Based on interviews and record review, the facility failed to update a care plan for one of three residents (Resident 1) for the use of a Hoyer Lift (a lift used for dependent residents requiring two caregivers to facilitate safe patient transfers) the recommended device by Physical Therapy (PT) and the Interdisciplinary Team (IDT). This failure resulted in a traumatic injury, of a right knee fracture for Resident 1. Findings: During a review of Resident 1's List Patient Notes, dated 3/11/21, the form indicated the last Physical Therapy Assessment was completed on 3/11/21. The form indicated Resident 1 was dependent for all mobility needs and a Hoyer lift was recommended to be used to get Resident 1 out of bed and into Resident's 1 manual wheelchair. …
F636 citations in California
Comprehensive assessments · Resident Assessment and Care Planning Deficiencies
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
California cites F636 more often than its own record predicts
1.01 times the share F636 takes of citations nationally.
Of every deficiency written in California in 2025, this is the portion that was F636.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F636 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 an accurate assessment was conducted and documented for one of one sampled residents (Resident 12) as indicated by the facility's policy and procedures (P&P) titled, Resident Assessments, last reviewed 3/2026, and, Accuracy of the Resident Assessment, last reviewed 3/2026. Resident 12's admission Record and Minimum Data Set (MDS - a resident assessment tool) did not reflect Resident 12's diagnosis of unspecified hearing loss. This failure increased Resident 12's risk of experiencing communication barriers and not receiving the required care and services from the facility. …
Based on interview and medical record review, the facility failed to timely complete the admission MDS assessments for two of 20 final sampled residents (Residents 92 and 143). - Resident 92's admission MDS assessment was late and incomplete.- Resident 143's admission MDS assessment was completed late.These failures had the potential to delay the establishment of a standardized, holistic baseline assessment of the residents' functional capabilities and health needs upon admission, as well as delay required submission of an assessment data to CMS.Findings: 1. Medical record review for Resident 92 was initiated on 5/5/26. Resident 92 was admitted on [DATE]. Review of Resident 92's EHR showed an admission MDS assessment dated [DATE]. …
The short window
Recent years
| Year | Share of California citations | vs expected |
|---|---|---|
| 2023 | 0.39% | 0.99× |
| 2024 | 0.26% | 0.88× |
| 2025 | 0.25% | 1.01× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else California surveyors cite →
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