Solano Post Acute

CMS lists this as a complaint inspection.

• Citation F0552. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that residents are fully informed and understand their health status, care and treatments.

• Citation F0658. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS has cited this home for F0658 4 times since 2024.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS has cited this home for F0684 3 times since 2023.

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CMS lists this as a complaint inspection.

• Citation F0755. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  CMS lists it as corrected on August 18, 2026.

  CMS has cited this home for F0755 4 times since 2022.

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CMS lists this as a complaint inspection.

• Citation F0600. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  CMS lists it as corrected on August 14, 2026.

  CMS has cited this home for F0600 3 times since 2024.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on August 14, 2026.

  CMS has cited this home for F0609 8 times since 2023.

• Citation F0610. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Respond appropriately to all alleged violations.

  CMS lists it as corrected on August 14, 2026.

  CMS has cited this home for F0610 4 times since 2023.

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CMS lists this as a complaint inspection.

• Citation F0600. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  CMS lists it as corrected on July 15, 2026.

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• Star rating

  The CMS overall star rating changed from 3 of 5 to 2 of 5.

• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS overall star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS health inspection star rating changed from 1 of 5 to 2 of 5.

CMS lists this as a complaint inspection.

• Citation F0607. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement policies and procedures to prevent abuse, neglect, and theft.

  CMS lists it as corrected on May 5, 2026.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on May 5, 2026.

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CMS lists this as a complaint inspection.

• Citation F0692. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide enough food/fluids to maintain a resident's health.

  CMS lists it as corrected on May 5, 2026.

  CMS has cited this home for F0692 2 times since 2024.

• Citation F0919. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Make sure that a working call system is available in each resident's bathroom and bathing area.

  CMS lists it as corrected on May 5, 2026.

• Citation F0677. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS lists it as corrected on May 5, 2026.

  CMS has cited this home for F0677 4 times since 2022.

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• Star rating

  The CMS staffing star rating changed from 4 of 5 to 3 of 5.

CMS lists this as a complaint inspection.

• Citation F0584. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on February 23, 2026.

  CMS has cited this home for F0584 2 times since 2024.

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CMS lists this as a standard inspection and a complaint inspection.

• Citation F0761. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: 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.

  CMS lists it as corrected on December 18, 2025.

  CMS has cited this home for F0761 3 times since 2024.

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on December 18, 2025.

  CMS has cited this home for F0812 3 times since 2024.

• Citation F0550. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  CMS lists it as corrected on December 18, 2025.

  CMS has cited this home for F0550 3 times since 2022.

• Citation F0880. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on December 18, 2025.

  CMS has cited this home for F0880 5 times since 2022.

• Citation F0925. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

  CMS lists it as corrected on December 18, 2025.

• Citation F0676. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

  CMS lists it as corrected on December 18, 2025.

  CMS has cited this home for F0676 2 times since 2023.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on December 18, 2025.

  CMS has cited this home for F0689 6 times since 2022.

• Citation F0755. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  CMS lists it as corrected on December 18, 2025.

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CMS lists this as a standard inspection.

• Citation K0353. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on December 18, 2025.

  CMS has cited this home for K0353 3 times since 2022.

• Citation K0363. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install corridor and hallway doors that block smoke.

  CMS lists it as corrected on December 18, 2025.

  CMS has cited this home for K0363 3 times since 2022.

• Citation K0923. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have proper medical gas storage and administration areas.

  CMS lists it as corrected on December 18, 2025.

• Citation K0324. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide properly protected cooking facilities.

  CMS lists it as corrected on December 18, 2025.

  CMS has cited this home for K0324 2 times since 2024.

• Citation K0355. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Properly select, install, inspect, or maintain portable fire extinguishes.

  CMS lists it as corrected on December 18, 2025.

  CMS has cited this home for K0355 2 times since 2022.

• Citation K0741. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

  CMS lists it as corrected on December 18, 2025.

• Citation K0920. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure proper usage of power strips and extension cords.

  CMS lists it as corrected on December 18, 2025.

  CMS has cited this home for K0920 3 times since 2022.

• Citation E0023. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Establish policies and procedures for medical documentation.

  CMS lists it as corrected on December 18, 2025.

  CMS has cited this home for E0023 3 times since 2022.

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• Name

  CMS lists a new name for this home. It was WINDSOR VALLEJO NURSING & REHABILITATION CENTER.

• Health citation

  CMS changed citation F0755 from severity D to E. It is from the health inspection on April 12, 2022. Severity E: potential for more than minimal harm, pattern.

CMS lists this as a complaint inspection.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on September 3, 2025.

• Citation F0610. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Respond appropriately to all alleged violations.

