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
Unsafe Room Temperatures During Heat Wave: Multiple residents were found in hot, uncomfortable rooms during a summer heat wave, with room temperatures measured above 81°F and several residents reporting sweating, dryness, and discomfort. The Ombudsman reported complaints about heat, the MD and ADM confirmed elevated room temperatures with an infrared gun, and the MD acknowledged the temperature logs did not capture hotter afternoon conditions. Residents with cognitive impairment and one resident with ALS were among those affected, and care plans already identified risk for dehydration and impaired skin integrity.
A facility failed to follow up on ordered psych consults for five residents after behavioral incidents and abuse allegations. Residents with diagnoses including dementia, psychosis, depression, and neurologic conditions were involved in assaults or reported being hit, and SS staff sent referrals by email but did not confirm whether the psych providers saw the residents. The MRD later stated the provider did not see the patients as scheduled, and the consult notes were not found in the system.
A resident with dementia, depression, and anxiety was seated in the dining room while other residents ate, but the lunch tray was not served with the group on two occasions. In a separate event, an LVN administered oral meds to another resident with intellectual disability and cerebral palsy in the dining room while wearing gloves, rather than in a private setting, which staff stated was not the facility’s practice and could be seen as disrespectful.
Failure to Offer Advance Directive Option: The facility did not provide the option to formulate an advance directive for five sampled residents. Records showed several residents were informed of the right to develop an advance directive, but documentation did not show the option was actually offered to the resident or RP. One resident had capacity to understand and make decisions, yet the social services assessment documented that no advance directive was in place, the opportunity was not offered, and no educational materials or state form were provided. Interviews with residents and SSD staff confirmed the omission.
Inadequate Water Temperatures in Shower and Sink Areas: Residents in Hallway A reported that shower water was too cool and that adjoining restroom sinks provided only cold water at night. A Maintenance Director measured one shower at 97.2 F to 100.1 F and another at 100.2 F to 106.7 F, while CNAs and an LVN stated the sink water stayed cold during the overnight shift and was used for bathing, hand hygiene, and incontinent care.
The facility failed to manage pain according to physician orders for several residents. One resident received acetaminophen for pain rated above the ordered mild-pain range and without documented nonpharmacological interventions, two residents received hydrocodone-acetaminophen when their pain scores did not match the ordered parameters, and another resident lacked an order covering moderate pain levels. Staff interviews and MAR review confirmed the medications were not always administered as ordered.
Unsafe Room Temperatures During Heat Wave
Penalty
Summary
The facility failed to provide a safe and comfortable homelike environment for nine sampled residents when room temperatures rose above the required maximum during a summer heat wave. On 7/30/26, surveyors entered the facility to investigate a complaint related to power outages, and the weather report showed a high of 84°F. A Hot Summer Weather Advisory from the California Department of Public Health was also reviewed, noting that elderly and medically compromised individuals are more susceptible to temperature extremes and dehydration. The local Ombudsman reported receiving complaints about hot temperatures at the facility and stated that room temperatures on the second floor had been between 81°F and 85°F during a recent visit. During observations and interviews, multiple residents were found in hot, uncomfortable rooms with signs of sweating or dryness. One resident was in bed with damp skin and said the room became very hot with three residents sharing a small room and fans did not always help. Another resident near a window had no fan available, dry lips and skin, and said the room was too hot and his mouth was dry. A resident near the window had a cracked window, sun shining through the blinds, damp skin, and said the fan did not reach her bed; she had purchased her own bedside fan. Other residents described being sweaty, tired, uncomfortable, or dry, and one resident with ALS stated the heat made her condition worse and that it felt like 98°F in her room. Several residents had cognitive impairment on MDS review, and the sampled residents’ care plans already identified risk for dehydration, fluid and electrolyte imbalance, and impaired skin integrity. At 4:30 p.m., the Maintenance Director and Administrator checked room temperatures with an infrared gun and confirmed readings above 81°F in all sampled rooms, including 86.5°F in one room, 84.4°F in another, and multiple rooms in the 82.4°F to 82.8°F range. The Maintenance Director later reviewed temperature logs showing only Monday morning readings of 70°F to 76°F and acknowledged they did not reflect afternoon temperatures during hotter times of day. The DON stated that maintaining temperatures below 81°F was important because higher temperatures put residents at risk for heat stroke, dehydration, and skin issues. The facility policy on homelike environment stated that staff and management maximize, to the extent possible, a personalized, homelike setting with comfortable and safe temperatures between 71°F and 81°F.
