CMS · California Department of Public Health publishes each citation’s tag, official description and scope/severity letter. The surveyor’s written findings are in the Statement of Deficiencies (CMS-2567) for each survey, linked above.
F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Scope/severity GHarm
Care planningFalls
Isolated; actual harm that is not immediate jeopardy.Corrected 2026-01-16Record 056281-20251209-F689
F584Honor 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.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-01-02Record 056281-20251209-F584
F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-01-02Record 056281-20251209-F605
F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Scope/severity DStandard
Dignity & rights
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-01-02Record 056281-20251209-F628
F641Ensure each resident receives an accurate assessment.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-01-21Record 056281-20251209-F641
F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-01-02Record 056281-20251209-F644
F645PASARR screening for Mental disorders or Intellectual DisabilitiesScope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-01-05Record 056281-20251209-F645
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-01-02Record 056281-20251209-F656
F658Ensure services provided by the nursing facility meet professional standards of quality.Scope/severity FStandard
Care planningRecords
Widespread; no actual harm, potential for more than minimal harm.Corrected 2026-01-21Record 056281-20251209-F658
F677Provide care and assistance to perform activities of daily living for any resident who is unable.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-01-02Record 056281-20251209-F677
F685Assist a resident in gaining access to vision and hearing services.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-01-02Record 056281-20251209-F685
F688Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-01-02Record 056281-20251209-F688
F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-01-02Record 056281-20251209-F755
F759Ensure medication error rates are not 5 percent or greater.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-01-02Record 056281-20251209-F759
F761Ensure 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.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-01-02Record 056281-20251209-F761
F791Provide or obtain dental services for each resident.Scope/severity DStandard
Care planning
Isolated; no actual harm, potential for more than minimal harm.Corrected 2026-01-02Record 056281-20251209-F791
F802Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2026-01-02Record 056281-20251209-F802
F803Ensure 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.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2026-01-02Record 056281-20251209-F803
F880Provide and implement an infection prevention and control program.Scope/severity EStandard
Infection control
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-01-02Record 056281-20251209-F880
F908Keep all essential equipment working safely.Scope/severity EStandard
Environment
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-01-02Record 056281-20251209-F908
F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Scope/severity EStandard
Environment
Pattern; no actual harm, potential for more than minimal harm.Corrected 2026-01-02Record 056281-20251209-F925
F911Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.Scope/severity CPaperwork
Environment
Widespread; potential for minimal harm.Correction not yet recordedRecord 056281-20251209-F911
F584Honor 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.Scope/severity EStandard
Dignity & rights
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-09-13Record 056281-20240823-F584
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-09-13Record 056281-20240823-F656
F658Ensure services provided by the nursing facility meet professional standards of quality.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-09-13Record 056281-20240823-F658
F758Implement 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.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-09-13Record 056281-20240823-F758
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2024-09-13Record 056281-20240823-F812
F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.Scope/severity DStandard
Environment
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-09-13Record 056281-20240823-F925
F911Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.Scope/severity BPaperwork
Environment
Pattern; potential for minimal harm.Corrected 2024-09-13Record 056281-20240823-F911
F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Scope/severity GHarm
Abuse & neglect
Isolated; actual harm that is not immediate jeopardy.Corrected 2024-03-14Record 056281-20240223-F600
F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Scope/severity DStandard
Abuse & neglect
Isolated; no actual harm, potential for more than minimal harm.Corrected 2024-03-14Record 056281-20240223-F609
F943Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.Scope/severity FStandard
Abuse & neglect
Widespread; no actual harm, potential for more than minimal harm.Corrected 2024-03-14Record 056281-20240223-F943
F758Implement 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.Scope/severity GHarm
Medication
Isolated; actual harm that is not immediate jeopardy.Corrected 2022-09-07Record 056281-20220715-F758
F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Scope/severity DStandard
Care planningRecords
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-09-07Record 056281-20220715-F656
F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Scope/severity EStandard
Medication
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-09-07Record 056281-20220715-F756
F757Ensure each resident’s drug regimen must be free from unnecessary drugs.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-09-07Record 056281-20220715-F757
F761Ensure 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.Scope/severity DStandard
Medication
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-09-07Record 056281-20220715-F761
F802Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2022-09-07Record 056281-20220715-F802
F803Ensure 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.Scope/severity FStandard
Food & nutrition
Widespread; no actual harm, potential for more than minimal harm.Corrected 2022-09-07Record 056281-20220715-F803
F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Scope/severity EStandard
Food & nutrition
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-09-07Record 056281-20220715-F812
F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Scope/severity EStandard
Care planningRecords
Pattern; no actual harm, potential for more than minimal harm.Corrected 2022-09-07Record 056281-20220715-F842
F880Provide and implement an infection prevention and control program.Scope/severity DStandard
Infection control
Isolated; no actual harm, potential for more than minimal harm.Corrected 2022-09-07Record 056281-20220715-F880
F911Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.Scope/severity BPaperwork
Environment
Pattern; potential for minimal harm.Corrected 2022-09-07Record 056281-20220715-F911