  CMS lists it as corrected on September 3, 2025.

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• Star rating

  The CMS staffing star rating changed from 3 of 5 to 4 of 5.

CMS lists this as a complaint inspection.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on July 4, 2025.

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• Star rating

  The CMS overall star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 5 of 5.

CMS lists this as a complaint inspection.

• Citation F0658. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on May 8, 2025.

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CMS lists this as a complaint inspection.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on March 28, 2025.

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CMS lists this as a complaint inspection.

• Citation F0557. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

  CMS lists it as corrected on March 24, 2025.

  CMS has cited this home for F0557 2 times since 2024.

See this home on CMS Care Compare

CMS lists this as a complaint inspection.

• Citation F0658. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on March 10, 2025.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on March 10, 2025.

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• Star rating

  The CMS overall star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS quality measures star rating changed from 5 of 5 to 4 of 5. CMS changed how it scores this rating for many homes at once.

• Special Focus Facility

  CMS no longer lists this home as a Special Focus Facility candidate.

• Health citation

  CMS removed citation F0726 from the health inspection on July 15, 2024.

• Fine

  CMS changed the fine from November 9, 2023 from $82,620 to $53,703.

• Fine

  CMS changed the fine from April 10, 2024 from $29,960 to $19,474.

CMS lists this as a complaint inspection.

• Citation F0880. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on February 28, 2025.

• Citation F0710. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

  CMS lists it as corrected on February 28, 2025.

• Citation F0772. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.

  CMS lists it as corrected on February 28, 2025.

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CMS lists this as a complaint inspection.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on March 10, 2025.

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CMS lists this as a complaint inspection.

• Citation F0694. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide for the safe, appropriate administration of IV fluids for a resident when needed.

  CMS lists it as corrected on February 19, 2025.

• Citation F0761. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on February 19, 2025.

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CMS lists this as a standard inspection and a complaint inspection.

• Citation F0558. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Reasonably accommodate the needs and preferences of each resident.

  CMS lists it as corrected on December 10, 2024.

• Citation F0695. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on December 10, 2024.

• Citation F0755. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  CMS lists it as corrected on December 10, 2024.

• Citation F0761. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: 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.

  CMS lists it as corrected on December 10, 2024.

• Citation F0803. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: 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.

  CMS lists it as corrected on December 10, 2024.

• Citation F0804. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

  CMS lists it as corrected on December 10, 2024.

• Citation F0812. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on December 10, 2024.

• Citation F0880. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on December 10, 2024.

• Citation F0641. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident receives an accurate assessment.

  CMS lists it as corrected on December 10, 2024.

• Citation F0658. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on December 10, 2024.

• Citation F0806. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

  CMS lists it as corrected on December 10, 2024.

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CMS lists this as a standard inspection.

• Citation E0037. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Establish staff and initial training requirements.

  CMS lists it as corrected on December 23, 2024.

• Citation K0345. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have approved installation, maintenance and testing program for fire alarm systems.

  CMS lists it as corrected on December 23, 2024.

• Citation K0914. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

  CMS lists it as corrected on December 31, 2024.

• Citation K0921. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Ensure that testing and maintenance of electrical equipment is performed.

  CMS lists it as corrected on December 31, 2024.

• Citation K0363. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install corridor and hallway doors that block smoke.

  CMS lists it as corrected on December 23, 2024.

• Citation K0324. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide properly protected cooking facilities.

  CMS lists it as corrected on December 23, 2024.

• Citation K0920. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure proper usage of power strips and extension cords.

  CMS lists it as corrected on December 31, 2024.

• Citation E0023. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Establish policies and procedures for medical documentation.

  CMS lists it as corrected on December 23, 2024.

• Citation E0039. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Conduct testing and exercise requirements.

  CMS lists it as corrected on December 23, 2024.

• Citation K0353. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on January 29, 2025.

• Citation K0918. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on December 31, 2024.

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• Star rating

  The CMS staffing star rating changed from 2 of 5 to 3 of 5.

• Health citation

  CMS removed citation F0580 from the health inspection on June 5, 2024.

• Fine

  CMS changed the fine from November 9, 2023 from $197,010 to $82,620.

CMS lists this as a complaint inspection.

• Citation F0584. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on September 11, 2024.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on September 11, 2024.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on September 11, 2024.

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• Special Focus Facility

  CMS now lists this home as a Special Focus Facility candidate.

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

CMS lists this as a complaint inspection.

• Citation F0926. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have policies on smoking.

  CMS lists it as corrected on July 16, 2024.

• Citation F0550. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  CMS lists it as corrected on July 16, 2024.

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CMS lists this as a complaint inspection.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on July 2, 2024.

