Based on observation, interview, and record review, the facility failed to protect, promote, and honor one of three sampled residents (Resident 23) right of not receiving cardiopulmonary resuscitation (CPR - emergency measures including manual chest compressions and rescue breaths to revive a person when breathing or heartbeat has stopped) measures as indicated in the Physician Orders for Life-Sustaining Treatment (POLST - a form that contains written medical orders for end-of life decisions communicated by a resident able to make informed decisions and if unable, by the resident's representative), dated [DATE]. Resident 23's POLST indicated Do Not Resuscitate (DNR- a medical order written by a doctor to instruct health care providers not to do CPR) instructing staff not to do CPR. …
F550 citations in California
Resident rights and dignity · Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
California cites F550 more often than its own record predicts
1.12 times the share F550 takes of citations nationally.
Of every deficiency written in California in 2025, this is the portion that was F550.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F550 findings written in California, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on interview and record review, the facility failed to honor six out of six sampled residents ' (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, and Resident 6) rights when they all were given written notices they would have to move into different rooms in the facility with no existing reason to do so, despite some of the residents having resided in their rooms for several years. This failure resulted in: 1. The potential for more than minimal harm for Resident 1, Resident 2, Resident 3, Resident 5, and Resident 6 when their collective right to a respectful and dignified existence was not honored by failing to allow all six residents ' rights to self-determination, affecting their right to a respectful and dignified environment, by not allowing them to remain in their… …
Based on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 18) was provided with assistance during meals. This deficient practice had the potential to cause Residents 18 to feel disregarded, humiliated, emotionally distressed, and also had the potential to compromise the residents' dignity and quality of life. Findings:During a review of Resident 18's admission Record, the admission Record indicated Resident 18 was originally admitted to the facility on [DATE] and readmitted on [DATE]. …
The short window
Recent years
| Year | Share of California citations | vs expected |
|---|---|---|
| 2023 | 2.31% | 1.12× |
| 2024 | 2.37% | 1.08× |
| 2025 | 2.38% | 1.12× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else California surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction