Based on observation, interview, and record review, the facility failed to ensure they had a Registered Nurse (RN) at least eight consecutive hours a day, seven days a week from 5/8/2023 to 6/5/2023 (28 days) to provide residents with required care and services to 41 residents residing at the facility and to one of two sampled resident (Resident 1), who had a pressure ulcers (a localized injury to the skin and underlying tissue resulting from prolonged pressure) to the left heel infected with Methicillin-resistant Staphylococcus aureus [(MRSA)-a type of bacteria that is resistant to most antibiotics {medication used to treat infections caused by bacteria}] and was not receiving ordered intravenous [(IV) administered into the veins] antibiotics (medication to treat infection), Vancomycin… …
F727 citations in California
Registered nurse coverage · Nursing and Physician Services Deficiencies
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
California cites F727 less often than its own record predicts
0.65 times the national share — cited less often here than elsewhere.
Of every deficiency written in California in 2025, this is the portion that was F727.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F727 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 the services of a full-time Director of Nursing (DON) to lead, guide, and direct nursing care for a census of 104.This failure decreased the facility's potential to provide accurate and safe nursing care and lead to confusion among nursing staff regarding leadership for resident needs.Findings:A review of the facility provided, STATION 2 DAILY ASSIGNMENT SHEET, dated 8/17/26, indicated a line for the DON's name and signature. Review of the assignment sheet for the DON name was blank. …
Based on interview and record review, this requirement was not met when the facility failed to obtain the services of a registered nurse for eight consecutive hours, seven days a week. This had the potential to adversely affect residents' care, which could lead to potential negative clinical outcomes. Findings: A review of the facility's Registered Nurse (RN) staffing/schedule documentation from the period of 11/1/24 to 11/30/24 indicated that the RN working as Director of Nursing (DON) was scheduled to work weekdays (Monday through Friday) leaving six weekend days (11/2, 11/3, 11/9, 11/10, 11/23, and 11/30/24) uncovered during this four-week time period. There are two days (11/28, and11/29/24) when the DON had time off. …
The short window
Recent years
| Year | Share of California citations | vs expected |
|---|---|---|
| 2023 | 0.40% | 0.59× |
| 2024 | 0.31% | 0.59× |
| 2025 | 0.28% | 0.65× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else California surveyors cite →
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