Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure one of 140 residents (Resident 134) was assessed for safe self-administration of medications. * The facility failed to ensure Resident 134 was safe to administer the zinc oxide ointment (medication used to treat and prevent skin irritation) medication found at bedside. This failure had the potential for Residents 134 to administer the medication inaccurately and negatively impact the health and safety of the resident.Findings: Review of the facility's P&P titled Self-Administration of Medications dated 4/2008 showed the residents who desired to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe… …
F554 citations in California
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
California cites F554 less often than its own record predicts
0.92 times the national share — cited less often here than elsewhere.
Of every deficiency written in California in 2025, this is the portion that was F554.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F554 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 observation, interview, medical record review, and facility P&P review, the facility failed to ensure two of six sampled residents (Residents 2 and 4) were assessed for safe self-administration of medications. * Resident 2 was observed with a full and uncovered 16 ounces tub of zinc oxide (a medicated cream used as a protective barrier for the affected skin areas) inside his restroom. * Resident 4 was observed with Halls cough drops on the bedside table. These failures had the potential for Residents 2 and 4 to administer the medications inaccurately and may negatively impact the health and safety of the residents.Findings: Review of the facility's P&P titled Resident Self-Administration of Medication revised 12/19/22, showed a resident may only self-administer medications after… …
The short window
Recent years
| Year | Share of California citations | vs expected |
|---|---|---|
| 2023 | 0.51% | 0.91× |
| 2024 | 0.43% | 0.80× |
| 2025 | 0.52% | 0.92× |
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