Based on interview and record review, the facility failed to ensure the admitting physician for one of seven sampled residents (Resident 1) reviewed the transcribed order for [MEDICATION(S)] ([CONDITION(S)] [sudden, uncontrolled electrical disturbance in the brain] medication) to ensure accuracy prior to signing for validation. This deficient practice resulted in Resident 1 receiving nine (9) doses of [MEDICATION(S)] that was seven (7) times less than the intended prescribed dose between the dates of 5/15/2021 to 5/19/2021. Subsequently, Resident 1 was transferred to a General Acute Care Hospital (GACH) for further evaluation due to uncontrolled body movement, potentially compromising the health and safety, and placing Resident 1 at risk for death. …
F711 citations in California
Nursing and Physician Services Deficiencies
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
California cites F711 less often than its own record predicts
0.98 times the national share — cited less often here than elsewhere.
Of every deficiency written in California in 2025, this is the portion that was F711.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F711 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 and record review, the facility failed to ensure that the primary care physician (Primary Medical Doctor 1 [PMD 1]) for one of four sampled residents (Resident 1), who had a history of hypothyroidism (a condition where the thyroid gland doesn't release enough thyroid hormone [plays a role in regulating weight, energy levels, growth and metabolism] into the bloodstream), reviewed Resident 1's General Acute Care Hospital 1 (GACH 1) progress notes, including medications essential to Resident 1's medical treatment. …
Based on observation, interview, and record review, the facility failed to ensure the attending physician reviewed the resident's total program of care and failed to write, sign, and date progress notes as required for 3 out of 12 sampled residents (Residents 1, 2, and 3). This failure had the potential to result in the residents not receiving timely evaluation of their medical regimen and necessary adjustments to treatments, placing the residents at risk for unmet medical needs and a decline in physical, mental, or psychosocial well being.During a review of Resident 1's Electronic Medical Record (EHR), the Resident 1's EHR indicated Resident 1 was admitted on [DATE] and has a Brief Interview for Mental Status (BIMS) Summary Score of 14 as of 06/01/2026. …
The short window
Recent years
| Year | Share of California citations | vs expected |
|---|---|---|
| 2023 | 0.14% | 1.30× |
| 2024 | 0.17% | 1.36× |
| 2025 | 0.12% | 0.98× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else California surveyors cite →
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