F659 in California. Pick another state for the same tag.
Against expectation — 2025
California cites F659 less often than its own record predicts
Versus expected share0.33×
0.33 times the national share — cited less often here than elsewhere.
Share of California citations0.01%
Of every deficiency written in California in 2025, this is the portion that was F659.
California0.01%
National0.04%
Share of all citations that were F659.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F659 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, isolatedFebruary 8, 2022
Based on interview and record review the facility did not ensure Staff were adequately trained in the use of the transport van liftgate resulting in two resident falls.
The falls resulted in resident injuries which caused pain and suffering which could lead to additional adverse clinical outcomes.
Findings:
On 10/29/2021 and 11/29/2021, Facility staff were transporting residents to appointments using the facility transport van with liftgate. On both occasions facility staff erred in the use of the liftgate resulting in injuries to one resident on each occasion. …
E · No harm, potential for more than minimal, patternJanuary 2, 2026
Based on observation, interview, and record review, the facility failed to ensure that direct care staff were qualified to respond and perform cardiopulmonary resuscitation (CPR) for one out of 66 identified full code (a resident who wants all possible life-saving measures used if their heart stops or they stop breathing, including CPR residents) (Resident 1). After further investigation, it was determined the facility failed to ensure that: 1.On [DATE], CNA 1, Registered Nurse (RN) 1, LVN 1, LVN 2, and LVN 5 did not call a code blue immediately when Resident 1 was found unresponsive on [DATE] between 3:05 PM to 3:10 PM. 2. On [DATE], LVN 1 and CNA 2 did not place Resident 1 on a firm, flat surface while performing CPR. …
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction