Based on observation, interview and record review, the facility failed to maintain acceptable room temperature ranging from 71 to 81 degrees Fahrenheit (F, A unit of temperature measurement) for 17 of 17 residents (Resident 1 to Resident 17) in the Sub-Acute (a medical facility that provides medical care to chronically ill patients who are medically stable) Unit. This deficient practice placed the 17 residents on the Sub-Acute Unit at risk for dehydration (excessive loss of body water) and/or heat stroke (internal body heat with complications involving the central nervous system that occur after exposure to high temperatures). …
F584 citations in California
Safe, clean, homelike environment · Resident Rights Deficiencies
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
California cites F584 less often than its own record predicts
0.78 times the national share — cited less often here than elsewhere.
Of every deficiency written in California in 2025, this is the portion that was F584.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F584 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 maintain a sanitary, comfortable and homelike environment when: 1. The linoleum flooring in Room 403's bathroom were torn, cracked, and peeling off around the base of the toilet exposing the subfloor and had a pungent musty odor. 2. 20 of 41 resident bathroom flooring (Rooms 101, 105, 111, 201, 206, 208, 301, 302, 305, 306, 308, 309, 310, 311, 401, 403, 406, 407, 408 and 410) were damaged and discolored. 3. There was an evidence of stagnant, dark colored liquid in the shower room (number) 3 with pungent musty odor on the missing tiles. The pungent musty odor had caused Resident 91 to feel sick and want to throw up. …
Based on observation, interview, and record review, the facility failed to maintain a comfortable and safe environment for two out of three sampled residents (Residents 1 and 2) when the ambient (surrounding air) temperature was measured at 86 degrees Fahrenheit ( F- unit of measure). This failure had the potential to result in discomfort and increased risk of heat-related illnesses for Resident 1 and Resident 2.Findings:During a review of Resident 1's admission Record, the admission Record indicated, Resident 1 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis including diabetes mellitus ( DM-a disorder characterized by difficulty in blood sugar control and poor wound healing), anemia (a condition where the body does not have enough health red blood cells)… …
The short window
Recent years
| Year | Share of California citations | vs expected |
|---|---|---|
| 2023 | 1.65% | 0.74× |
| 2024 | 1.78% | 0.84× |
| 2025 | 1.64% | 0.78× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else California surveyors cite →
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