Based on interview and record review the facility failed to ensure one of three sampled residents (Resident A) received a post-discharge plan of care, which contained the necessary information for the continuation of care after discharge. This failure resulted in Resident A ' s family calling the facility for advice and sending Resident A to the emergency room, within 24 hours of his discharge from the facility. Findings: On March 28, 2025, at 9:50 a.m., an unannounced visit to the facility was conducted to investigate quality of care concern and discharge rights. On March 28, 2025, at 1 p.m., an interview was conducted with the Social Service Assistant (SSA). …
F661 citations in California
Resident Assessment and Care Planning Deficiencies
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
California cites F661 less often than its own record predicts
0.70 times the national share — cited less often here than elsewhere.
Of every deficiency written in California in 2025, this is the portion that was F661.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F661 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 interview, closed medical record review, and facility P&P review, the facility failed to ensure the reconciliation of medications was thoroughly performed and documented in the medical record upon discharge for one of two closed records reviewed (Resident 99). This failure posed the risk for not identifying discrepancies or differences in Resident 99's pre-discharge and post-discharge medication orders, which had the potential to negatively affect Resident 99's well-being. …
The short window
Recent years
| Year | Share of California citations | vs expected |
|---|---|---|
| 2023 | 0.13% | 0.49× |
| 2024 | 0.09% | 0.40× |
| 2025 | 0.04% | 0.70× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else California surveyors cite →
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