Above average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Centinela Skilled Nursing & Wellness Centre West during CMS and state inspections, most recent first.
Unlabeled turkey sandwich meat was found in the delivery refrigerator during a kitchen tour. The DS stated the meat was used for resident snacks and sandwiches and that refrigerated food items were required to have a label and open/use-by date. The facility's Food Storage policy required all food items to be correctly labeled and dated.
A resident with dementia, a hx of falls, and a cognitive communication deficit was observed wearing eyeglasses with the left lens taped into the frame. An ophthalmology consult had recommended an optometry referral for glasses evaluation, but the record did not show that the referral was made, and the resident did not have alternative glasses. Staff stated the taped eyeglasses were not dignified.
A resident with muscle weakness, major depressive disorder, dorsalgia, and type 2 DM with a foot ulcer was found unable to reach the call light because it was wrapped around the bed siderail. The resident stated the device could not be reached, and a CNA, RN, and DON all confirmed that the call light should have been within reach for the resident to request help or notify staff in an emergency.
Inaccurate MDS Medication Coding: A resident with MDD had an MDS that incorrectly indicated routine antipsychotic use, even though physician orders showed no antipsychotic was prescribed and the MDSC confirmed the resident was receiving an antidepressant instead. The MDSC stated the assessment was not accurate, and the facility policy required MDS assessments to accurately reflect resident-specific issues using the RAI Manual.
Failure to Develop Timely Care Plans for Identified Resident Needs: The DON and RN identified that two residents had assessed needs that were not reflected in timely care plans. One resident had fall risk, dysphagia, and broken teeth, with a delayed fall-risk plan and delayed oral/dental plan; the other resident had dementia, a history of falls, vision problems, and ophthalmology findings, but no care plan was in place for the resident-specific interventions noted by staff.
Conflicting smoking supervision care plans were found for two residents. One resident had hemiplegia, hemiparesis, paraplegia, and generalized weakness, with a smoking/safety assessment stating staff would supervise smoking, yet the tobacco care plan said both that supervision was required and not required. Another resident had Type 2 DM, a below-knee amputation, generalized weakness, and lack of coordination, and the care plan for [NAME] use also stated both that supervision was required and not required. The MDSC and DON stated the care plans should be specific and not conflicting.
A resident with type 2 DM, dementia, dysphagia, and hypotension was readmitted after a GACH stay, but the physician orders did not indicate continuation of the prior sliding-scale NovoLog insulin. The MAR showed insulin had been given regularly before transfer and in the hospital, yet the DON stated the insulin and BG monitoring orders should have been clarified with the MD on readmission; an LVN later checked the resident's BG at 141.
Failure to arrange a recommended optometry referral for a resident with dementia, a hx of falls, and cognitive communication deficit. Ophthalmology documented moderate cataracts and blepharochalasis and recommended an optometry eval for glasses, but the Social Services note did not show the referral was made. The SSD confirmed the referral was not completed after reviewing the consult.
Oxygen Administered Above Ordered Rate: A resident with COPD, chronic respiratory failure, emphysema, and pulmonary hypertension was ordered oxygen at 2-3 L/min via NC as needed for SOB to keep O2 saturation above 92%. During observations, the resident was receiving oxygen at 4 L/min, and an LVN confirmed the flow rate exceeded the physician order and stated it should not have been running at that level. The facility policy required oxygen to be administered as ordered by the provider.
Lidocaine Patch Left On Past Ordered Removal Time: A resident with COPD, hypertensive heart disease with heart failure, and chronic pain syndrome had a lidocaine patch still on the left leg during a med pass even though it was ordered to be removed earlier. The LVN removed the prior patch, and the DON stated meds should be given as scheduled and that leaving the patch on longer than ordered would continue delivering medication and could cause adverse side effects, skin irritation, and harm.
An unopened prefilled pen of Lantus was found stored in a medication cart instead of the refrigerator. RN and DON interviews confirmed that unopened insulin should remain refrigerated until use, and the facility policy required medications to be stored according to manufacturer recommendations, including refrigeration when needed.
Failure to Properly Explain Binding Arbitration Agreement: A resident with capacity to make decisions was entered into a binding arbitration agreement during admission, but the document was signed by his daughter instead of him. The resident stated arbitration was not explained and he would not have agreed to it if it had been explained, while the AD said the daughter’s signature was an error and the ADM stated residents must be fully informed before signing.
A resident with sepsis and significant mobility needs developed a severe cough, congestion, and breathing difficulty, but no Covid-19 test was documented after symptoms began despite an order for weekly and as-needed testing. In the soiled linen sorting area, staff used a handwashing sink for hand hygiene, but the hot-water pedal did not dispense water and the sink did not provide warm water, even though signage directed staff to wash with warm running water.
