F657 in California. Pick another state for the same tag.
Against expectation — 2025
California cites F657 less often than its own record predicts
Versus expected share0.73×
0.73 times the national share — cited less often here than elsewhere.
Share of California citations1.37%
Of every deficiency written in California in 2025, this is the portion that was F657.
California1.37%
National1.87%
Share of all citations that were F657.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F657 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, isolatedJune 12, 2025
Based on interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan for one of six sampled residents (Resident 1) when:
1. Resident 1 was admitted to the facility with diagnoses of Type 2 Diabetes Mellitus (Type 2 DM- a disorder in which blood sugar or glucose levels are abnormally high)
and licensed nursing staff did not develop an individualized care plan intervention to monitor Resident 1's blood glucose levels, from 5/4/25 to 5/18/25.
This failure resulted in Resident 1 experiencing significant change in condition. …
D · No harm, potential for more than minimal, isolatedAugust 28, 2026
Based on interview and record review, the facility failed to update the care plans for one out of four sampled residents (Resident 1).This failure had the potential for staff to not provide relevant and up to date care for Resident 1. Findings:During a review of Resident 1's admission Record, the admission record indicated Resident 1 was originally admitted to the facility on [DATE] and readmitted on [DATE]. Resident 1's diagnoses included Type 2 Diabetes Mellitus (a disease that results in too much sugar in the blood) with Diabetic Chronic Kidney Disease (long-term kidney damage), repeated falls, and abnormalities of gait (manner of walking) and mobility.During a review of Resident 1's History & Physical (H&P), dated 7/1/2026, the H&P indicated Resident 1 did not have the capacity to… …
B · No harm, potential for minimal, patternApril 30, 2026
Based on interview, observation, medical record review, and facility P&P review, the facility failed to ensure the comprehensive plan of care was revised to reflect current care needs and interventions for three of 12 final sampled residents (Residents 3, 11, and 23) and one nonsampled resident (Resident 17). * The facility failed to revise Resident 11's care plan to address Resident 11's hospitalization on 3/9/26. * The facility failed to revise Resident 17's care plan for seizure precautions to include padded side rails. * The facility failed to ensure Resident 23's care plan for wound care management was revised to include the use of the low air loss mattress. …
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