Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.
F837 in California. Pick another state for the same tag.
Against expectation — 2025
California cites F837 more often than its own record predicts
Versus expected share1.51×
1.51 times the share F837 takes of citations nationally.
Share of California citations0.08%
Of every deficiency written in California in 2025, this is the portion that was F837.
California0.08%
National0.05%
Share of all citations that were F837.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F837 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.
G · Actual harm, isolatedMay 15, 2024
Based on observation, interview, and record review, the facility failed to implement their policy and procedure (P&P) titled, Pressure Ulcer (or injury is localized damage to the skin and underlying soft tissue usually over a bony prominence) Prevention for one of three sampled residents (Resident 1) when:
1. Resident 1 was not assessed for risk for developing pressure injuries upon admission.
2. Physician was not notified to obtain treatment for Resident 1's left heel redness.
3. A care plan (resident centered health document designed to facilitate communication among members of the care team with the resident) was not developed to address Resident 1's left heel redness.
4. …
D · No harm, potential for more than minimal, isolatedAugust 13, 2026
Based on observation, interview, and record review, the facility failed to conduct background checks (a formal review of a job candidate's record [such as criminal history/criminal convictions, sex offender, education, and past employment] that is heavily regulated by state worker protection laws) prior to employment and direct access to residents for two out of 108 staff (Certified Nurse's Aide [CNA] 2 and Registered Nurse [RN] 1) as indicated in the facility's policy and procedures (P&P) titled Background Screening Investigations last revised on 3/2026. This deficient practice of failing to conduct background checks placed increased the risk for psychosocial, physical, emotional, and financial harm to the residents in the facility. …
B · No harm, potential for minimal, patternJuly 22, 2024
Based on observations, interviews, and record review the facility's governing body (individuals such as facility owner(s), Chief Executive Officer(s), or other individuals who are legally responsible to establish and implement policies regarding the management and operations of the facility) failed provide effective leadership oversight of processes and policies and procedures by failing to ensure the administrator was onsite and available via phone on a full-time basis.
This deficienct practice had the potential to not meet/address direct the day-to day functions of the facility in accordance with current federal, state, and local standard, guidelines, and regulations that govern nursing facilities to assure that the highest degree of quality care is provided to the residents. …
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