Two residents in the facility were not dressed in their own clothes, compromising their dignity and socialization potential. One resident, with conditions like hemiplegia and aphasia, was observed in a hospital gown all day, with staff only dressing them for dining or visitors. Another resident, with heart failure and aphasia, was similarly observed. The CNA and DON acknowledged the importance of dressing residents in their own clothes, as per facility policy, which was not followed.
A resident with severe cognitive impairment and difficulty swallowing was not offered dentures during meals, as observed on multiple occasions. Staff interviews confirmed the oversight, which contradicted facility policies on resident rights and quality of life.
A resident with hemiplegia and aphasia was unable to use the standard call light device due to physical limitations, as observed during a survey. Staff interviews revealed that a touch pad call light would better accommodate the resident's needs, but it was not provided, contrary to the facility's policy on accommodating resident needs.
A facility failed to provide a resident with the Notice of Medicare Non-Coverage (NOMNC) form 48 hours before the end of skilled nursing services, as required by policy. The Social Service Director admitted the form was given only one day prior, potentially affecting the resident's right to appeal. The resident, with intact cognitive skills and requiring supervision for daily activities, was not properly informed in accordance with the facility's Medicare Denial Process policy.
A resident with multiple health conditions was found to be living in a room with chipped paint on the wall next to their bed, which was not addressed in a timely manner by the facility. The issue was known to the facility's Administrator and Maintenance Director, and it was noted in the maintenance log. The facility's policy emphasizes the importance of a clean and comfortable environment, but this was not upheld for the resident.
A resident in an LTC facility, with diagnoses including chronic kidney disease and dysphagia, refused dental treatment, and the facility failed to develop a care plan addressing this refusal. The resident reported that staff did not discuss the risks and benefits of not having dentures. Both an LVN and the DON acknowledged the necessity of a care plan to set goals and interventions, as per the facility's policy on Comprehensive Person-Centered Care Planning.
A resident with ascites did not have their abdominal girth measured weekly as ordered by the physician, which is a failure to follow professional standards of practice. The resident had chronic kidney disease and psychosis, with moderately impaired cognitive skills. The DON confirmed that the measurements were not recorded, and it was the licensed nurse's responsibility to document them. This oversight could lead to negative effects such as abdominal discomfort and shortness of breath.
A resident with a Stage 3 pressure ulcer was found lying on a low air loss mattress (LALM) set incorrectly at 350 pounds, despite weighing only 100.2 pounds. The Director of Nursing (DON) and Treatment Nurse 1 (TN 1) confirmed that the LALM setting should be based on the resident's current weight to ensure effective wound management. The facility's policy indicated that the LALM should distribute body weight appropriately to prevent skin breakdown, but the responsibility to check the correct setting lay with the licensed nurses.
A resident with end-stage renal disease and heart failure did not have their fluid intake monitored and recorded as per the physician's order of a 1200 ml fluid restriction. Despite the facility's policies requiring strict documentation, the intake was not recorded in the MAR for over a month. A nurse confirmed the oversight, highlighting the risk of fluid overload due to the lack of monitoring.
A resident with dementia was prescribed Seroquel for constant screaming without proper behavioral monitoring or justification. The facility's protocol to monitor behavior for 72 hours before administering antipsychotic medication was not followed, and there was no behavioral screening log. The facility's policy requires antipsychotic drugs to be used only for specific diagnosed conditions, which was not documented in this case.
A resident with multiple health issues, including dysphagia and malnutrition, did not receive necessary dental follow-up after a recommendation for teeth extraction. Despite the resident's request and a previous dental consultation, the Social Services Director failed to arrange the required medical clearance, leading to a deficiency in care.
A resident at an LTC facility, who was cognitively intact and required substantial assistance for ADLs, was at risk for financial abuse after $11,000 went missing. Despite the care plan indicating emotional distress risk, it lacked interventions to secure belongings or prevent further loss. Interviews with staff revealed the care plan was not updated with necessary actions, contrary to the facility's policy on comprehensive care planning.
The facility failed to implement its policies on safeguarding residents' personal property and preventing abuse. A resident with chronic conditions and cognitive impairment reported her wallet containing $647 went missing. Staff interviews confirmed the facility did not secure the resident's money as required, placing her and others at risk of financial abuse and emotional harm.
Unlabeled Turkey Sandwich Meat in Refrigerator
Penalty
Summary
The facility failed to ensure that a clear Tupperware container holding turkey sandwich meat in the delivery refrigerator was labeled and dated. During a concurrent observation and interview on the initial kitchen tour, the Dietary Supervisor observed the container with a green lid and stated that the turkey sandwich meat was used for resident snacks and sandwiches. The Dietary Supervisor also stated that food items in the refrigerator were required to have a label and an open and use-by date, and that failing to label the container could result in residents consuming expired or spoiled food. Review of the facility's Food Storage policy, dated 7/25/2019, showed that all food items were to be correctly labeled and dated.