See this home on CMS Care Compare

CMS lists this as a complaint inspection.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on May 6, 2024.

See this home on CMS Care Compare

CMS lists this as a complaint inspection.

• Citation F0776. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.

  CMS lists it as corrected on May 21, 2024.

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CMS lists this as a complaint inspection.

• Citation F0600. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  CMS lists it as corrected on April 15, 2024.

See this home on CMS Care Compare

CMS lists this as a complaint inspection.

• Citation F0580. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

  CMS lists it as corrected on May 3, 2024.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on May 3, 2024.

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CMS fine of $19,474 on April 10, 2024.

See this home on CMS Care Compare

• Ownership

  CMS lists this home under a new chain.

CMS lists this as a complaint inspection.

• Citation F0692. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide enough food/fluids to maintain a resident's health.

  CMS lists it as corrected on February 29, 2024.

• Citation F0842. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  CMS lists it as corrected on February 29, 2024.

• Citation F0557. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

  CMS lists it as corrected on February 29, 2024.

• Citation F0610. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Respond appropriately to all alleged violations.

  CMS lists it as corrected on February 29, 2024.

• Citation F0677. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS lists it as corrected on February 29, 2024.

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CMS lists this as a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

256 of 1,165 California homes (22%) got a citation at the actual harm level in 2024.

• Citation F0677. Severity G: actual harm, isolated.

  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS lists it as corrected on February 12, 2024.

• Citation F0812. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on February 12, 2024.

See this home on CMS Care Compare

CMS lists this as a complaint inspection.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on January 26, 2024.

See this home on CMS Care Compare

CMS lists this as a complaint inspection.

• Citation F0559. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

  CMS lists it as corrected on December 5, 2023.

  CMS has cited this home for F0559 2 times since 2022.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on December 5, 2023.

See this home on CMS Care Compare

CMS lists this as a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

81 of 1,165 California homes (7%) got a citation at the actual harm level in 2023.

• Citation F0610. Severity G: actual harm, isolated.

  The rule CMS cited: Respond appropriately to all alleged violations.

  CMS lists it as corrected on December 19, 2023.

• Citation F0686. Severity G: actual harm, isolated.

  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  CMS lists it as corrected on December 7, 2023.

• Citation F0684. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on December 19, 2023.

• Citation F0725. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

  CMS lists it as corrected on December 7, 2023.

• Citation F0676. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

  CMS lists it as corrected on December 7, 2023.

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CMS fine of $53,703 on November 9, 2023.

See this home on CMS Care Compare

CMS lists this as a standard inspection.

Severity H is the second-highest of CMS's four levels. It means a resident was harmed.

25 of 1,165 California homes (2%) got a citation at the actual harm level in 2022.

• Citation F0689. Severity H: actual harm, pattern.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on June 8, 2022.

• Citation F0880. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on July 7, 2022.

• Citation F0550. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  CMS lists it as corrected on May 10, 2022.

• Citation F0677. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS lists it as corrected on July 7, 2022.

• Citation F0755. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  CMS lists it as corrected on July 7, 2022.

• Citation F0756. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  CMS lists it as corrected on May 13, 2022.

• Citation F0758. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: 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.

  CMS lists it as corrected on May 13, 2022.

• Citation F0559. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

  CMS lists it as corrected on May 10, 2022.

• Citation F0730. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Observe each nurse aide's job performance and give regular training.

  CMS lists it as corrected on July 7, 2022.

• Citation F0759. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure medication error rates are not 5 percent or greater.

  CMS lists it as corrected on May 10, 2022.

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CMS lists this as a standard inspection.

• Citation K0355. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Properly select, install, inspect, or maintain portable fire extinguishes.

  CMS lists it as corrected on May 17, 2022.

• Citation K0920. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure proper usage of power strips and extension cords.

  CMS lists it as corrected on May 17, 2022.

• Citation E0023. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Establish policies and procedures for medical documentation.

  CMS lists it as corrected on May 17, 2022.

• Citation E0030. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: List the names and contact information of those in the facility.

  CMS lists it as corrected on May 17, 2022.

• Citation E0031. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide emergency officials' contact information.

  CMS lists it as corrected on May 17, 2022.

• Citation K0161. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Use approved construction type or materials.

  CMS lists it as corrected on May 17, 2022.

• Citation K0353. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Inspect, test, and maintain automatic sprinkler systems.

  CMS lists it as corrected on May 17, 2022.

• Citation K0363. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Install corridor and hallway doors that block smoke.

  CMS lists it as corrected on May 17, 2022.

• Citation K0919. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Meet requirements for the use of electrical equipment.

  CMS lists it as corrected on May 17, 2022.

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