Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Los Angeles Comm Hospital during CMS and state inspections, most recent first.
Infection control and EBP protocols were not followed for two residents during wound care and tracheal suctioning. A Treatment Nurse placed a box of gloves and wound supplies on a resident’s bed, used gloves from that box during treatment, then returned the box to the wall mount and an unopened dressing to the cart after they had been in contact with the resident. In another room, a RT provided tracheal suctioning to a resident with a trach and mechanical ventilation needs without wearing the required gown, and stated the PPE was forgotten.
Failure to Obtain Informed Consent Before Applying Restraints: The facility placed soft wrist and mitten restraints on two residents with severe cognitive and functional impairment, tracheostomy care needs, and respiratory diagnoses without complete consent documentation. The restraint consent forms did not show that permission was obtained before application and did not identify the person giving consent, and the DON confirmed the forms were incomplete and did not prove consent was received.
PRN lorazepam orders for two residents exceeded the 14-day limit for psychotropic use. One resident with anxiety disorder and impaired cognition had a year-long PRN Ativan order despite being calm and usually relaxed, while another resident with schizophrenia, bipolar disorder, and severe cognitive impairment had a 30-day PRN Ativan order for anxiety/agitation. The DON stated both orders should have been limited to 14 days and reordered if still needed, and there was no documentation supporting a longer duration.
A facility failed to develop care plans for three residents with significant needs. One resident had a sacral wound, pain treated with hydrocodone-acetaminophen, impaired cognition, and dependence for mobility and ADLs, but no care plan for pain or the medication. Another resident had respiratory failure, CHF, anoxic brain injury, a Foley catheter, and swollen hands, but no care plan for the catheter or edema. A third resident with chronic respiratory failure, CAD, severe cognitive impairment, total ADL dependence, oxygen therapy, and tracheostomy care had no care plan for a scab above the upper lip.
Failure to Document and Assess Resident Changes of Condition: Staff did not document or properly assess bilateral hand edema for one resident with severe cognitive impairment, CHF, respiratory failure, oxygen therapy, and tracheostomy care, and did not document or address a scab above another resident’s lip. The DON confirmed there were no nursing notes for either finding, and an LPN stated she noticed the swelling and scab but did not document or report them to the physician.
Foley Catheter Not Maintained to Drain Properly: A resident with DM, enlarged prostate, and seizures was observed with an indwelling Foley catheter hanging from the middle of the bed with a dependent loop and urine backing up in the tubing. RN stated the catheter was not draining properly because of the loop, that urine should flow freely into the collection bag, and that the setup could increase infection and discomfort. The facility policy stated catheter care should provide comfort and proper urine drainage.
A resident with chronic respiratory failure, hemiplegia, severe cognitive impairment, and an order for oxygen therapy with O2 sat monitoring was repeatedly observed without a pulse oximetry probe attached. The cord was seen hanging off the bed and later unplugged on top of the bed. The DON and RT both confirmed the probe should have been in place to monitor O2 saturation, and RT stated he had provided respiratory care earlier that day but did not know why it was off.
A resident with a pressure injury and an open wound had repeated PRN Norco 5-325 mg orders for severe pain that remained active beyond the required 7-day renewal interval. The DON reviewed the facility policy for opioid medication orders and stated that the policy was not followed.
Room Space Requirement Not Met in Shared Room: The facility failed to meet the required 80 sq. ft. per resident in a shared room. A Client accommodations Analysis Form and a Room Waiver Request Letter identified room [ROOM NUMBER] as not meeting the standard, and the waiver stated ventilator-dependent residents would not be admitted there. Surveyors observed two residents in the room, neither of whom was ventilator dependent, and the DON confirmed this during interview.
Two residents in a persistent vegetative state had peripheral line dressings that were not changed according to the facility's policy, increasing their risk of infection. Additionally, a medication cart was not cleaned after a liquid medication spill, posing a risk of cross-contamination.
The facility did not post the results of complaint investigations by the CDPH from the past three years in accessible areas, as required by federal regulations. The DON confirmed that only the last recertification survey was available, omitting recent complaint investigation results. The ACON highlighted the importance of posting these results for transparency and compliance with resident rights.