Resident Wore Taped Eyeglasses
Penalty
Summary
The facility failed to maintain dignity for Resident 49 when the resident was observed wearing eyeglasses with the left lens taped into the frame. Resident 49 was admitted and later readmitted to the facility with diagnoses including dementia, a history of falling, and a cognitive communication deficit. The resident's MDS dated 10/31/2025 indicated adequate vision with eyeglasses, moderate cognitive impairment, and a need for supervision or touch assistance for walking. Resident 49's ophthalmology consult dated 5/27/2025 documented moderate cataracts and blepharochalasis and recommended an optometry referral for evaluation for glasses. The record did not show that an optometry referral was made after that recommendation, and the social services note did not include information about new glasses. On 11/18/2025 and again on 11/19/2025, Resident 49 was observed at the bedside wearing eyeglasses with the left lens taped in place. The resident could not state whether he had been seen by an optometrist. The SSD stated the resident had been eligible for new eyeglasses since November 2024, and RN 2 stated the taped eyeglasses were not dignified and that the resident did not have alternative glasses.
Call Light Not Within Reach
Penalty
Summary
The facility failed to ensure that the call light device was placed within reach for one resident. The resident had diagnoses including muscle weakness, major depressive disorder, unspecified dorsalgia, and type 2 DM with a foot ulcer. The resident’s H&P indicated the resident had the capacity to understand and make decisions, and the MDS indicated the resident comprehended most conversation and required moderate assistance with some ADLs and dependent assistance for toileting, lying to sitting on bed, and personal hygiene. During a concurrent observation and interview, the call light was found wrapped around the bed siderail where the resident could not reach it. The resident looked for the device, found the cord, but could not untangle it from the siderail and was unable to press the call light button. The resident stated the call light could not be reached and that, if unable to reach it, the resident would call out for help, but it was not good if the resident could not tell nurses when something was needed right away or in an emergency. A CNA also observed that the call light was not within reach and stated it should have been placed next to the resident in case of an emergency. The RN and DON stated that call lights should be within reach.
Inaccurate MDS Medication Coding
Penalty
Summary
The facility failed to ensure the MDS was accurately completed for one sampled resident with major depressive disorder. The resident’s admission record showed the resident had been admitted and later readmitted to the facility, and the MDS dated 9/14/2025 indicated the resident had no cognitive impairments, required substantial to maximum assistance for most mobility while out of bed, and routinely received antipsychotic medications. A review of physician medication orders from 9/1/2025 through 11/20/2025 showed the resident was not ordered an antipsychotic. During interviews, the MDS Coordinator stated the resident was not receiving antipsychotics during the timeframe reflected in the MDS and was receiving an antidepressant instead. The MDS Coordinator also stated the MDS incorrectly indicated routine antipsychotic use and that the assessment was not accurate. The facility’s RAI Process policy stated the purpose of the process was to provide resident assessments that accurately depicted resident-specific issues and that the MDS Coordinator was to use the RAI Manual as a reference when completing the assessment.
Failure to Develop Timely Care Plans for Identified Resident Needs
Penalty
Summary
The facility failed to develop timely care plans for two sampled residents. Resident 32 was admitted with generalized muscle weakness, gait and mobility abnormalities, and dysphagia, and the MDS showed moderate cognitive impairment, use of a walker, set-up/clean-up assistance for eating, and broken teeth. A fall risk evaluation dated 10/22/2025 identified Resident 32 as at risk for falls, but the care plan titled "At risk for falls" was not created until 11/18/2025. The DON stated staff were aware of the fall risk on 10/22/2025 and that the fall risk care plan should have been developed that same day. Resident 32 also had a Social Services Assessment dated 10/27/2025 that indicated a dental consult was needed due to missing and broken teeth, and the MDS also noted broken teeth. A care plan titled "Oral/dental health problems related to obvious or likely cavity or broken natural teeth" was not developed until 11/18/2025. For Resident 49, the admission record listed dementia, history of falling, and cognitive communication deficit; the MDS showed moderate cognitive impairment, adequate vision with glasses, and supervision or touch assist for walking. An ophthalmology consult dated 5/27/2025 documented moderate cataracts and blepharochalasis, and RN 2 stated Resident 49 had vision problems requiring resident-specific interventions, but no care plan was in place. The facility policy stated comprehensive person-centered care plans were to be developed within seven days from completion of the comprehensive MDS.
