Based on observation, interview, and record review, the facility failed to ensure identification and reporting of a suspicion of crime to appropriate agency for three of 27 sampled residents (Resident 211, Resident 56, and Resident 2) in a universe of 92 residents when: 1. The facility failed to report verbal abuse of the physician to Resident 211. 2. Resident 56 felt staff were retaliating against him, after he had filed a complaint with the California Department of Public Health (CDPH). 3. The family member struck Resident 2 multiple times as witnessed by facility staff. These failures resulted in physical and mental abuse of the residents. Findings: 1. During a recertification survey of the facility, on (MONTH) 30, (YEAR) at 8:00 AM, an observation of Resident 211 was made. …
F608 citations in California
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
No F608 citations were recorded in California for 2025. That means none appear in the CMS file for that year — not that the requirement does not apply.
In the surveyor’s words
What California surveyors wrote
F608 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 implement their written policies and procedures for abuse prevention and investigation for one of four sampled residents (1), when the reporting was delayed more than 24 hours and the suspected perpetrators were not removed from the schedule after receiving a complaint from Resident 1 on 10/01/22 for rough handling by certified nursing assistant A and B (CNA A and B). These failures potentially posed a risk for Resident 1 not to have a safe environment and ineffectively implemented Abuse Procedures in the facility. Findings: During a review of the entity reported incident (ERI), dated 10/03/22, indicated Resident 1 reported the allegation of abuse on 10/01/22 for being roughly handled and hit by the CNAs. …
What else California surveyors cite →
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