A facility failed to accurately complete the MDS assessment for a resident by not encoding a psychotic disorder diagnosis, despite the resident receiving Quetiapine for psychosis. The MDS Nurse admitted the error, and the ACON stressed the importance of MDS accuracy for proper care. The facility's policy requires assessments to be certified for accuracy.
A facility failed to update the PASRR Level I screening for a resident with a new diagnosis of psychosis, who was prescribed Quetiapine for symptoms manifested by pulling out tubes. The DON acknowledged the oversight, as the initial screening indicated no serious mental illness, and a re-evaluation was required to determine the need for specialized services.
A resident with severe cognitive impairment and respiratory failure was using non-behavioral restraints to prevent tube removal. The care plan required releasing and repositioning the restraints every two hours, but the restraint flow sheet lacked these instructions. This discrepancy was confirmed by staff and could lead to increased discomfort for the resident.
A resident with severe medical conditions and dependent on staff for all ADLs had their hair care neglected, resulting in matted hair with dandruff. Observations and staff interviews confirmed that hair care was not provided as scheduled, despite facility policy requiring shampooing as part of the bathing program.
A facility failed to label the oxygen tubing for a resident with chronic respiratory failure, which is necessary for infection control. The tubing was not dated, making it unclear when it was last changed, posing a potential risk for respiratory infection. Interviews with the DON and ACNO confirmed that labeling is a facility policy, and the lack of adherence to this policy was noted.
A facility failed to act on a pharmacy consultant's recommendation to review and justify the use of Quetiapine for a resident with chronic respiratory failure and a tracheostomy. The resident was receiving the medication for psychosis, but there was no documentation supporting this diagnosis. The Director of Nursing did not follow through with the recommendation, risking unnecessary medication administration.
A facility failed to implement non-pharmacological interventions before administering Quetiapine to a resident without a documented diagnosis of psychosis. The resident, with chronic respiratory failure and a gastrostomy tube, was prescribed the medication for pulling out tubes, but there was no evidence of attempted behavioral interventions or a pattern of behavior justifying its use. Interviews revealed that the behavior was not indicative of psychosis, and the medication was deemed unnecessary, contrary to facility policy requiring alternative interventions before psychoactive medication use.
The facility failed to maintain a medication error rate below 5%, as observed when two residents did not receive their scheduled nebulizer medications on time. LVNs noted the delays, and the DRT confirmed the late administration, which was not documented promptly as per facility policy.
A facility failed to refrigerate an intravenous medication, Amikacin, as required by its labeling. During an observation, an RN found the medication stored in an IV cart instead of a refrigerator, despite being scheduled for administration later that day. The RN acknowledged the error, noting that improper storage could render the medication ineffective or expired. Facility policy requires proper storage conditions, including temperature control.
A facility failed to meet the required square footage for a resident room, which was intended for two residents. The room measured 155 square feet, below the required 160 square feet. The facility had submitted a waiver request for this deficiency, and the DON stated that the room was unoccupied and posed no harm to resident safety or well-being.
Infection Control and EBP Failures During Wound Care and Tracheal Suctioning
Penalty
Summary
The facility failed to follow infection control and Enhanced Barrier Precaution (EBP) protocols for two residents during wound care and tracheal suctioning. Resident 2 had a history of a pressure injury and an open wound, was cognitively impaired, dependent on staff for most care, and had an unhealed Stage 4 pressure injury. During wound care at the bedside, the Treatment Nurse placed a box of gloves on the resident’s bed with multiple single-use wound dressings, used gloves from that box during treatment, and later returned the box of gloves to the wall mount. The nurse also placed an unopened dressing back onto the treatment cart after it had been on the resident’s bed. During interview, the Treatment Nurse stated the box of gloves should not have been returned to the wall mount because it had been in contact with Resident 2 and was contaminated. The Infection Control Manager stated the gloves box could not be disinfected once in contact with a resident and should have remained with that resident, and that the dressing should not have been returned to the treatment cart because its packaging was considered contaminated and could not be disinfected between use. The Infection Control Manager identified both items as cross-contamination risks with the potential to spread infection among residents. Resident 23 had severe cognitive impairment, was unable to provide information about his neurological state of health, and had physician orders for respiratory therapist assistance with mechanical ventilation and tracheostomy care. During an observation in the resident’s room, an infection prevention and control protocol sign was posted at the entrance, and a respiratory therapist was providing tracheal suctioning through the tracheostomy tube without wearing a gown. The respiratory therapist stated she forgot to put on a gown before starting the suctioning care and acknowledged that the resident was on EBP and that PPE, including a gown, was required under the facility’s infection prevention and control policies.
Failure to Obtain Informed Consent Before Applying Restraints
Penalty
Summary
The facility failed to ensure informed consent was obtained before placing bilateral soft wrist restraints on Resident 13. Resident 13 had quadriplegia, chronic respiratory failure, a tracheostomy, and severely impaired cognitive skills for daily decision making. The resident was dependent on staff for ADLs, required oxygen therapy and tracheostomy care, and was documented as using limb restraints daily while in bed. The care plan stated the resident would not pull out the tracheostomy tube and included interventions to explain the risks and benefits of restraints to the resident and family. During record review, Resident 13's consent form for bilateral soft wrist restraints did not indicate that consent was obtained prior to the restraints being applied. The form also did not identify the person who gave consent. During interview, the DON stated the name of the person who consented was required on the form because it proved the facility received permission to place the restraints, and stated the consent form was incomplete and restraints were placed on Resident 13 without consent. The facility also failed to ensure informed consent was obtained before applying a right hand mitten restraint to Resident 24. Resident 24 had chronic respiratory failure, hemiplegia, neurologic and functional limitations, severely impaired cognitive skills for daily decision making, and was dependent on staff for all ADLs. The resident required oxygen therapy and tracheostomy care, and the care plan addressed the resident not pulling out the trach and tube. The consent form for the right hand mitten restraint did not indicate consent was obtained prior to application and did not identify the person who gave consent. The DON stated that if the consent did not have a name, it meant the facility did not receive consent to apply restraints to Resident 24.
PRN Lorazepam Orders Exceeded Allowed Duration
Penalty
Summary
The facility failed to ensure PRN lorazepam orders did not exceed a 14-day administration period for two residents. One resident had diagnoses including anxiety disorder, moderately impaired cognition, and significant dependence for mobility and personal care. That resident had a physician order for lorazepam 0.5 mg every 24 hours PRN for anxiety, with the order written for one year. During observation, the resident was lying in bed, breathing unlabored, calm, and not restless, agitated, or showing mood concerns. CNA and LVN interviews described the resident as usually relaxed and generally calm, with restlessness only sometimes related to sacral pain. A second resident had diagnoses including schizophrenia and bipolar affective disorder, severe cognitive impairment, and dependence for mobility and hygiene. That resident had a physician order for lorazepam 1 mg every six hours PRN for anxiety/agitation, with a 30-day duration. The LVN stated the resident was typically confused and that reorientation was usually effective in stopping restlessness or agitation. The DON stated PRN psychotropics were to be limited to a 14-day administration period and that both lorazepam orders should have been limited to 14 days and reordered if still needed; the DON also stated there was no documentation supporting a duration beyond 14 days. The facility policy stated psychoactive medications were to be used in the lowest possible dose and discontinued when no longer required, and that when medications were ordered outside the Unnecessary Drug Guidelines, the physician was to document why the medication was appropriate.
Failure to Develop Care Plans for Pain, Foley Catheter, Edema, and Skin Issue
Penalty
Summary
The facility failed to develop care plans for three sampled residents. Resident 2 was admitted with diagnoses that included a pressure injury and an open wound, had moderately impaired cognition, required substantial to maximal assistance to roll in bed, was dependent for all other mobility, and was dependent for bathing, dressing, and toileting hygiene. Resident 2 also had an order for hydrocodone-acetaminophen 5-325 mg every 6 hours as needed for severe pain. During observation, Resident 2 was seen with a sacral wound measuring 10 cm long, 4.3 cm wide, and 1.1 cm deep. The DON stated Resident 2 did not have a care plan to address pain or the administration of hydrocodone-acetaminophen, and that the care plan should include monitoring for side effects such as sedation or dependency, interventions for medication administration, non-pharmacological interventions, and ongoing monitoring of effectiveness. Resident 7 was observed with swollen hands on two occasions. Resident 7’s records showed diagnoses including respiratory failure and CHF, was nonresponsive with anoxic brain injury, had severely impaired cognitive skills for daily decision making, and was dependent on staff for all ADLs. The MDS also indicated Resident 7 required oxygen therapy, tracheostomy care, and had a Foley catheter. The patient order dated 12/23/2025 indicated an indwelling urinary catheter. During interview and record review, the DON stated the electronic medical record did not contain a care plan for the Foley catheter or bilateral hand edema, and stated a care plan was needed to address catheter care, infection prevention, and guidance for staff. Resident 14 was observed with a scab above the left side of the upper lip on two occasions. Resident 14’s records showed diagnoses including chronic respiratory failure and coronary artery disease, had severely impaired cognitive skills for daily decision making, was dependent on staff for all ADLs, and required oxygen therapy and tracheostomy care. During interview and record review, the DON stated the electronic medical record did not contain a care plan addressing the left upper lip scab and stated the scab should be treated and initiated in the care plan. The facility policy titled Care Planning stated staff were to ensure a coordinated and comprehensive written plan was developed based on the resident assessment instrument and the individual needs of the resident.
Failure to Document and Assess Edema and a Scab
Penalty
Summary
The facility failed to ensure staff documented and properly assessed bilateral hand edema for one resident who was admitted with respiratory failure, CHF, an anoxic brain injury, severe cognitive impairment, and dependence on staff for all ADLs, oxygen therapy, and tracheostomy care. During an observation, the resident was lying in bed and had bilateral hand edema, but the electronic medical record did not show any documentation addressing the swelling. The DON reviewed the record and confirmed there were no nursing progress notes documenting the bilateral hand edema, and stated nursing staff must document all changes of condition, assess residents, inform the family, inform the doctor, and carry out doctor orders. An LVN who worked with the resident stated she noticed the resident’s right arm was swollen but did not document or report the swelling because she was busy. She also stated she did not notice the bilateral hand edema during the other days she worked with the resident. The LVN stated she was required to assess residents every day and document any new findings, and that swollen hands were a change of condition that needed to be documented and reported to the physician because the resident might need a higher level of care. The facility also failed to document and address a scab above another resident’s lip. During an observation, the resident was lying in bed and had a scab above the lip. The resident had diagnoses including chronic respiratory failure and coronary artery disease, and was severely cognitively impaired and dependent on staff for all ADLs, oxygen therapy, and tracheostomy care. The DON reviewed the record and found no documentation addressing the scab, stating that if changes of condition were not documented, nursing staff would be unaware of resident changes. The DON also stated the resident did not receive any care for the scab because the physician was not notified, and the LVN stated she noticed the scab about one month earlier but did not notify the physician or document it.
Foley Catheter Not Maintained to Drain Properly
Penalty
Summary
The facility failed to ensure that Resident 20’s Foley catheter drained properly into the collection bag and was maintained without a dependent loop. Resident 20 was admitted with diagnoses including DM, enlarged prostate, and seizures. The resident’s H&P dated 6/17/2025 indicated he was not oriented, nonverbal, and his eyes did not visually track. The MDS dated 12/30/2025 indicated the resident was comatose and dependent on staff for ADLs. During a concurrent observation and interview on 02/5/2026 at 1:47 p.m., RN 1 observed Resident 20’s indwelling Foley catheter hanging from the middle of the bed with a dependent loop and full of urine. RN 1 stated the urine was backing up into the resident’s bladder and not draining properly because of the dependent loop, and that urine should flow down easily from the Foley catheter tube into the urine collection bag. RN 1 also stated that backflow of urine can increase the chances of infection and/or discomfort, and that the Foley catheter should be maintained straight without any dependent loops. The facility’s policy titled Care of the Indwelling Catheter, dated 03/2025, indicated the facility would provide patient comfort and proper urine drainage.
