Based on interview, medical record review, and facility document review, the facility failed to ensure there was a hospice staff calendar with projection of the hospice staff visits for the past and incoming months for one of 16 final sampled residents (Resident 16). * Resident 16's hospice binder failed to show the calendar projections for the hospice nursing staff visits. This failure posed the risk of not providing appropriate, timely and individualized care to the resident.Findings: On 8/17/26 at 0852 hours, an observation was conducted of Resident 16 in the resident's room. Resident 16 was awake, lying on her bed in a low position with bilateral floor paddings and was receiving oxygen via nasal cannula. Medical record review for Resident 16 was initiated on 8/17/26. …
F849 citations in California
Administration Deficiencies
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
California cites F849 more often than its own record predicts
1.07 times the share F849 takes of citations nationally.
Of every deficiency written in California in 2025, this is the portion that was F849.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F849 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, medical record review, and facility document review, the facility failed to ensure care was coordinated with the hospice provider for one of 12 sampled residents (Resident 8) reviewed for hospice. * The resident's hospice binder was not completed to show when the hospice provider visited Resident 8. This failure had the potential for the resident not receive the ordered hospice care services. Findings: Medical record review for Resident 8 was initiated on 10/2/25. Resident 8 was admitted to the facility on [DATE]. Review of Resident 8's Order Summary Report showed physician's order dated 3/13/25, for hospice services to a hospice provider for diagnosis of terminal Cerebrovascular (CVA) Disease (a group of disorders that affect the blood vessels in the brain). …
The short window
Recent years
| Year | Share of California citations | vs expected |
|---|---|---|
| 2023 | 0.34% | 1.09× |
| 2024 | 0.31% | 1.03× |
| 2025 | 0.29% | 1.07× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else California surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction