Based on observation, interview and record review, the facility failed to: 1. Ensure oral care to maintain good oral hygiene was provided for one of five sampled residents (Resident 1) who was dependent on staff to carry out all activities of daily living (ADLs- everyday tasks necessary for self-sufficiency and independent living). 2. Ensure that two of five sampled residents (Residents 2, and 3) were provided with routine dental visits. As a result of the noncompliance described above, four (4) live maggots (small, wormlike fly larva [a worm-like creature, which emerges from an egg]) were found in Resident 1 ' s mouth on 7/16/2023; Resident 2 and Resident 3 were not seen for routine dental visits for over two (2) years while admitted at the facility placing the residents at increased risk… …
F677 citations in California
ADL care for dependent residents · Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
California cites F677 less often than its own record predicts
0.56 times the national share — cited less often here than elsewhere.
Of every deficiency written in California in 2025, this is the portion that was F677.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F677 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 facility failed to provide care and services for one of three sampled residents (Resident 1) who was high risk for falls, had history of falls, and had a diagnosis of Dementia (decline in memory and thinking, severe enough to interfere with daily life) when Resident 1 was left waiting in the room to be toileted for approximately 30 minutes. This failure resulted in Resident 1 falling, sustaining laceration (cut) to the top of the head requiring three staples (little wire), and compression fracture (a type of broken bone that can cause the spine to collapse) of T (thoracic- middle section of spine) 5 (T5- is the fifth bone of the thoracic spine located in the middle of the back). …
Based on observation, interview, and record review, the facility failed to ensure residents were assisted with activities of daily living (ADL, basic self-care tasks) to maintain personal hygiene for three of 25 sampled residents (Resident 112, Resident 130 and Resident 66) when they did not receive their scheduled showers.These failures increased the risk of skin-related infections and had the potential to diminish the residents' sense of dignity. Findings: 1.Resident 112 was admitted to the facility in mid 2026 with diagnoses that included a left below the knee amputation, a condition where the body does not use insulin properly causing sugar buildup in the blood, and muscle weakness. …
The short window
Recent years
| Year | Share of California citations | vs expected |
|---|---|---|
| 2023 | 1.18% | 0.42× |
| 2024 | 1.29% | 0.53× |
| 2025 | 1.26% | 0.56× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else California surveyors cite →
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