Based on interview and record review, the facility failed to provide alternate call system for nine of 62 residents from 3/9/2024 to 3/12/2024 when the facility's call system was nonfunctional. As a result: 1. Resident 58 continued to suffer burning pain to his left leg at a level 9 out of 10 (9/10 - zero is no pain and 10 is severe pain) because the call light system was not working, and staff were not responding to the Resident 58 calling for help/pain medication. 2. Residents 26, 49, 51, 58, 64, 119, 120, and 219 banged on the tables, yelled, and screamed for staff to get help. Residents 49, 64, 119, and 120 waited for 30 minutes to 1 hour for staff assistance. Residents 119 needed help to go to the rest room. Resident 120 needed to be turned and repositioned. …
F919 citations in California
Call system · Environmental Deficiencies
Make sure that a working call system is available in each resident's bathroom and bathing area.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
California cites F919 more often than its own record predicts
1.73 times the share F919 takes of citations nationally.
Of every deficiency written in California in 2025, this is the portion that was F919.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F919 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 one (1) of two (2) sampled residents (Resident 1) call light (a bedside button or cord that a patient presses to ask nurses and staff for help) was not broken.This deficient practice has potential for delay in meeting Resident 1's need for assistance and can lead to frustration, falls and accidents.Findings:During a review of Resident 1's admission Record, the admission Record indicated the resident was admitted to the facility on [DATE] with the following but not limited to diagnoses of muscle weakness, epilepsy (a chronic neurological disease that causes sudden, repeated and unprovoked seizures), history of falling, and dementia (a progressive state of decline in mental abilities). …
Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the call light system was functioning for one of six sampled residents (Resident 2). * Resident 2's call light was not working when it was pressed. This failure had the potential for delayed provision of assistance to the resident.Findings: Review of the facility's P&P titled Call Lights: Accessibility and Timely Response dated 12/19/22, showed the facility was to assure it was adequately equipped with a call light. The staff will report problems with a call light or the call system to the supervisor and/or maintenance director. On 12/30/25 at 1142 hours, an observation and concurrent interview was conducted with Resident 2. …
The short window
Recent years
| Year | Share of California citations | vs expected |
|---|---|---|
| 2023 | 0.70% | 1.61× |
| 2024 | 0.69% | 1.55× |
| 2025 | 0.77% | 1.73× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else California surveyors cite →
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