Conflicting Smoking Supervision Care Plans
Penalty
Summary
The facility failed to review, update, and revise the care plans for two residents to address supervision while smoking. Resident 10 was admitted with diagnoses including hemiplegia, hemiparesis, paraplegia, and generalized muscle weakness. The H&P and MDS indicated the resident had the capacity to understand and make decisions and had clear comprehension, but also required maximal assistance with several activities of daily living. The smoking and safety assessment stated the resident had insufficient fine motor skills to securely hold tobacco and that staff would supervise the resident while smoking. The multidisciplinary care conference also stated the resident required staff assistance when going outside to smoke, but the care plan for tobacco use contained conflicting language indicating both that supervision was required and that it was not required. Resident 54 was admitted with diagnoses including Type 2 DM, absence of the right leg below the knee, generalized muscle weakness, and lack of coordination. The H&P and MDS indicated the resident had the capacity to understand and make decisions and had clear comprehension, while also requiring supervision or moderate assistance with several ADLs. The care plan for [NAME] use, initiated on admission and revised later, also contained conflicting language stating the resident both required supervision and did not require supervision. During interview, the MDSC stated the care plan should not have both statements and should have been patient-centered and specific, and the DON stated care plans should be resident-centered, very specific, and not contain conflicting information.
Failure to Clarify and Continue Insulin Orders After Hospital Readmission
Penalty
Summary
Failed to ensure blood glucose monitoring and insulin orders were clarified and continued after a resident was readmitted from the hospital. The resident had diagnoses including type 2 diabetes mellitus, dysphagia, hypotension, and dementia. The H&P stated the resident did not have the capacity to understand and make decisions, and the MDS indicated severely impaired cognitive skills and dependence on staff for ADLs. The October 2025 MAR showed an order for NovoLog Flex Pen Solution per sliding scale, and the resident received insulin on 14 days that month as needed per sliding scale. Blood glucose records showed the resident received insulin on 10/23/2025 before transfer to a GACH, and GACH records showed insulin was given there on 10/25/2025. The resident was readmitted to the facility on 11/1/2025, but the physician orders dated 11/1/2025 did not indicate to continue insulin. During interview, the DON stated the protocol for readmitting diabetic residents was to call the resident's doctor to verify the previous insulin order and carry out any new orders, and stated the resident's blood glucose monitoring and insulin orders should have been clarified with the doctor upon readmission. During observation on 11/20/2025, an LVN checked the resident's blood glucose level and it was 141.
Failure to Arrange Recommended Optometry Referral
Penalty
Summary
The facility failed to ensure an optometry referral was made for Resident 49 after an ophthalmology consult recommended an evaluation for glasses. Resident 49 was admitted and later readmitted to the facility with diagnoses including dementia, history of falling, and cognitive communication deficit. The Minimum Data Set dated 10/31/2025 indicated the resident had adequate vision with glasses, moderate cognitive impairment, and required supervision or touch assist for walking. The ophthalmology consult dated 5/27/2025 documented moderate cataracts and blepharochalasis and recommended an optometry referral for a glasses evaluation. A Social Services progress note dated 7/14/2025 noted the most recent ophthalmology consult was 5/27/2025, but did not indicate that an optometry referral had been made in response to the recommendation. During interview, the Social Services Director stated she reviewed ophthalmology consult notes and would make an optometry referral when recommended, but confirmed that no referral was made for Resident 49 after the 5/27/2025 recommendation.
Oxygen Administered Above Ordered Rate
Penalty
Summary
The facility failed to ensure oxygen was administered as ordered for one resident with COPD, chronic respiratory failure, emphysema, and pulmonary hypertension. The resident’s face sheet showed the resident was admitted with these diagnoses, and the MDS dated 9/18/2025 indicated the resident was cognitively intact and required partial to moderate assistance with ADLs. The resident’s H&P dated 11/2/2025 indicated the resident had the capacity to understand and make decisions. The physician order dated 9/26/2025 directed that oxygen may be used at 2-3 L/min via nasal cannula to keep O2 saturation above 92% as needed for shortness of breath. During observation on 11/18/2025 at 11:12 a.m., the resident was receiving oxygen via nasal cannula at 4 L/min. During a later observation and interview on 11/20/2025 at 10:15 a.m., LVN 1 again observed the resident receiving oxygen via nasal cannula in bed at 4 L/min and stated the physician order was for 2-3 L/min and that the oxygen should not have been running at 4 L/min. The facility’s Oxygen Therapy policy stated oxygen and oxygen saturation levels were to be administered as ordered by the provider.
Lidocaine Patch Left On Past Ordered Removal Time
Penalty
Summary
Provide pharmaceutical services to meet the needs of each resident was not met for Resident 24 when a lidocaine patch ordered to be removed at 8:59 p.m. each day was still in place on the resident’s left leg during a medication pass observation. Resident 24 was admitted with diagnoses including COPD, hypertensive heart disease with heart failure, and chronic pain syndrome. The resident’s H&P indicated the resident had the capacity to understand and make decisions, and the MDS indicated clear comprehension and need for supervision with several activities of daily living. During the observation, the patch dated the previous day was found still applied, and the LVN removed it, cleaned and assessed the area, and applied a new patch. In interview, the LVN stated the patch should not have been left on and that it was important to follow physician orders. The DON stated medication orders should be followed as scheduled and that leaving the patch on longer than ordered would continue distributing medication to the resident’s system and could cause adverse side effects, skin irritation, and harm. The facility policy stated medications shall be administered according to physician orders and that residents shall receive medications in a timely, safe, and documented manner.
Unopened Lantus Stored in Medication Cart Instead of Refrigerator
Penalty
Summary
An unopened prefilled pen of Lantus was observed stored in the medication cart at the westback medication cart during a concurrent observation and interview with RN 1. RN 1 acknowledged that the insulin was stored in the cart while unopened and stated that unopened insulin prefilled pens and vials should be kept in the refrigerator until they are opened. RN 1 also stated that once an insulin vial is opened it may remain in the cart for 28 days. During an interview, the DON stated that all unopened insulin was required to be stored in the refrigerator until used to maintain the accuracy and potency of the medication. The DON stated the insulin was stored in the refrigerator to preserve effectiveness, and that storing it outside the refrigerator could affect its effectiveness. The facility policy titled, Storage of Medications, stated medications and biologicals are to be stored safely, securely, and properly following manufacturer recommendations, and medications requiring refrigeration are to be kept in a refrigerator with a thermometer for temperature monitoring.
Failure to Properly Explain Binding Arbitration Agreement
Penalty
Summary
The facility failed to ensure that correct information was provided to Resident 7 before asking him to enter into a binding arbitration agreement. Resident 7 was initially admitted with diagnoses including surgical aftercare for bilateral below-the-knee amputations and polyneuropathy. His H&P dated 9/25/2025 indicated he had the capacity to understand and make decisions. However, the Arbitration Agreement dated 9/25/2025 showed the resident’s daughter signed the document, entering him into the agreement. During interview, Resident 7 stated he was responsible for signing all paperwork presented to him on admission and would not have asked his daughter to sign anything. He stated binding arbitration was not explained to him and that he would not have agreed to it if it had been explained. The Admissions Director stated the daughter’s signature was an error and said he recalled Resident 7 signing the document himself, while also stating he was responsible for explaining binding arbitration to new residents. The Administrator stated binding arbitration means giving away the right to a court trial if there is a dispute and that residents should be fully informed before signing. The facility policy stated admissions staff must explain arbitration in a language and manner the resident and/or responsible party understands.
Failure to Test Symptomatic Resident for Covid-19 and Lack of Warm Water at Handwashing Sink
Penalty
Summary
Infection prevention and control was not maintained when Resident 48 was not tested for Covid-19 after first showing respiratory symptoms. Resident 48 had diagnoses including sepsis, no cognitive impairment, and required substantial to maximum assistance with mobility. The resident had a physician order to be tested for Covid-19 weekly and as needed, and the last documented test was on 11/10/2025. On 11/12/2025, the change of condition assessment documented a severe cough with yellow/green phlegm, chest congestion, difficulty breathing, and runny nose/nasal congestion. A later assessment on 11/18/2025 documented increased cough with white, cloudy sputum, chest congestion, and mild chest tightness, but no Covid-19 test was documented. During observation, the resident was sitting up in bed with a strong cough and stated she had been coughing for a week, was spitting up large amounts of white, creamy sputum, and was very fatigued due to frequent coughing. The IPN stated residents with cough and/or fever were to be tested for Covid-19 and confirmed the resident had not been tested since the coughing started. In addition, the facility failed to ensure warm running water was available at the handwashing sink in the soiled linen sorting area of the laundry room. The Housekeeping Supervisor stated this area was a dirty area where soiled linens were separated and sorted for washing, and staff used the sink for hand hygiene. During observation, the sink had hot-water and cold-water pedals, but pressing the hot-water pedal did not dispense any water, and the sink did not provide hot or warm water. Signage above the sink instructed staff to wash hands with warm running water. The Maintenance Supervisor stated the hot water had been turned off six months earlier and could not identify who directed that action, explaining it was turned off because the sink had an attached eyewash station. The IPN stated she had never been told hot water should be disconnected at an eyewash station and stated hand hygiene was to be done with warm water for effective handwashing and infection prevention.
