F655 in California. Pick another state for the same tag.
Against expectation — 2025
California cites F655 less often than its own record predicts
Versus expected share0.76×
0.76 times the national share — cited less often here than elsewhere.
Share of California citations0.50%
Of every deficiency written in California in 2025, this is the portion that was F655.
California0.50%
National0.66%
Share of all citations that were F655.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F655 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.
K · Immediate jeopardy, patternJanuary 9, 2020
Based on interview and record review, the facility failed to develop and implement a baseline care plan at admission that contained specific interventions directing staff to implement needed care and supervision for one of four sampled residents, (Residents 1 and 2).
Resident 1, who required supervision while smoking, smoked marijuana in his room on 1/1/2020 and kept two cigarettes given by staff at his bedside. The facility did not implement the care plan interventions to supervise the resident while smoking and to offer provide safe storage for smoking devices.
Resident 1 had a history of [REDACTED]. Resident 2, who had a history of [REDACTED]. …
Based on observation, interview, and record review, the facility failed to develop a baseline care plan for falls within 48 hours of admission for one of three sampled residents (Resident 1) with a history of falls that included the necessary information for staff to ensure the safety and well-being of Resident 1. This failure resulted in Resident 1 falling, breaking her right hip and transfer to a local hospital for surgical repair.
Findings:
During a review of Resident 1's Admission Record (AR), the AR indicated, the facility admitted Resident 1 on 10/23/22. …
D · No harm, potential for more than minimal, isolatedAugust 21, 2026
Based on interview and record review, the facility failed to ensure a written summary of the baseline care plan (the minimum healthcare information necessary to properly care for each resident immediately upon their admission) was provided to the resident's representative for one of two residents (Resident 116) reviewed for baseline care planning. This failure had the potential for the resident and representative to not be informed of the initial plan of care, goals and services for the resident.Findings: Resident 116 was admitted to the facility on [DATE] with diagnoses including Parkinson's Disease (brain disorder that causes uncontrollable movements and difficulty with balance and coordination) and pneumonia (severe lung infection that causes air sacs inside the lungs to fill up with… …
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