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Top 10 Most Common RCFE Citations

Know what CCLD inspectors find most often. Each entry includes what they look for and exactly how to stay compliant.

1

Personnel Requirements — General

§ 87411 — View full regulation →

Staffing violations are the #1 cited deficiency statewide. This covers inadequate staffing ratios, unqualified staff, missing certifications, and insufficient supervision.

What Inspectors Look For
  • Current CPR and First Aid certifications for all direct-care staff
  • Adequate staff-to-resident ratio for the facility's capacity and resident needs
  • Completion of required orientation training for new employees
  • Staff competency in handling emergencies
How to Stay Compliant
  • Track all staff certification expiration dates and renew 30+ days before expiry
  • Document your staffing plan in your Plan of Operation with specific ratios
  • Complete new hire orientation training within first 2 weeks of employment
  • Maintain a staffing schedule that accounts for absences and resident acuity levels
Penalty: Type A or B depending on severity. Type A if staffing gap creates immediate risk.
2

Failure to report unusual incidents to CCLD within required timeframes is among the most common citations. Many operators don't realize all the events that require reporting.

What Inspectors Look For
  • Timely reporting of deaths, serious injuries, and abuse/neglect allegations
  • Documentation of all unusual incidents in facility records
  • Reports filed within 24 hours for emergencies, 7 days for non-emergencies
  • Evidence that staff understand what constitutes a reportable incident
How to Stay Compliant
  • Post the complete list of reportable incidents where staff can reference it
  • Train all staff on what events require CCLD notification and the timeline
  • Use a standardized incident report form and maintain copies for at least 5 years
  • When in doubt, report it. Over-reporting is never penalized; under-reporting is.
Penalty: Type A if failure to report concealed abuse or immediate danger. Type B for late reporting.
3

Incidental Medical and Dental Care Services

§ 87465 — View full regulation →

Medication management violations including improper storage, incomplete MARs, missing physician orders, and staff administering medications without proper authorization.

What Inspectors Look For
  • Medications stored in locked cabinets with proper temperature control
  • Complete and accurate Medication Administration Records (MARs)
  • Current physician orders for all medications including PRN parameters
  • Controlled substances double-counted and logged at every shift change
How to Stay Compliant
  • Audit MARs weekly for completeness — every dose given or refused must be documented
  • Implement shift-change controlled substance counts with two staff signatures
  • Review all PRN orders to ensure they include dosage, frequency, and conditions for use
  • Dispose of expired or discontinued medications promptly with proper documentation
Penalty: Type A for medication errors causing harm. Type B for documentation gaps.
4

Incomplete or non-compliant admission agreements are frequently cited. The agreement must contain all required elements per HSC 1569.880 and be signed before or at admission.

What Inspectors Look For
  • All required elements present: basic rate, services included, refund policy
  • Resident and/or representative signature on or before admission date
  • No prohibited provisions (waiver of rights, mandatory arbitration without consent)
  • Copy provided to resident and/or responsible party
How to Stay Compliant
  • Use a standardized admission agreement template reviewed by legal counsel
  • Maintain a checklist of all required elements to verify completeness before signing
  • Provide the agreement in the resident's primary language when possible
  • Review and update agreements annually to reflect current regulations
Penalty: Typically Type B. Type A if agreement contains prohibited provisions that harm residents.
5

Incomplete employee files are a common finding. Required documents include health screening, TB clearance, criminal background clearance, and training documentation.

What Inspectors Look For
  • Health screening results for all employees
  • Current TB test results (initial + periodic updates)
  • Criminal record clearance or exemption documentation
  • Signed acknowledgment of personal rights and reporting requirements
How to Stay Compliant
  • Create a personnel file checklist and audit all files quarterly
  • Track TB test renewal dates (every 4 years or per county requirements)
  • Don't let new staff work unsupervised until background clearance is received
  • Keep training certificates and completion records in each employee's file
Penalty: Type B in most cases. Type A if an employee without clearance had resident contact.
6

Maintenance and Operation

§ 87303 — View full regulation →

Physical plant deficiencies: facility maintenance issues including fire safety equipment, cleanliness, adequate lighting, functioning plumbing, and safe outdoor areas.

What Inspectors Look For
  • Fire extinguishers inspected and tagged within the last year
  • Working smoke detectors in all required locations
  • Facility clean, free of hazards, and in good repair
  • Hot water temperature between 105°F-120°F at resident-accessible fixtures
How to Stay Compliant
  • Create a monthly facility inspection checklist covering all physical plant requirements
  • Schedule annual fire extinguisher service and document it
  • Test smoke detectors monthly and replace batteries at least annually
  • Check water temperature quarterly and document readings
Penalty: Type A for immediate safety hazards. Type B for maintenance deficiencies.
7

Personal Rights of Residents

§ 87468 — View full regulation →

Violations of resident rights including privacy, dignity, access to visitors, personal property, and the right to file complaints without retaliation.

What Inspectors Look For
  • Personal Rights document posted in a common area and given to each resident
  • Evidence that residents can receive visitors at reasonable hours
  • No evidence of retaliation against residents who filed complaints
  • Residents have access to their personal possessions and private space
How to Stay Compliant
  • Post the Personal Rights form (LIC 613A) in a visible common area
  • Include Personal Rights acknowledgment in the admission process
  • Train staff on resident rights during orientation and annually
  • Document all resident grievances and their resolution
Penalty: Type A if rights violation causes harm or involves retaliation. Type B otherwise.
8

Missing or incomplete pre-admission appraisals. Each resident must be evaluated before or within 30 days of admission to ensure the facility can meet their needs.

What Inspectors Look For
  • Completed appraisal for every current resident
  • Appraisal addresses functional capabilities, health conditions, and behavioral needs
  • Assessment that the facility can meet the resident's identified needs
  • Physician report (LIC 602A) completed within the required timeframe
How to Stay Compliant
  • Use the standardized pre-admission appraisal form and complete all sections
  • Ensure the physician report is no older than 1 year at admission
  • Document your assessment that the facility can meet the resident's specific needs
  • If needs exceed capability, document the decision not to admit or arrange additional services
Penalty: Type B in most cases. Type A if a resident with unmet needs was harmed.
9

Failure to conduct annual reappraisals of residents or reappraisals when a resident's condition significantly changes.

What Inspectors Look For
  • Annual reappraisal documented for every resident within the past 12 months
  • Reappraisal conducted when resident's condition significantly changed
  • Updated care plan reflecting reappraisal findings
  • Current physician report supporting the reappraisal
How to Stay Compliant
  • Track each resident's reappraisal due date and schedule 30 days in advance
  • Train staff to recognize and report significant changes in resident condition
  • Update the resident's care plan within 7 days of any reappraisal
  • Coordinate with physicians to obtain updated medical assessments as needed
Penalty: Type B. Type A if failure to reappraise led to unmet care needs causing harm.
10

General Food Service Requirements

§ 87555 — View full regulation →

Food service violations including inadequate meal quality, failure to accommodate dietary needs, improper food storage, and insufficient meal spacing.

What Inspectors Look For
  • Three meals per day plus snacks, with no more than 14 hours between dinner and breakfast
  • Dietary accommodations for medical, religious, and cultural needs
  • Proper food storage temperatures and labeling
  • Current food handler certification for staff who prepare meals
How to Stay Compliant
  • Maintain a weekly menu that shows all three meals and snack options
  • Document each resident's dietary needs and how they're accommodated
  • Check and log refrigerator temperatures daily (below 41°F)
  • Ensure at least one staff member on each shift has a food handler card
Penalty: Type A for food safety hazards. Type B for documentation and menu deficiencies.

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