Based on observation, interview, and record review the facility failed to provide reasonable accommodations to meet resident needs for one of 27 sampled residents (Resident 387) by failing to assess the resident for call light accommodation needs and provide an appropriate call device that Resident 387 could use independently and without risk for injury or harm. 1. On 11/25/2023 at 6:22 PM Resident 387 was observed to have a silver bell with a black handle tightly tied to resident's left middle finger with a white gauze causing an indentation (area of skin that looks pushed in close to the bone of the finger) and redness, pain, and swelling to the resident's left middle finger. 2. On 11/25/2023 at 7:57 PM, the same bell was observed tied to Resident 387's left index finger. 3. …
F558 citations in California
Accommodation of needs · Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
California cites F558 more often than its own record predicts
1.52 times the share F558 takes of citations nationally.
Of every deficiency written in California in 2025, this is the portion that was F558.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F558 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 the call light (a device used by a resident to signal his/her need for assistance from staff) was within the resident's reach while in bed for one of four sampled residents (Resident 3).This deficient practice had the potential to delay the provision of care services and result in the resident's needs not being met.Findings:During a review of Resident 3's admission Record, the admission Record indicated the facility initially admitted the resident on 9/15/2004 and was readmitted on [DATE] with diagnoses including encephalopathy (any disease, damage, or malfunction that alters how the brain works) unspecified, multiple sclerosis (MS-a chronic, progressive disease involving damage to the nerve cells in the… …
Based on observation, interview, medical record review, and facility P&P review, the facility failed to provide the reasonable accommodations to meet the needs of one of 12 final sampled residents (Resident 62). * The facility failed to ensure the call light for Residents 62 was within the residents' reach. This failure had the potential to negatively impact the residents' well-being.Findings: Review of the facility's P&P titled Call Lights: Accessibility and Timely Response dated 10/2025 showed the facility is adequately equipped with a call light at each residents' bedside, toilet, and bathing facility to allow residents to call for assistance. Staff should facilitate call light placement within reach of resident and secure it as needed. …
The short window
Recent years
| Year | Share of California citations | vs expected |
|---|---|---|
| 2023 | 2.06% | 1.88× |
| 2024 | 2.07% | 1.80× |
| 2025 | 1.68% | 1.52× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else California surveyors cite →
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