Safety Report: California Nursing & Rehabilitation Center
How to read this report. Every nursing home receives some citations. One citation does not mean a facility is unsafe. Look at how serious the findings were, whether the same problems keep coming back, and whether things are getting better or worse. Learn how inspections work.
Official ratings
Medicare's star ratings compare nursing homes within the same state for health inspections. A 5-star facility performed better than most in its state; a 1-star facility performed worse than most.
Stars are calculated by CMS, not by us. We do not create our own safety score.
Serious documented violations
2Immediate jeopardy citations (severity J–L)
1Actual harm citations (severity G–I)
20Requirements cited on more than one inspection
G
Government finding: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies · Tag F686
K
Government finding: Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies · Tag F692
J
Government finding: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies · Tag F689
Citations by topic
3Abuse, neglect & exploitation
5Infection control
11Medications & pharmacy
9Accidents & supervision
Topics use CMS's own deficiency categories; “accidents & supervision” counts tag F689 (free of accident hazards / adequate supervision). Counts cover the last three inspection cycles, including complaint investigations.
Is it getting better or worse?
Fewer citations in the most recent cycle (20) than in the cycle before (36).
An inspection cycle is roughly one year and includes the standard inspection plus complaint investigations. Counts depend partly on how many complaint investigations occurred, so treat small changes with caution. Red bars include at least one serious citation.
Staffing and rating trends will appear as we collect monthly CMS releases. We have one month so far, so a staffing trend cannot yet be determined.
Repeat findings
These requirements were cited on more than one inspection date in the last three cycles.
| Requirement | Times cited | Inspection dates |
|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F689) | 9 | June 17, 2026; June 17, 2025; March 3, 2025; February 4, 2025; November 19, 2024; October 7, 2024; August 12, 2024; April 18, 2024; April 15, 2022 |
| Provide appropriate treatment and care according to orders, resident’s preferences and goals. (F684) | 6 | March 9, 2026; July 30, 2025; June 24, 2025; March 3, 2025; April 18, 2024; April 15, 2022 |
| Provide and implement an infection prevention and control program. (F880) | 4 | May 7, 2026; August 27, 2025; March 3, 2025; December 26, 2023 |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F812) | 3 | May 7, 2026; March 3, 2025; April 15, 2022 |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (F755) | 3 | May 7, 2026; March 3, 2025; April 15, 2022 |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. (F867) | 2 | July 9, 2026; March 3, 2025 |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. (F573) | 2 | June 11, 2026; July 2, 2024 |
| 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. (F761) | 2 | May 7, 2026; April 15, 2022 |
| Provide safe and appropriate respiratory care for a resident when needed. (F695) | 2 | May 7, 2026; March 3, 2025 |
| Ensure each resident’s drug regimen must be free from unnecessary drugs. (F757) | 2 | May 7, 2026; April 15, 2022 |
| Provide enough food/fluids to maintain a resident's health. (F692) | 2 | July 30, 2025; March 3, 2025 |
| 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. (F803) | 2 | March 3, 2025; April 15, 2022 |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (F756) | 2 | March 3, 2025; April 15, 2022 |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. (F690) | 2 | March 3, 2025; April 15, 2022 |
| Ensure services provided by the nursing facility meet professional standards of quality. (F658) | 2 | March 3, 2025; April 15, 2024 |
| 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. (F584) | 2 | March 3, 2025; July 8, 2024 |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. (F912) | 2 | March 3, 2025; April 15, 2022 |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (F609) | 2 | October 7, 2024; January 19, 2024 |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. (F557) | 2 | October 7, 2024; August 12, 2024 |
| Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. (F625) | 2 | April 9, 2024; April 15, 2022 |
Fines and enforcement
| Date | Type | Amount / length |
|---|---|---|
| February 4, 2025 | Payment Denial | Payment denial for 18 days, starting April 1, 2025 |
| February 4, 2025 | Fine | $70,591 |
| November 19, 2024 | Fine | $8,021 |
| December 11, 2023 | Fine | $4,233 |
Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.
Complete inspection history
July 9, 2026 — 2 citations (includes serious) · complaint investigation
G
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Actual harm to a resident (not immediate jeopardy) · Isolated · Quality of Life and Care Deficiencies · F686 · complaint · corrected July 24, 2026
D
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
No actual harm, but potential for more than minimal harm · Isolated · Administration Deficiencies · F867 · complaint · corrected July 24, 2026
June 17, 2026 — 1 citation · complaint investigation
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected June 30, 2026
June 11, 2026 — 1 citation · complaint investigation
D
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F573 · complaint · corrected June 13, 2026
May 7, 2026 — 15 citations
F
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
No actual harm, but potential for more than minimal harm · Widespread · Administration Deficiencies · F851 · corrected June 5, 2026
F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F812 · corrected June 5, 2026
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F761 · corrected June 5, 2026
E
Provide safe and appropriate respiratory care for a resident when needed.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F695 · corrected June 5, 2026
D
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F887 · corrected June 5, 2026
D
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F880 · corrected June 5, 2026
D
Ensure that residents are free from significant medication errors.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F760 · corrected June 5, 2026
D
Ensure medication error rates are not 5 percent or greater.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F759 · corrected June 5, 2026
D
Ensure each resident’s drug regimen must be free from unnecessary drugs.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F757 · corrected June 5, 2026
D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F755 · corrected June 5, 2026
D
Provide 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.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F688 · corrected June 5, 2026
D
Provide care and assistance to perform activities of daily living for any resident who is unable.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F677 · corrected June 5, 2026
D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F636 · corrected June 5, 2026
D
Ensure that residents are fully informed and understand their health status, care and treatments.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F552 · corrected June 5, 2026
D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F550 · corrected June 5, 2026
March 9, 2026 — 1 citation · complaint investigation
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · complaint · corrected March 20, 2026
August 27, 2025 — 1 citation · complaint investigation
D
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F880 · complaint · corrected September 18, 2025
July 30, 2025 — 2 citations · complaint investigation
D
Provide enough food/fluids to maintain a resident's health.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F692 · complaint · corrected August 19, 2025
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · complaint · corrected August 19, 2025
June 24, 2025 — 1 citation · complaint investigation
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · complaint · corrected July 16, 2025
June 17, 2025 — 1 citation · complaint investigation
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected June 20, 2025
March 3, 2025 — 24 citations (includes serious)
K
Provide enough food/fluids to maintain a resident's health.
