Citations in California
Statistics, citations and compliance trends for long-term care facilities in California.
Statistics for California (Last 12 Months)
Financial Impact (Last 12 Months)
Latest citations in California
A resident with seizures and epilepsy did not receive Keppra as ordered when nursing staff allowed the medication to stop without timely MD confirmation, then later discontinued the wrong duplicate order during med recap. The resident had recurrent seizures requiring hospital transfer, and the record showed the DON confirmed the stop was mistaken while the pharmacist noted abrupt Keppra discontinuation can cause withdrawal seizures.
Failure to Protect Resident from Physical Abuse by Another Resident: A bedbound resident with limited functional ability was struck on the head with an overhead table by another resident who had documented aggressive and abusive behaviors. The injured resident sustained a scalp laceration, blunt trauma, and a closed head injury, required ED treatment with staples, and later stated he was afraid when the other resident hit him. The aggressor had prior incidents of verbal aggression, threats, and spitting, and the DON stated the resident required supervision to prevent further abuse.
Food storage and kitchen equipment were found out of compliance with policy when a container of mashed potatoes was left improperly closed, a blender pitcher had a lingering odor with peeling cover and residue, a peanut butter jar lid was smeared, and the can opener and food grater had dried food residue. A torn freezer bag exposed beef patties and other items, the label was unreadable, and another blender had a chipped, calcified paddle with dried residue. Dietary staff and the DS confirmed the conditions did not meet food safety and storage standards.
Hand hygiene and glove-use practices were not followed during incontinent care for two residents. One CNA cleaned feces from a resident, doffed gloves, put on new gloves without hand hygiene, and then touched the resident and clean bed sheets while repositioning. Another CNA used the same gloves after incontinent care to reposition a resident and touch bed sheets and side rails. Both residents had severe cognitive impairment and required extensive assistance with personal care, and the IP and DON stated staff should perform hand hygiene after glove removal and before donning new gloves.
A cognitively intact resident with seizure disorder/epilepsy and chronic pain was not informed when medication changes occurred, despite staff stating residents should be educated about such changes and the care plan emphasizing resident-centered care. The resident said he felt frustrated and out of control when not told about his medications. Staff also failed to give ordered Norco for over 12 hours after it ran out, even though the nurse acknowledged it could have been given from the emergency supply; the resident reported pain at 8/10 and said the medication usually reduced it to about 4/10.
Failure to Report, Investigate, and Prevent Resident-to-Resident Abuse: A resident with schizoaffective disorder and aggressive behaviors threatened and spit on another resident, but staff did not recognize the conduct as abuse, did not report it to the Ombudsman, police, or CDPH, and did not complete the required monitoring documentation. The same resident was later placed in a room with a bedbound resident and allegedly struck that resident with an overhead table, causing a head laceration and hospital transfer. The DON and an LVN stated spitting was not abuse, while the record showed the facility’s policies required abuse identification, investigation, and reporting.
Failure to Maintain Antiseizure Medication Orders
Penalty
Summary
The facility failed to provide resident-centered nursing care and follow physician orders for a resident with seizures and epilepsy when his Keppra was allowed to stop without timely physician confirmation. The resident was a 78-year-old male with diagnoses including seizures, epilepsy, diabetes mellitus, and Parkinsonism. After a witnessed seizure in the ED in April 2026, the hospital discharge summary stated this was his second seizure and recommended ongoing antiepileptic therapy, with Keppra 500 mg twice daily to continue indefinitely. The facility order, however, was entered for Keppra 500 mg twice daily for 30 days, ending on 5/18/26. The resident received his last dose of Keppra on 5/18/26, and the medication was not reordered. Nursing staff did not contact the physician to confirm whether the stop date was intentional. The resident then had another seizure on 5/23/26 and was sent to the ED. After the resident returned from the hospital on 5/29/26, the facility record showed two Keppra orders: one indefinite order and one 30-day order. During medication recap, nursing staff discontinued the duplicate order without the stop date and maintained the 30-day order, which again resulted in Keppra stopping when the 30-day order ended. The resident received his last dose of Keppra on 6/28/26 and did not receive the medication on 6/29/26 or 6/30/26. Nursing staff did not contact the physician until 7/1/26 to verify whether the discontinuation was intentional. The resident stated staff did not inform him about medication changes and that his antiseizure medications had been decreased. The DON confirmed the medication had been discontinued mistakenly during medication recap, and the pharmacist stated abrupt discontinuation of Keppra could cause withdrawal seizures and that stopping it placed the resident at risk of further seizures. The resident’s care plan included seizures and giving seizure medication as ordered, but it did not address the discontinuation of Keppra.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. Resident 1 was admitted with muscle weakness and wasting, had no capacity to make medical decisions per the H&P, and required maximal assistance for oral hygiene, showers, and toileting hygiene. On 6/18/2026 at about 8:45 AM, a scream was heard from Resident 1’s room, and Resident 1 alleged that Resident 2 hit him on the head with an overhead table. Resident 1 was found bleeding with an approximately three-inch laceration to the left side of the skull and reported 3/10 pain. Resident 1 was transferred to a GACH after the incident. ED documentation described Resident 1 as bedbound and noted blunt trauma, a scalp laceration, and a closed head injury. The laceration was heavily contaminated, irrigated with saline, and repaired with two staples. During later interview, Resident 1 stated he was afraid when Resident 2, who was irritated, hit him on the head with the overhead table. Resident 2 had diagnoses including schizoaffective disorder, insomnia, and anxiety, and the record showed a history of aggressive and abusive behavior toward other residents. The care plan identified potential verbal and physical abusive behaviors and noted prior incidents including calling another resident names, threatening to beat that resident, and spitting on that resident. The facility moved Resident 2 to Resident 1’s room after those behaviors, and the DON stated Resident 2 required supervision to prevent further abuse of other residents. On the day of the incident, the behavior incident form stated Resident 2 said he pushed the overhead table and hit Resident 1 on the head, and the DON did not respond when asked whether staff provided supervision to prevent the assault.
Food Storage and Equipment Not Kept Clean or Properly Covered
Penalty
Summary
Food handling and food service sanitation were not maintained in accordance with the facility’s policy and procedure during observations in the kitchen. A clear container of mashed potatoes was not properly closed. Blender 1 had a lingering vegetable smell, a top cover that was peeling off, and food residue present. A classic peanut butter jar had peanut butter smeared on the outside of the red lid, and the can opener had dry crusted food residue. A bag containing beef patties, cinnamon rolls, and chocolate chip cookies was torn, exposing the contents, and the label on the bag was unreadable. The food grater had dry food residue, and Blender 2 had a chipped gray plastic insert paddle, calcification, and dried food residue. During interviews, the Dietary staff confirmed the observed conditions and stated that food containers should be labeled and properly closed, blenders should be in good condition without peeling, chipping, or calcification, and equipment used in food handling should be clean and sanitized. The Dietary Supervisor reviewed the facility’s policies on date marking and food storage and stated that food should be clearly marked, refrigerated food should be labeled and monitored for use by date, foods should be kept covered or in tightly sealed containers, and all equipment used in handling food must be cleaned and sanitized to prevent contamination. The Dietary Supervisor also stated the policies were not followed.
Hand Hygiene and Glove Use Not Followed During Incontinent Care
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when staff failed to follow hand hygiene and glove removal practices during incontinent care for two residents. Resident 9 had diagnoses including gastrostomy status, GERD, interstitial pulmonary disease, and dementia, and the MDS indicated severe cognitive impairment, dependence for multiple ADLs, and that the resident was always incontinent of bowel and bladder. During observation, CNA 7 provided incontinent care, cleaned feces from the resident, doffed gloves while touching the outside of the dirty gloves, put on a new pair of gloves without performing hand hygiene, and then touched the resident while repositioning and touched clean bed sheets. Resident 13 had diagnoses including benign prostatic hyperplasia and encounter for palliative care, and the MDS indicated severe cognitive impairment with dependence for toileting hygiene, shower/bathing, lower body dressing, and footwear. During observation, CNA 8 provided incontinent care and then used the same gloves while repositioning the resident and touching the resident's bed sheets and side rails. Both CNAs stated they should have changed gloves and performed hand hygiene after incontinent care. The IP and DON stated staff are supposed to perform hand hygiene after glove removal and before donning new gloves, and that gloves are not a substitute for hand hygiene.
Failure to Inform Resident of Medication Changes and Delay in Pain Medication
Penalty
Summary
Nursing staff failed to provide resident-centered care for a cognitively intact 78-year-old male resident with seizure disorder/epilepsy, DM, and parkinsonism by not informing him when changes were made to his medication regimen. The resident stated he wanted to be informed about his care and medication changes because, without that information, he had no control and no way of knowing whether a nurse had made a mistake. He also stated he felt frustrated and horrible when he was not informed, and he reported that no nurse had explained that some of his medications had been changed. The record showed the resident had physician-ordered levetiracetam (Keppra) for seizure control and hydrocodone-acetaminophen (Norco) for moderate to severe pain. The MARs documented that Keppra was last given on 6/28/26 and then was not administered on 6/29/26 or 6/30/26, with the medication later reordered on 7/1/26. Facility staff stated that medication changes were discussed in stand-up meetings and then communicated to the resident by the charge nurse or unit manager, but the DON confirmed the nursing progress notes did not document that the resident had been educated about medication changes. Nursing staff also failed to medicate the resident for pain per physician orders. The resident’s care plan identified acute/chronic pain and directed staff to administer the opioid as prescribed, with a goal that he would verbalize adequate relief of pain or ability to cope with incompletely relieved pain. The MAR showed Norco was administered regularly in June, but on 7/2/26 the resident reported he had not received Norco since the previous day, had requested it at 9 a.m. and again at 2 p.m., and his pain was 8/10. The nurse stated the Norco had run out the previous day and had been reordered, but none was given during the day shift while awaiting pharmacy delivery, even though she acknowledged it could have been administered from the emergency supply. The DON confirmed the medication had been on order since the previous day and that the resident had not received Norco since approximately 1:52 a.m. when it was administered from the emergency kit.
Failure to Report, Investigate, and Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to implement its Abuse Prevention Program and Resident-to-Resident Altercations policies when Resident 2, who had diagnoses including schizoaffective disorder and parkinsonism and was later placed on 72-hour monitoring for verbal aggression and spitting, was not adequately managed after an altercation with Resident 3. On 6/15/2026, Resident 2 was documented as being irritated, calling Resident 3 names, threatening to beat Resident 3 up, and spitting on Resident 3, with the spit landing on Resident 3’s shirt. The facility moved Resident 2 to another room, but the record showed the 72-hour monitoring documentation was incomplete, with no note covering the final 11 hours of the ordered monitoring period. The facility also failed to report and investigate the abuse allegations involving Resident 2 and Resident 3. During interview, the DON and LVN1 stated that spitting was not abuse and that there was no need to report the incident as abuse. The DON stated she did not report the incident to the Ombudsman, local police, or CDPH because spitting and name calling were not considered abuse. Later, LVN1 used a Google search and stated that spitting at another resident was considered physical abuse, and the DON stated the physical abuse between Resident 2 and Resident 3 should have been reported and investigated. The facility’s policy stated that all altercations, including those that may represent resident-to-resident abuse, were to be investigated and reported. The facility further failed to protect Resident 1, who was bedbound and dependent on staff for multiple activities of daily living, from physical abuse by Resident 2. On 6/18/2026, Resident 1 alleged that Resident 2 hit him on the head with an overhead table, causing a laceration and bleeding. Resident 1 was transferred by emergency services to a general acute care hospital and was diagnosed with blunt trauma, closed head injury, and scalp lacerations. The record also showed that Resident 2 had been moved into Resident 1’s room after the earlier altercation with Resident 3, and the DON did not respond when asked whether supervision had been provided to prevent Resident 2 from hitting Resident 1. The report also states that staff were not able to identify all types of abuse, and that Resident 1 and Resident 3 were not protected from abuse from Resident 2.
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Compliance trends in California
Data through Jun 2026Comparisons below measure the most recent period Jul 2025 – Jun 2026 against the prior period Jul 2024 – Jun 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Jul 2025 – Jun 2026 vs the prior period Jul 2024 – Jun 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Trusted data from CMS and state health departments
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