Based on interview and record review, the facility failed to have sufficient and competent nursing staff to provide one of five sampled residents (Resident 1) the necessary nursing care based on the resident's comprehensive plan of care. For Resident 1, who was dependent on staff for care, and was at risk for urinary tract infection (UTI - infection that happens when germs enter the urethra [the tube that conducts urine from the urinary bladder, a sac that holds urine for temporary storage, to the outside of the body) due to the use of an indwelling urinary catheter (a hollow flexible tube inserted in the bladder through the urethra to drain urine), bleeding, and hypoglycemia (condition that occurs when the sugar levels [glucose]in the blood are too low), the facility failed to ensure: 1. …
F725 citations in California
Sufficient nursing staff · Nursing and Physician Services Deficiencies
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
California cites F725 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 F725.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F725 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 ensure it had sufficient nursing staff on duty to provide supervision to 14 of 14 residents who were at high risk for falls and needed increased supervision due to cognitive impairment when:1. Resident 1, who was placed in front of the nurses' station on 3/26/26 for supervision, made repeated attempts to stand up from his wheelchair while staff were busy performing other tasks. Resident 1 had an unwitnessed fall at 5:29 A.M. while in front of the nurses' station.2. Resident 2, who was placed in front of the nurses' station for supervision on 1/15/26, had an unwitnessed fall at 6:30 A.M. while staff were busy performing other tasks.3a. …
Based on interview and record review, the facility failed to provide sufficient number of certified nursing assistants (CNAs) on [DATE] and [DATE] according to the facility's Facility Assessment Tool (FAT - facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies), updated [DATE]. The facility also failed to save CNA staffing assignments from [DATE] and [DATE].This failure had the potential to result in residents receiving inadequate care and supervision which can lead to falls, elopement, and delayed recognition of residents' significant changes in condition. …
The short window
Recent years
| Year | Share of California citations | vs expected |
|---|---|---|
| 2023 | 0.71% | 0.89× |
| 2024 | 0.50% | 0.62× |
| 2025 | 0.44% | 0.56× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else California surveyors cite →
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