Immediate jeopardy to resident health or safety · Pattern · Quality of Life and Care Deficiencies · F692 · corrected March 28, 2025
F
Make sure that a working call system is available in each resident's bathroom and bathing area.
No actual harm, but potential for more than minimal harm · Widespread · Environmental Deficiencies · F919 · corrected March 28, 2025
F
Keep all essential equipment working safely.
No actual harm, but potential for more than minimal harm · Widespread · Environmental Deficiencies · F908 · corrected March 28, 2025
F
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
No actual harm, but potential for more than minimal harm · Widespread · Administration Deficiencies · F867 · corrected March 28, 2025
F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F812 · corrected March 28, 2025
F
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F801 · corrected March 28, 2025
E
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F880 · corrected March 28, 2025
E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F804 · corrected March 28, 2025
E
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F802 · corrected March 28, 2025
E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F755 · corrected March 28, 2025
D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F842 · corrected April 19, 2025
D
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
No actual harm, but potential for more than minimal harm · Isolated · Nutrition and Dietary Deficiencies · F813 · corrected March 28, 2025
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Nutrition and Dietary Deficiencies · F803 · corrected March 28, 2025
D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F756 · corrected March 28, 2025
D
Provide safe and appropriate respiratory care for a resident when needed.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F695 · corrected March 28, 2025
D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F690 · corrected March 28, 2025
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · corrected March 28, 2025
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · corrected March 28, 2025
D
Ensure services provided by the nursing facility meet professional standards of quality.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F658 · corrected March 28, 2025
D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F656 · corrected March 28, 2025
D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F644 · corrected March 28, 2025
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F584 · corrected March 28, 2025
D
Give the resident's representative the ability to exercise the resident's rights.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F551 · corrected March 28, 2025
B
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
No actual harm, potential for minimal harm · Pattern · Environmental Deficiencies · F912 · corrected March 28, 2025
February 4, 2025 — 1 citation · complaint investigation
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected March 4, 2025
November 19, 2024 — 2 citations (includes serious) · complaint investigation
J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Immediate jeopardy to resident health or safety · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected December 6, 2024
D
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F657 · complaint · corrected December 6, 2024
October 7, 2024 — 4 citations · complaint investigation
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected October 29, 2024
D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · complaint · corrected October 29, 2024
D
Keep residents' personal and medical records private and confidential.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F583 · complaint · corrected October 29, 2024
D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F557 · complaint · corrected October 29, 2024
August 12, 2024 — 2 citations · complaint investigation
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected August 29, 2024
D
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F557 · complaint · corrected August 29, 2024
July 8, 2024 — 1 citation · complaint investigation
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F584 · complaint · corrected July 31, 2024
July 2, 2024 — 1 citation · complaint investigation
D
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F573 · complaint · corrected July 19, 2024
April 18, 2024 — 2 citations · complaint investigation
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected May 3, 2024
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · complaint · corrected May 3, 2024
April 15, 2024 — 1 citation · complaint investigation
D
Ensure services provided by the nursing facility meet professional standards of quality.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F658 · complaint · corrected April 25, 2024
April 9, 2024 — 1 citation · complaint investigation
D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F625 · complaint · corrected April 18, 2024
January 19, 2024 — 1 citation · complaint investigation
D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · complaint · corrected January 24, 2024
December 26, 2023 — 1 citation · complaint investigation
D
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F880 · complaint · corrected January 4, 2024
December 12, 2023 — 1 citation · complaint investigation
D
Protect each resident from the wrongful use of the resident's belongings or money.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F602 · complaint · corrected January 3, 2024
April 15, 2022 — 11 citations
F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F812 · corrected May 16, 2022
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F803 · corrected May 16, 2022
E
Ensure each resident’s drug regimen must be free from unnecessary drugs.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F757 · corrected May 16, 2022
E
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F756 · corrected May 16, 2022
E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Pattern · Pharmacy Service Deficiencies · F755 · corrected May 16, 2022
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F761 · corrected May 16, 2022
D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F690 · corrected May 16, 2022
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · corrected May 16, 2022
D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F684 · corrected May 16, 2022
D
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F625 · corrected May 16, 2022
B
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
No actual harm, potential for minimal harm · Pattern · Environmental Deficiencies · F912 · corrected May 16, 2022
Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare