Based on observation, interview, and record review, the facility failed to provide a safe, functional, and sanitary environment for 57 out of 59 residents who received food from the facility's kitchen, when:1. a grease trap (a plumbing device, type of drain, intended to capture fats, oils and grease from wastewater), located in the dishwashing area under the two-compartment sink, was not maintained in good repair and caused wastewater (includes substances such as food scraps, oils, soaps and chemicals) to back-up on to the kitchen floor. This occurred while a County Department of Health Services (CDHS) Inspector was present on 3/18/25.2. …
F921 citations in California
Safe, clean, comfortable environment · Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
California cites F921 less often than its own record predicts
0.93 times the national share — cited less often here than elsewhere.
Of every deficiency written in California in 2025, this is the portion that was F921.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What California surveyors wrote
F921 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 and record review, the facility failed to ensure the hand sink in a resident's bathroom was inspected during daily rounds by the maintenance staff and/or the facility's administrative staff, to ensure it was mounted securely to the bathroom wall and did not detach and fall off the wall causing a resident to fall and sustain injuries for one of three sampled residents (Resident 1). This deficient practice resulted in the hand sink in Resident 1's bathroom detaching from the wall and falling to the floor when Resident 1 placed her hands on it while washing her face. Resident 1 fell to the floor and sustained a left hip fracture, a bump with discoloration to her left eye and a bump with discoloration to the left side of the back of her head. …
Based on observation, interview, and record review, the facility failed to maintain and provide a safe and comfortable environment including maintain temperature within 71-81-degree Fahrenheit when the west wing air-conditioning unit (AC Unit #A) became nonfunctional on 8/26/2026 at 5 AM. This deficient practice not only exposed residents, visitors and staff to excessive room temperatures but also had the potential to cause residents to experience heat-related illnesses, such as heat cramps (painful muscle cramps and spasms), heat exhaustion (more severe than heat cramps and results from a loss of water and salt in the body), and heat stroke (the most severe form of heat illness, occurs when the body's heat-regulating system is overwhelmed by excessive heat. …
The short window
Recent years
| Year | Share of California citations | vs expected |
|---|---|---|
| 2023 | 0.75% | 0.87× |
| 2024 | 0.74% | 0.93× |
| 2025 | 0.78% | 0.93× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else California surveyors cite →
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