Failure to Follow Up on Ordered Psych Consults for Five Residents
Penalty
Summary
The facility failed to provide services according to professional standards when social services did not follow up on psychology/psychiatry consults ordered for five residents. The record showed orders for psych consults with follow-up treatment as indicated for Residents 1, 2, 3, 4, and 5, but the medical records director later stated that, after a deeper review, the provider did not see the patients as scheduled and the lapse was acknowledged by the facility. Social services staff stated they only emailed providers for resident psych consultations and did not call to follow up to confirm whether residents on the referral list were seen. Resident 1 had diagnoses including ileostomy care, hemiplegia/hemiparesis after cerebral infarction, and substance dependence in remission. After an altercation in which Resident 1 struck Resident 2 with a closed fist on the left face, social services documented that a psych referral was sent. Resident 2 had diagnoses including type 2 DM, psychosis, major depressive disorder, bipolar disorder, and dementia with agitation, and the clinical record documented that Resident 2 was yelling at staff when the assault occurred. The social services director and social services staff could not confirm that either resident’s psych consult had been completed. Resident 3 had diagnoses including metabolic encephalopathy, Marfan syndrome, and major depressive disorder, and was documented as an alleged aggressor after punching Resident 4 in the face. Resident 4 had diagnoses including cerebral infarction, metabolic encephalopathy, Alzheimer’s disease, and adult failure to thrive, and was documented as the victim of the assault. Resident 5 had diagnoses including COPD and unspecified dementia with psychotic disturbance and reported that someone hit her, though she could not identify who. For Residents 3, 4, and 5, social services confirmed psych consult orders and referrals were sent, but staff were unsure whether the consultations were completed because the notes were not in the system and no phone follow-up was made to verify the residents were seen.
Late Meal Service and Public Medication Administration
Penalty
Summary
Facility staff failed to promote dignity and respect for Resident 3 when the resident’s lunch tray was not served with the other residents in the dining room on 7/30/2026 and again on 7/31/2026. Resident 3 was admitted with diagnoses including dementia, major depressive disorder, and anxiety, and the MDS indicated the resident had moderately impaired cognitive skills for daily decision making and required supervision or substantial assistance with multiple activities of daily living. During observation, Resident 3 was seated at a dining table with other residents while the other residents were eating, but Resident 3 had no lunch tray present. During the first observation, Treatment Nurse 1 verified that Resident 3 had no lunch tray and was watching the other residents eat, and stated he did not know why the tray was not included with the others. The Assistant DON later stated the resident was not served lunch on time and should have been served between 12:00 PM and 12:15 PM with the other residents in the dining room. On the second day, Resident 3 was again observed seated at the dining table at 12:15 PM with no lunch tray while other residents were eating. The DON and Dietary Supervisor stated the delay left the resident waiting while others ate, and the Dietary Supervisor stated the system for getting the dining room resident list to the kitchen staff was not working. Facility staff also failed to maintain Resident 4’s dignity during medication administration in the dining room. Resident 4 was admitted with diagnoses including mood disorder, intellectual disability, and cerebral palsy, and the MDS indicated the resident required substantial assistance with several activities of daily living. During observation, LVN 1 administered oral medication to Resident 4 in the dining room while wearing gloves. Treatment Nurse 1 stated medication should not be given in a public area and that the resident should have been assisted back to the room for private medication administration. The DON stated the resident could feel disrespected and that other residents might think the resident had an infectious disease because staff wore gloves while giving the medication.
