Based on interview and record review, the facility failed to honor the rights of one of two residents (Resident 5) when Resident 5 ' s medical decision-maker, Family Member 2 (FM2) was not asked or notified before starting to give Resident 5 a new pain medication MS (morphine sulphate) Contin (a long-acting pain medication made with morphine, an opiate). This failure resulted in Resident 5 becoming over sedated (state of calmness, relaxation, or sleepiness), requiring naloxone (a medication that reverses the potentially deadly effects of opiate toxicity), when he was administered a new medication before FM2 had been given a chance to consider the risks and benefits or permission for them to give it to him. …
F552 citations in California
Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
California cites F552 more often than its own record predicts
1.87 times the share F552 takes of citations nationally.
Of every deficiency written in California in 2025, this is the portion that was F552.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F552 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, medical record review, and facility P&P review, the facility failed to ensure the residents and/or resident representatives were provided with the right to self-determination for one of five sampled residents reviewed for unnecessary medications (Residents 7). * The facility failed to ensure the informed consent for the Abilify (antipsychotic medication) specified nonpharmacological interventions to be provided to Resident 7. This failure had the potential to compromise the resident's right, or the right of the designated representative, to be fully informed regarding the psychotropic medication, including possible nonpharmacological approaches, in order to make an informed decision.Findings: Review of the AFL 25-27 titled AB 48 - Nursing Facility Resident Informed… …
Based on interview, medical record review, and facility P&P review, the facility failed to ensure the informed consent was completed prior to the use of a psychotropic medication for one of five final sampled residents (Resident 80) reviewed for informed consent. * The facility failed to ensure Resident 80's informed consent included the date and signature of the physician under the prescriber's section of the form. This failure had the potential to violate the residents' rights of not being fully informed of the medications and treatments. …
The short window
Recent years
| Year | Share of California citations | vs expected |
|---|---|---|
| 2023 | 0.61% | 2.03× |
| 2024 | 0.87% | 2.27× |
| 2025 | 1.01% | 1.87× |
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