Based on interview and record review, the facility failed to provide treatment and services for one of two sampled Residents (Resident 1), after being hit on the face and head, in accordance with current professional standard of practice by failing to: 1. Conduct a neurological assessment (to check the mental status, reflexes [automatic action the body does in response to anything that can trigger a physical or behavioral change], and movement to evaluate the brain and nervous system [transmits signals between the brain and the rest of the body]) to include checking of patterns of speech, speech clarity, gag reflex (occurs in the back of the mouth and triggered when the body wants to protect itself from swallowing something), facial drooping (loss of motor control on one side of the face… …
F658 citations in California
Professional standards of care · Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
California cites F658 more often than its own record predicts
1.42 times the share F658 takes of citations nationally.
Of every deficiency written in California in 2025, this is the portion that was F658.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F658 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 nursing staff failed to provide care that met professional standards of nursing for two residents (Resident 3 and Resident 8) of 16 sampled residents when:1. Nurses did not assess, prevent, and identify the development of a pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) on Resident 3's left cheek; and,2. Nurses did not notify the physician when Resident 8 experienced significant and progressive weight loss.These failures resulted in Resident 3 obtaining a facility-acquired Stage 2 pressure injury (a partial-thickness loss of skin, presenting as a shallow open sore or wound) and Resident 8 unhappy and concerned about her weight loss. …
Based on observation, interview, and record review, the facility failed to ensure care and services were provided according to accepted standards of clinical practice for one of 25 sampled residents (Resident 48) for a census of 121, when: The Ace bandage wrap (a stretchable elastic strip used to apply gentle, supportive compression to sprains, strains, and leg swelling) order was without clear treatment indication (It is the clinical justification for using a specific therapy to reach a therapeutic goal); There was no nursing evaluation on the leg swelling; and, There was no nursing evaluation on the continued use of the Ace wrap bandage. …
The short window
Recent years
| Year | Share of California citations | vs expected |
|---|---|---|
| 2023 | 2.40% | 1.50× |
| 2024 | 2.27% | 1.38× |
| 2025 | 2.52% | 1.42× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else California surveyors cite →
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