Failure to Offer Advance Directive Option
Penalty
Summary
The facility failed to provide the option to formulate an advance directive for five sampled residents: Residents 10, 158, 163, 169, and 213. The facility’s policy stated that residents would be given information about advance directives upon admission and, if no advance directive existed, would be provided an opportunity to complete one upon resident request. Survey review found that this opportunity was not provided or documented for the five residents reviewed. Resident 213’s record showed the resident was informed of the right to develop an advance directive, but the record did not show the facility provided the resident or responsible party the opportunity to formulate one. Resident 213 had a full LPS conservatorship status, was cognitively intact on the MDS, and had a diagnosis of schizoaffective disorder. Similar findings were identified for Resident 169, whose record showed full LPS conservatorship status, cognitive intactness on the MDS, and a diagnosis of schizoaffective disorder, but no documentation that the resident or responsible party was offered the opportunity to formulate an advance directive. Resident 158’s record showed the resident was informed of the right to develop an advance directive, but the resident refused to sign the acknowledgement and the record did not show the facility provided the resident or responsible party the opportunity to formulate one. Resident 158 stated during interview that the facility did not provide information or the option to form an advance directive. Resident 163’s record also showed the resident was informed of the right to develop an advance directive, but no documentation showed the resident or responsible party was offered the opportunity to formulate one; the resident stated the facility did not provide information or the option to form an advance directive. Resident 10’s record showed the resident had capacity to understand and make decisions, yet the social services assessment documented that an advance directive was not in place, the opportunity to complete one was not offered, and no educational materials, including the state form, were provided. The SSD and SSD-STP acknowledged that the residents were not offered the option to formulate advance directives.
Inadequate Water Temperatures in Shower and Sink Areas
Penalty
Summary
The facility failed to ensure comfortable water temperatures for residents in Hallway A. Resident 49 stated the shower water in Shower Room A was too cold, and Resident 114 also stated the shower water was too cool and she wanted it warmer. During observation, the Maintenance Director tested Shower Room A and found Shower 2 reached only 97.2 F and then increased to a maximum of 100.1 F, which he described as lukewarm and below the 104 F he said it should be. Shower 3 initially measured 100.2 F and then increased to 106.7 F, which he stated was appropriate. CNA 4 stated that when she recently showered Resident 49, the resident asked for hotter water, but the shower lever was already turned all the way to hot and the water would not get hot. Resident 64 stated her scheduled shower had not yet occurred, but the shower temperature had been cool for a few weeks. Residents 73, 107, 114, 144, and 184, along with CNAs and an LVN, reported that the adjoining restroom sinks in Hallway A did not provide hot water at night. Resident 114 stated that between about 2300 and 0500 there was no hot water in her room sink and that CNAs had to use cold water when cleaning her after bowel movements. Resident 184 stated the hot water was turned off at night and that the sink water stayed cold. CNA 5 and CNA 6, both working the 2300 to 0700 shift, stated the water on Hallway A was usually cold at the beginning of their shift and did not get warm until around 0500, so they had to clean residents with cold water after incontinent episodes. LVN 11 stated the plumbing was old and that the water had to be run for a while to get warm, but then clarified that the water was always cold when she washed her hands. Resident 107 stated she only got cold water at night in her restroom sink, and Resident 73 stated the CNAs used the sink water to clean him up at night and it was always cold.
Pain medications given outside ordered parameters and missing pain-level coverage
Penalty
Summary
The facility failed to provide necessary pain management care and services for four residents. The report identified that pain medications were administered outside of ordered pain parameters, nonpharmacological interventions were not provided before medication administration, and one resident did not have an order covering all pain levels. The facility’s pain management policy stated that residents receiving pain interventions would be monitored for effectiveness and side effects, and that nonpharmacological interventions, effectiveness of PRN medications, and physician notification would be documented. For one resident, acetaminophen 325 mg was given after the resident reported generalized pain at a level of 6 on a 0 to 10 scale, even though the order was for mild pain only, defined as 1 to 4. The nurse did not offer or provide any nonpharmacological interventions before giving the medication, and the medication was administered outside the ordered parameters without notifying the physician. The resident’s record showed capacity to make his own medical decisions. For another resident, hydrocodone-acetaminophen 5-325 mg was administered multiple times when the documented pain level was outside the ordered range. The resident had an earlier order for moderate pain at 5 to 7, later changed to severe pain at 8 to 10, yet the MAR showed doses given for pain levels of 8 when the moderate-pain order was active and for pain levels of 7 after the severe-pain order was in place. Staff interviews confirmed the medication was to be given only within the physician’s ordered pain parameters. A third resident received hydrocodone-acetaminophen 10-325 mg for a pain level of 4 even though the order was for pain levels of 5 to 10. Another resident had orders for acetaminophen for mild pain and hydrocodone-acetaminophen for severe pain, but the record did not show any physician order for pain levels of 5 to 7. The resident’s MAR showed repeated use of hydrocodone-acetaminophen for severe pain, and no PRN acetaminophen was documented as given. The DON acknowledged that there should have been an order covering pain levels of 5 to 7.
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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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