F561 in California. Pick another state for the same tag.
Against expectation — 2025
California cites F561 less often than its own record predicts
Versus expected share0.51×
0.51 times the national share — cited less often here than elsewhere.
Share of California citations0.20%
Of every deficiency written in California in 2025, this is the portion that was F561.
California0.20%
National0.38%
Share of all citations that were F561.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F561 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.
G · Actual harm, isolatedNovember 5, 2019
Based on interview and record review, the facility failed to allow one of 4 sampled residents (Resident 3) to make choices about smoking after the resident's daughter requested the facility to take away his smoking supplies. This failure lead to Resident 3 eloping from the facility to buy cigarettes and having a physical altercation with other smoking resident, Resident 4.
Findings:
During a review of the clinical record for Resident 3, the Record of Admission indicated Resident 3 was admitted to the facility on [DATE]. The MDS (Minimum Data Set- an assessment tool) dated 6/12/19, indicated Resident 3's cognition was moderately impaired. He also had behavior of threatening, screaming, or cursing at others four to six days a week. …
D · No harm, potential for more than minimal, isolatedAugust 21, 2026
Based on interview and record review, the facility failed to ensure resident rights when nursing staff did not administer Parkinson's (a progressive brain disorder that damages nerve cells, leading to problems with movement, balance, and coordination) medications within a 30 minute window of the scheduled administration time for one resident (Resident 83) out of a sampled seven residents, as requested by Resident 83's family on 62 occasions. This failure resulted in Resident 83 experiencing symptoms of increased tremors and hallucinations and increased Resident 83's potential to fall.Findings:A review of Resident 83's admission record indicated Resident 83 was admitted to the facility on [DATE] with a diagnosis of Parkinson's Disease.A review of Resident 83's order summary dated 7/24/26,… …
B · No harm, potential for minimal, patternDecember 18, 2025
Based on observation, interview, medical record review, and facility P&P review, the facility failed to facilitate the resident's preferences and choices for shaving for one of 19 final sampled residents (Resident 41). * The facility failed to assist Resident 41 with her hygiene preferences in regard to shaving her facial hair and underarms. This failure posed the risk of the resident not being able to choose their hygiene preferences. Findings: Review of the facility's P&P for Shaving the Resident revised February 2018 showed the purpose of this procedure is to promote cleanliness and to provide skin care. Under the Preparation section, showed to review the resident's care plan to assess any special needs of the resident. …
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