum Data Set Coordinator | Reviewed fall prevention policy and confirmed professional standard to follow physician orders. |
Inspection Report
Routine
Deficiencies: 13
Date: May 19, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, infection control, food service, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to develop timely and comprehensive care plans for residents, failure to follow physician orders for nutritional supplements, inadequate supervision during resident transfers, improper medication labeling, failure to implement gradual dose reductions for psychotropic medications, inadequate infection control practices including improper cleaning of glucometers and unsafe handling of COVID-19 test swabs, and failure to provide nutritionally equivalent food alternatives for residents with dietary restrictions.
Deficiencies (13)
Failed to develop and implement baseline care plan for oxygen therapy within 48 hours of admission for Resident 23.
Failed to develop a person-centered comprehensive care plan for activities of daily living for Resident 23.
Failed to follow physician order for nutritional supplement for Resident 26, resulting in missed doses and weight loss.
Failed to ensure adequate supervision during mechanical lift transfer of Resident 23, placing resident at risk for falls.
Failed to maintain acceptable nutritional status for Resident 26 due to missed nutritional supplements and inadequate intake.
Failed to monitor side effects of anticoagulant medication for Resident 33.
Failed to implement gradual dose reduction for psychotropic medication for Resident 25 despite pharmacist recommendation.
Failed to properly label injectable insulin pen for Resident 43 with full pharmacy prescription information.
Food service staff lacked competency in proper cooling procedures for potentially hazardous foods.
Failed to provide nutritionally equivalent protein alternative for Resident 25's dietary restrictions during lunch meal.
Failed to accurately document nutritional supplement consumption for Resident 294 in the electronic medical record.
Failed to maintain effective infection prevention and control program including improper handling of rapid COVID-19 nasal swab tests and inadequate cleaning and disinfection of glucometers.
Failed to ensure resident rooms accommodated no more than four residents as required.
Report Facts
Missed nutritional supplement doses: 10
Weight loss: 10
Residents per room: 8
Distance: 280
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 3 | Licensed Vocational Nurse | Named in findings related to failure to develop care plan, medication administration, and infection control practices. |
| Director of Nursing | Director of Nursing | Named in findings related to care plan expectations, medication administration, and infection control oversight. |
| DON | Director of Nursing | Named in findings related to medication monitoring and psychotropic medication dose reduction. |
| LVN 1 | Licensed Vocational Nurse | Named in findings related to medication administration and psychotropic medication monitoring. |
| Clinical Psychologist | Clinical Psychologist | Named in findings related to psychotropic medication evaluation and gradual dose reduction. |
| AD | Admissions Director | Named in findings related to improper handling of rapid COVID-19 nasal swab test. |
| DSM | Dietary Services Manager | Named in findings related to food service and nutritional supplement documentation. |
| RD | Registered Dietitian | Named in findings related to nutritional supplement monitoring and food service. |
| LVN 2 | Licensed Vocational Nurse | Named in findings related to nutritional supplement documentation. |
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