Based on interview and record review, the facility failed to provide one of five sampled residents (Resident 1) with nursing care in a manner that maintained his dignity and respect, when Registered Nurse 1 (RN 1):1. Did not cease performing a rectal (of, relating to, or situated near the rectum, which is the final section of the large intestine) treatment/procedure after Resident 1 complained of pain and asked RN 1 to stop.2. Did not ensure privacy during care/treatment which required Resident 1 to be partially unclothed from the waist down.3. Did not provide explanation of care/treatment to Resident 1 prior to performing an invasive (involving the introduction of instruments or other objects into the body or body cavities) rectal medication insertion. …
F557 citations in California
Resident Rights Deficiencies
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
California cites F557 more often than its own record predicts
2.04 times the share F557 takes of citations nationally.
Of every deficiency written in California in 2025, this is the portion that was F557.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F557 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, and record review, the facility failed to ensure lunch trays were served in a timely manner for one of six sampled residents (Resident 107). This deficient practice had the potential to negatively affect Resident 107s' psychosocial wellbeing.Findings: During a review of Resident 107's admission Record, the admission Record indicated Resident 107 was admitted to the facility on [DATE]. Resident 107's diagnoses included dysphagia (difficulty swallowing), diabetes mellitus (DM- a disorder characterized by difficulty in blood sugar control and poor wound healing), and congestive heart failure (CHF- a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling). …
Based on interview, medical record review, and facility P&P review, the facility failed to ensure the discharge process was followed for one of five sampled residents (Resident 1). * The discharge section of the Resident's Clothing and Possessions form for Resident 1 was not completed. This failure had the potential to affect the ability of the resident or resident's responsible party to be informed of their belongings.Findings: Review of the facility's P&P titled Resident Personal Belongings revised 12/19/22, showed it is the policy of this facility to protect the resident's right to possess personal belongings such as clothing and furnishings for their use while in the facility and assure the personal belongings and/or possessions are rightfully returned to the resident, or to the… …
The short window
Recent years
| Year | Share of California citations | vs expected |
|---|---|---|
| 2023 | 0.48% | 1.90× |
| 2024 | 0.50% | 1.87× |
| 2025 | 0.48% | 2.04× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else California surveyors cite →
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