Failure to Dress Residents Appropriately
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident 27 and Resident 24, were dressed appropriately, which compromised their dignity and potential for socialization. Resident 27, who was admitted with conditions including hemiplegia, chronic kidney disease, and aphasia, was observed wearing a hospital gown throughout the day. Despite being dependent on staff for personal hygiene and dressing, the staff only dressed Resident 27 when taken to the dining room or when visitors were present. The Certified Nursing Assistant (CNA) acknowledged that dressing the resident daily would aid in socialization and prevent feelings of depression. The Director of Nursing (DON) confirmed that there was no policy for keeping residents in hospital gowns during the day and emphasized the importance of dressing residents in their own clothes. Similarly, Resident 24, who had diagnoses including heart failure, dysphasia, and aphasia, was also observed wearing a hospital gown throughout the day. The resident required substantial assistance from staff for personal hygiene and dressing. The CNA noted that dressing Resident 24 in personal clothing was important for fostering a sense of togetherness with other residents. The DON recognized that not dressing the resident was a dignity issue and could lead to feelings of sadness. The facility's policies indicated that residents should be dressed in their own clothes, yet this was not adhered to, leading to the identified deficiency.
Failure to Provide Dentures During Meals
Penalty
Summary
The facility failed to ensure that a resident was offered his dentures before eating, which could potentially affect his ability to chew food effectively. The resident, who was admitted with diagnoses including heart failure, dysphasia, and aphasia, had a severely impaired cognition and required substantial assistance with personal hygiene and transfers. Observations on multiple occasions revealed that the resident was not provided with his dentures during meals, both in his room and in the dining room. Interviews with staff, including a CNA and the DON, confirmed that the resident required feeding assistance and should have been offered his dentures to aid in chewing and eating. The facility's policies on resident rights and quality of life emphasized the importance of providing an environment that meets individual needs and treating cognitively impaired residents with dignity. However, the staff failed to adhere to these policies by not ensuring the resident had access to his dentures during meals.
Inadequate Call Light Device for Resident
Penalty
Summary
The facility failed to provide an appropriate call light device for one of the residents, identified as Resident 27, which could potentially delay the resident's ability to call for assistance. Resident 27 was admitted with diagnoses including hemiplegia, chronic kidney disease, and aphasia, which affected their ability to communicate and perform certain physical tasks independently. The Minimum Data Set (MDS) assessment indicated that Resident 27 was dependent on staff for personal hygiene, showering, dressing, and transfers, and was usually understood by others. However, during an observation, Resident 27 was unable to grasp and press the standard call light button to request assistance. Interviews with facility staff, including an LVN and the DON, revealed that Resident 27 would benefit from a touch pad call light device, which would be easier for the resident to use given their physical limitations. The LVN emphasized the importance of having the appropriate call light device to ensure timely assistance, especially in emergencies such as falls or choking. The DON acknowledged that Resident 27 did not have the correct call light device and confirmed the necessity of a touch pad call light to accommodate the resident's needs. The facility's policy on accommodating resident needs highlighted the importance of evaluating and providing adaptive devices to support residents' independence and dignity, which was not adhered to in this case.
Failure to Provide Timely Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) form to a resident 48 hours prior to the end of skilled nursing services, as required. This deficiency was identified during an interview and record review involving the Social Service Director (SSD) and Resident 205. The SSD acknowledged that the NOMNC form was given to Resident 205 only one day before the end of Medicare Part A skilled services, which was contrary to the facility's policy of providing the notice 48 to 72 hours in advance. This lapse in procedure potentially compromised the resident's right to appeal the decision regarding financial coverage. Resident 205, who was admitted to the facility with diagnoses including chronic obstructive pulmonary disease, alcoholic liver disease, and diabetes mellitus, had intact cognitive skills for daily decision-making and required supervision for certain activities of daily living. The facility's policy, titled Medicare Denial Process, mandates that Medicare beneficiaries be properly notified when they no longer meet the requirements for covered skilled services. However, the SSD's failure to adhere to this policy resulted in Resident 205 not being properly informed in a timely manner, thus affecting the resident's ability to exercise their right to appeal.
Failure to Maintain Homelike Environment Due to Chipped Paint
Penalty
Summary
The facility failed to provide a homelike environment for one of its residents, identified as Resident 34, due to the presence of chipped paint on the wall next to the resident's bed. This issue was observed during a survey, where it was noted that the chipped paint could negatively impact the resident's quality of life. Resident 34, who has diagnoses including aphasia, chronic kidney disease, and atherosclerotic heart disease, was found to require substantial assistance with personal hygiene, showering, and dressing. Despite the resident's inability to make decisions, the Minimum Data Set indicated that Resident 34 was usually able to understand others. The deficiency was acknowledged by the facility's Administrator during an observation and interview, where it was confirmed that the chipped paint was known and needed repair. The Maintenance Director also confirmed that the need for painting had been reported in the maintenance log nearly a month prior to the survey. The facility's policy on Resident Rights emphasizes the importance of providing an environment that meets individual resident needs, which includes maintaining a clean and comfortable living space. However, the failure to address the chipped paint in a timely manner resulted in a deficiency in providing a homelike environment for Resident 34.
Failure to Develop Care Plan for Dental Service Refusal
Penalty
Summary
The facility failed to ensure that a care plan was developed for a resident who refused dental services, which is a communication tool for patient care between nurses. This deficiency was identified for one out of six sampled residents, referred to as Resident 2. The absence of a care plan for the refusal of dental services had the potential to place Resident 2 at risk for not receiving appropriate interventions to prevent discomfort when eating. Resident 2 was admitted to the facility with diagnoses including chronic kidney disease, dysphagia, and aortic aneurysm. The resident's Minimum Data Set indicated intact cognition and required supervision for personal hygiene and transfers. During interviews, it was revealed that Resident 2 refused dental treatment as documented in the dental record titled Elite Mobile Dental. The resident expressed that staff did not review the risks and benefits of not having dentures, which would have made chewing food easier. Both the Licensed Vocational Nurse and the Director of Nursing acknowledged the need for a care plan when dental treatment is refused, emphasizing the importance of setting goals and interventions to prevent mouth infections and to educate the resident on the risks and benefits of treatment. The facility's policy on Comprehensive Person-Centered Care Planning required that care plans be developed and updated based on assessed needs, but this was not followed in Resident 2's case.
Failure to Measure Abdominal Girth as Ordered
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not measuring the abdominal girth weekly as per the physician's order. This deficiency was identified for a resident diagnosed with ascites, a condition where fluid accumulates in the abdomen. The resident's medical history included chronic kidney disease and psychosis, and they had fluctuating capacity to understand and make decisions. The Minimum Data Set indicated that the resident had moderately impaired cognitive skills for daily decision-making and required supervision for personal care tasks. The Director of Nursing confirmed during an interview and record review that the abdominal girth measurements were not recorded on the specified dates in September and October. It was the responsibility of the licensed nurse to perform these measurements and document them in the Treatment Administration Record. The facility's policy emphasized the importance of following physician orders to maintain the resident's highest practicable wellbeing. The failure to measure the abdominal girth as ordered could lead to negative effects such as abdominal discomfort, weakness, and shortness of breath.
Incorrect LALM Setting for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a low air loss mattress (LALM) was set and maintained at the correct setting for a resident with a Stage 3 pressure ulcer on the sacral area. The resident, who was totally dependent on staff for personal hygiene and at risk of developing pressure ulcers, was observed lying on a LALM set at 350 pounds, despite weighing only 100.2 pounds. This incorrect setting was identified during an observation and interview with the Director of Nursing (DON), who acknowledged that the setting should be based on the resident's current weight to ensure effective wound management. The facility's policy and procedure for mattress resources indicated that the LALM should distribute the resident's body weight appropriately to prevent skin breakdown. However, the DON and Treatment Nurse 1 (TN 1) confirmed that the responsibility to check the correct setting of the LALM lay with the licensed nurses. The incorrect setting of the LALM could result in delayed wound healing and worsening of the resident's pressure ulcer, as it would cause extra pressure on the bony prominence and discomfort for the resident.
Failure to Monitor Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident with end-stage renal disease and heart failure by not monitoring and recording the resident's daily fluid intake as per the physician's order. The resident, who had a fluctuating capacity to understand and make decisions and required maximum assistance with daily activities, was on a 1200 ml fluid restriction due to their medical condition. However, the facility did not document the fluid intake in the Medication Administration Records (MAR) for over a month, from September to October 2024. During an interview, a registered nurse acknowledged the oversight and emphasized the importance of adhering to the fluid restriction to prevent complications such as fluid overload, swelling, and shortness of breath. The facility's policies on intake and output recording and fluid restrictions required strict monitoring and documentation of fluid intake for residents with such orders, but these were not followed in this case, leading to the deficiency.
Failure to Justify Antipsychotic Medication Use for a Resident with Dementia
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of dementia was free from the use of antipsychotic medication without proper justification. Resident 49, who was admitted with diagnoses including dementia, urinary tract infection, cerebral ischemia, and muscle weakness, was found to be severely cognitively impaired and required maximal assistance with daily activities. Despite not exhibiting any physical behavioral symptoms directed towards others, the resident was prescribed Seroquel, an antipsychotic medication, for psychotic features manifested by constant screaming. The Director of Nursing (DON) acknowledged that the protocol before administering antipsychotic medications was to monitor a resident's behavior for 72 hours, which was not followed in this case. The original order for Seroquel was placed for dementia, and later revised to indicate psychotic features as the reason for its use. However, there was no behavioral screening log to monitor the resident's behavior, and the facility's policy stated that antipsychotic drugs should not be given unless necessary to treat a specific diagnosed condition documented in the clinical record. This oversight had the potential to result in the use of unnecessary psychotropic drugs for the resident.
Failure to Follow Up on Dental Services for a Resident
Penalty
Summary
The facility failed to ensure a dental services follow-up for a resident, leading to a deficiency in care. The resident, who was admitted with diagnoses including metabolic encephalopathy, dysphagia, protein-calorie malnutrition, and iron deficiency, was cognitively intact and required assistance with daily activities, including eating and oral hygiene. Despite experiencing a toothache a month prior and expressing a desire to see a dentist for dentures, the resident did not receive the necessary follow-up for dental services after a recommendation for teeth extraction was made in August. Interviews revealed that the Social Services Director (SSD) was responsible for arranging the medical clearance needed for the dental procedure but failed to do so. The SSD acknowledged the oversight and the potential consequences of not following up on dental services, such as discomfort and difficulty eating. The Director of Nursing (DON) confirmed that the Social Services Department was responsible for ensuring dental services and acknowledged the lack of follow-up for the resident. The facility's policy indicated that the Social Services Staff was responsible for arranging dental appointments, but this was not adhered to in this case.
Failure to Implement Comprehensive Care Plan for Financial Abuse Risk
Penalty
Summary
The facility failed to develop and implement a comprehensive and patient-centered care plan for a resident following allegations of financial abuse, where the resident was missing $11,000. The resident, who was cognitively intact and required substantial assistance for activities of daily living, was admitted with diagnoses including hypertensive heart disease, peripheral vascular disease, and chronic obstructive pulmonary disease. Despite the resident's care plan indicating a risk for emotional distress related to financial abuse, it lacked specific interventions to secure the resident's belongings or prevent further financial loss. Interviews with facility staff, including the Director of Nursing, MDS Coordinator, and Social Services Director, revealed that the care plan was not updated with necessary interventions to address the financial abuse risk. The facility's policy on comprehensive person-centered care planning emphasized the need for interdisciplinary care to meet residents' needs, but the care plan did not reflect this standard. The Social Services Director noted that without documented interventions, it is assumed that necessary actions are not being implemented, highlighting a gap in the care plan's execution.
Failure to Safeguard Resident's Personal Property and Prevent Financial Abuse
Penalty
Summary
The facility failed to implement its policies and procedures regarding the safeguarding of residents' personal property and the prevention of abuse, neglect, and theft. Specifically, the facility did not follow its Theft and Loss Policy, which mandates that residents' personal property be safeguarded and any missing property be investigated and documented. Resident 1, who had chronic kidney disease, chronic obstructive pulmonary disease, and a cognitive communication deficit, reported that her wallet containing $647 went missing. Despite the facility's policy requiring that residents' money and valuables be taken to the business office for safekeeping, Resident 1's wallet was not properly secured, leading to its loss. Interviews with staff, including a Certified Nurse Assistant, Licensed Vocational Nurse, Social Service Director, and Director of Nursing, confirmed that the facility did not take appropriate measures to safeguard Resident 1's money, which could have led to emotional distress and potential safety risks for the resident. Additionally, the facility did not adhere to its Abuse Prevention, Screening, and Training Program, which prohibits any form of resident abuse, neglect, misappropriation of property, and exploitation. The policy defines financial abuse as the deliberate misplacement, exploitation, or wrongful use of a resident's belongings or money without consent. The failure to secure Resident 1's wallet and the subsequent loss of $647 placed Resident 1 and other residents at risk of financial abuse and emotional harm. The facility's inaction in safeguarding residents' property and investigating the loss demonstrates a significant lapse in following established protocols designed to protect residents from abuse and neglect.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 7,235 citations issued within 25 miles in the last 12 months — including the 32 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Inglewood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Osage Healthcare & Wellness Centre | 0 mi | ★★★★★ | 25 | 0 |
| Inglewood Health Care Center | 0.8 mi | ★★★★★ | 32 | 0 |
| Century Villa, Inc | 1.3 mi | ★★★★★ | 12 | 0 |
| Primrose Post-acute | 1.5 mi | ★★★★★ | 7 | 0 |
| Hawthorne Healthcare & Wellness Centre, Lp | 1.5 mi | ★★★★★ | 17 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.