Safety Report: Avamere Rehabilitation of King City
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
0Immediate jeopardy citations (severity J–L)
0Actual harm citations (severity G–I)
8Requirements cited on more than one inspection
No citations at the “actual harm” or “immediate jeopardy” level in the last three inspection cycles.
Citations by topic
1Abuse, neglect & exploitation
0Infection control
4Medications & pharmacy
0Accidents & 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?
More citations in the most recent cycle (14) than in the cycle before (12).
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 |
|---|---|---|
| Provide appropriate treatment and care according to orders, resident’s preferences and goals. (F684) | 3 | August 13, 2026; February 20, 2026; July 19, 2024 |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. (F755) | 2 | February 20, 2026; December 5, 2025 |
| Provide activities to meet all resident's needs. (F679) | 2 | December 5, 2025; July 19, 2024 |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. (F725) | 2 | January 10, 2025; July 19, 2024 |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F812) | 2 | July 19, 2024; April 10, 2023 |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (F656) | 2 | July 19, 2024; April 10, 2023 |
| 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. (F688) | 2 | July 19, 2024; April 10, 2023 |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (F657) | 2 | July 19, 2024; April 10, 2023 |
Fines and enforcement
No federal fines or payment denials in the last three years.
Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.
Complete inspection history
August 13, 2026 — 4 citations · complaint investigation
E
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F628 · complaint · corrected September 1, 2026
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 · complaint · corrected September 1, 2026
D
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
No actual harm, but potential for more than minimal harm · Isolated · Nursing and Physician Services Deficiencies · F711 · complaint · corrected September 1, 2026
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 September 1, 2026
February 20, 2026 — 2 citations · complaint investigation
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 · complaint · corrected March 13, 2026
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 13, 2026
December 5, 2025 — 8 citations
E
Provide activities to meet all resident's needs.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F679 · corrected January 6, 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 · complaint · corrected November 19, 2025
D
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F740 · corrected January 6, 2026
D
Provide safe, appropriate pain management for a resident who requires such services.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F697 · corrected January 6, 2026
D
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
No actual harm, but potential for more than minimal harm · Isolated · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F605 · corrected January 6, 2026
D
Reasonably accommodate the needs and preferences of each resident.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F558 · corrected January 6, 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 January 6, 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 · complaint · corrected September 17, 2024
January 10, 2025 — 1 citation · complaint investigation
E
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
No actual harm, but potential for more than minimal harm · Pattern · Nursing and Physician Services Deficiencies · F725 · complaint · corrected January 30, 2025
July 19, 2024 — 12 citations
F
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
No actual harm, but potential for more than minimal harm · Widespread · Nursing and Physician Services Deficiencies · F725 · complaint · corrected August 27, 2024
E
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 · Pattern · Nutrition and Dietary Deficiencies · F812 · corrected August 27, 2024
E
Provide activities to meet all resident's needs.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F679 · corrected August 27, 2024
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 · complaint · corrected August 27, 2024
D
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
No actual harm, but potential for more than minimal harm · Isolated · Nutrition and Dietary Deficiencies · F805 · corrected August 27, 2024
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 August 27, 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 · corrected August 27, 2024
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 · complaint · corrected August 27, 2024
D
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F676 · corrected August 27, 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 · corrected August 27, 2024
D
PASARR screening for Mental disorders or Intellectual Disabilities
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F645 · corrected August 27, 2024
D
Ensure each resident receives an accurate assessment.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F641 · corrected August 27, 2024
April 10, 2023 — 10 citations
E
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 · Pattern · Nutrition and Dietary Deficiencies · F812 · corrected April 26, 2023
E
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
No actual harm, but potential for more than minimal harm · Pattern · Nursing and Physician Services Deficiencies · F727 · corrected April 26, 2023
E
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F578 · corrected April 26, 2023
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 April 26, 2023
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 April 26, 2023
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 April 26, 2023
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 · corrected April 26, 2023
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 April 26, 2023
D
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F585 · corrected April 26, 2023
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 April 26, 2023
Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare