California Nursing Home Inspections & Deficiencies
How California nursing home inspections work, what Statements of Deficiencies and F-tags mean, how scope and severity are graded, and what families should look for beyond the deficiency count.
Who inspects nursing homes in California?
The California Department of Health's Center for Health Facilities Regulation oversees nursing homes for compliance with state laws, state regulations and applicable federal requirements. California Department of Public Health (CDPH) states that it conducts unannounced annual on-site inspections and unannounced follow-up inspections when facilities have been cited for noncompliance or when consumer complaints warrant investigation.
For Medicare- and Medicaid-certified nursing homes, California's survey work also feeds into the federal CMS enforcement and Care Compare systems. CMS publishes inspection dates and health deficiencies for certified nursing homes and uses inspection results as the foundation of the health-inspection component of the Five-Star Quality Rating System.
Types of nursing home inspections families may see
A nursing home's inspection history can include several kinds of survey activity:
- Standard health inspections: comprehensive regulatory surveys conducted on a recurring basis.
- Complaint investigations: inspections or investigations triggered by allegations involving resident care, rights, safety or regulatory compliance.
- Facility-reported incident investigations: reviews connected with certain incidents reported by the nursing home.
- Focused infection-control inspections: surveys addressing infection-prevention and control requirements.
- Follow-up or revisit inspections: surveys used to determine whether previously cited problems were corrected.
- Fire-safety / Life Safety Code inspections: separate inspections dealing with physical plant and fire-safety requirements.
CMS's current nursing home datasets distinguish standard, complaint and infection-control deficiencies and publish inspection dates from the most recent three years.
What is a Statement of Deficiencies?
When inspectors identify noncompliance, the findings are documented in a Statement of Deficiencies, often called an SOD. California Department of Public Health (CDPH) specifically identifies the Statement of Deficiencies as the report used to document problems found during nursing home inspections.
The report generally identifies:
- The regulatory requirement involved.
- The deficiency or citation tag.
- The facts inspectors relied on.
- The residents, records, interviews or observations reviewed.
- The scope and severity of the deficiency.
- Whether the problem was found during a standard, complaint or other inspection.
The narrative portion can be much more useful than the short citation description because it explains what inspectors actually observed or learned.
What are nursing home F-tags?
Federal nursing home requirements are organized into citation codes commonly called F-tags. Each tag identifies a specific federal requirement. CMS maintains a citation-code lookup table that provides the tag number, deficiency description and category.
Examples of areas covered by F-tags include:
- Resident rights and freedom from abuse.
- Care planning and resident assessment.
- Accident prevention and supervision.
- Pressure injuries and skin care.
- Medication and pharmacy services.
- Nursing and physician services.
- Food, nutrition and hydration.
- Infection prevention and control.
- Quality assurance and facility administration.
The tag tells you which rule was cited. It does not, by itself, tell you how serious the particular incident was. For that, look at scope and severity.
How scope and severity are graded
CMS evaluates deficiencies using two dimensions: severity and scope.
Severity: how serious was the impact or risk?
CMS describes four general harm levels:
- No actual harm with potential for minimal harm.
- No actual harm but potential for more than minimal harm.
- Actual harm that is not immediate jeopardy.
- Immediate jeopardy to resident health or safety.
CMS defines immediate jeopardy as noncompliance that has caused, or is likely to cause, serious injury, harm, impairment or death.
Scope: how many residents were affected?
Scope is classified as:
- Isolated — limited to one or a small number of residents or situations.
- Pattern — more than isolated but not affecting the entire facility.
- Widespread — systemic or affecting residents throughout the facility.
These two dimensions combine into the familiar CMS scope/severity letter codes. CMS nursing home deficiency data currently publish codes from B through L. Higher-level codes generally represent more serious or more widespread noncompliance.
What is a Plan of Correction?
After deficiencies are cited, the facility is generally required to explain how it will correct the problems and prevent recurrence. California makes facility correction plans available along with nursing home inspection information.
A useful Plan of Correction should address more than the resident named in the inspection. Families should look for whether the facility:
- Corrected the immediate problem.
- Identified other residents who could be affected.
- Changed policies, staffing, training or supervision where necessary.
- Established monitoring to determine whether the correction is working.
- Set a completion date and assigned responsibility.
CMS can conduct revisits or other follow-up activity to determine whether a facility returned to substantial compliance. CMS enforcement remedies can become more serious when significant deficiencies persist.
Why repeat deficiencies matter
A single citation may represent an isolated failure that was promptly corrected. Repeated citations involving the same subject can suggest a more persistent systems problem.
When reviewing several years of inspections, look for recurring themes such as:
- Repeated accident-prevention or supervision deficiencies.
- Recurring infection-control problems.
- Repeated pressure-injury or wound-care findings.
- Ongoing medication-administration problems.
- Repeated resident-rights or abuse-related citations.
- Recurring failures to follow care plans.
Complaint inspections can reveal problems between annual surveys
A nursing home may receive a complaint investigation even when its most recent standard survey looked relatively good. CMS's public deficiency data identify whether a citation came from a complaint inspection, and California states that it conducts unannounced follow-up inspections based on consumer complaints when appropriate.
CMS's health-inspection methodology currently incorporates substantiated complaint findings over a multi-year period. That is one reason families should not look only at the latest annual survey date.
If you are concerned about care in a current facility, see our California nursing home complaint guide.
How should a family read an inspection report?
- Start with the survey date. Determine whether you are reading the newest standard survey, a complaint investigation or a revisit.
- Identify the tag and category. Understand the requirement that was cited.
- Read the narrative. Find out what inspectors actually observed, reviewed or were told.
- Check scope and severity. Was the issue isolated, patterned or widespread? Was there actual harm or immediate jeopardy?
- Look for complaint involvement. A complaint citation may reveal a problem that occurred between annual surveys.
- Check correction status. CMS data identify whether deficiencies were corrected and the correction date where available.
- Compare with earlier surveys. Repeating themes are often more informative than the raw citation count.
- Ask the facility what changed. Management should be able to explain the problem and what was done to prevent recurrence.
Questions to ask a facility about a deficiency
- What exactly did inspectors find?
- Was any resident harmed?
- Was the problem isolated or systemic?
- What immediate correction was made?
- What policy, staffing or training changes followed?
- How is the facility monitoring for recurrence?
- Was a revisit completed?
- Has the facility been cited for a similar problem before?
How inspection results affect CMS star ratings
The health-inspection domain is the starting point for CMS's overall Five-Star Quality Rating. CMS currently bases the health-inspection calculation on the two most recent standard health inspections plus certain complaint and infection-control findings from the applicable three-year period, with more recent findings generally carrying greater weight.
Health-inspection stars are also assigned relative to other facilities in the same state. Our CMS nursing home star ratings guide explains how California facilities are compared.
Where can California families find inspection reports?
California Department of Public Health (CDPH) states that nursing home inspection reports, facility correction plans and licensing information are available for each nursing home. California's facility-license search also posts inspection and complaint-investigation reports in the facility's provider details.
You can also use:
- Our California nursing home directory to identify facilities.
- Our nursing home comparison tool to compare facilities.
- Medicare Care Compare for federal inspection and rating information.
- CMS Provider Data for downloadable health-deficiency and inspection datasets.
If you are choosing a facility, inspection history should be combined with staffing, ratings and an in-person visit. See our How to Choose a Nursing Home in California guide and our California staffing guide.
Official sources and further reading
- California Department of Health — Nursing Home Information for Residents and Caregivers
- California Department of Health — Facility Inspection and Complaint Reports
- California Department of Health — Nursing Home Quality
- California Department of Health — Nursing Home Visit Talking Points
- CMS — Nursing Home Enforcement
- CMS Provider Data — Health Deficiencies
- CMS Provider Data — Citation Code Look-up