Pulse Oximetry Not Applied for Resident Requiring Respiratory Monitoring
Penalty
Summary
The facility failed to ensure pulse oximetry was applied for one resident receiving respiratory services. Resident 24 had diagnoses including chronic respiratory failure and hemiplegia, was severely cognitively impaired, dependent on staff for all ADLs, and required oxygen therapy. The resident’s care plan for impaired gas exchange directed staff to maintain effective gas exchange as evidenced by pulse oximetry within normal range and to assess and record signs of hypoxia. Physician orders dated 11/17/2025 directed oxygen therapy and to maintain oxygen saturation at 95%. Surveyors observed Resident 24 on multiple occasions without a pulse oximetry probe attached: on 2/2/2026 at 10:22 a.m., on 2/4/2026 at 3:40 p.m., and on 2/5/2026 at 11:00 a.m. The pulse oximetry cord was observed hanging off the bed during one observation and unplugged on top of the bed during another. During a concurrent observation and interview, the DON stated she did not know why the probe was not attached and confirmed it had to be attached to monitor oxygen saturation. RT 2 stated Resident 24 should have pulse oximetry to monitor oxygen saturation, said he had provided respiratory care that morning and the probe had been on, and stated he did not know why it was off.
Opioid Orders Exceeded Required Renewal Interval
Penalty
Summary
The facility failed to ensure that orders for hydrocodone-acetaminophen 5-325 mg (Norco), an opioid medication used for moderate to severe pain, did not exceed the 7-day limit for one resident. Resident 2 was admitted with diagnoses that included a pressure injury and an open wound. Review of the resident’s physician orders for October 2025 through January 2026 showed repeated PRN orders for Norco 5-325 mg every 6 hours as needed for severe pain that remained active for periods longer than 7 days. The orders identified in the record included Norco 5-325 mg PRN for severe pain dated 10/26/25 to 11/25/25, 11/25/25 to 12/24/25, 12/25/25 to 1/24/26, and 1/24/26 to 2/23/26. During a concurrent interview and record review, the DON reviewed the facility policy titled Preparation and Administration of Medications, dated 4/2025, which stated that all opioid medication orders were to be renewed every 7 days with a new order. The DON stated the purpose of re-evaluating opioid medication for order renewal was to prevent opioid dependency and unwanted side effects, and stated the facility’s policy was not followed.
Room Space Requirement Not Met in Shared Room
Penalty
Summary
The facility failed to meet the required room size measurement of 80 square feet per resident in one room with multiple residents. A review of the facility’s Client accommodations Analysis Form dated 2/2/2026 indicated that one room did not meet the 80 sq. ft. per resident requirement, and a Room Waiver Request Letter dated 10/10/2025 identified room [ROOM NUMBER] as not meeting that standard. The waiver letter stated the facility would not admit ventilator-dependent residents to room [ROOM NUMBER] and that any resident in the room who developed a need for a ventilator would be moved out. During observations from 2/2/2026 to 2/6/2026, surveyors did not identify adverse effects related to the reduced room space, and the residents in room [ROOM NUMBER] were not ventilator dependent. During a concurrent interview and record review on 2/5/2026, the DON confirmed the two residents in the room were not ventilator dependent and stated the facility would ensure their health and safety was not adversely affected.
Infection Control and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the timely changing of peripheral line dressings for two residents, placing them at risk for infection. Resident 19 had a peripheral line dressing on the right forearm that was not changed for seven days, despite the facility's policy requiring a change every 72 hours. Similarly, Resident 17's peripheral line dressing on the right hand was not changed for six days. Both residents were in a persistent vegetative state, dependent on ventilators, and required assistance with personal care, increasing their vulnerability to infections. Additionally, the facility did not maintain proper sanitation of a medication cart, as a sticky liquid medication spill was observed on the cart, potentially leading to cross-contamination. The facility's policy mandates that medication carts be kept free of spills to prevent contamination and ensure the effectiveness of medications. The failure to clean the medication cart after the spill was noted during an observation with an LVN, who acknowledged the risk of cross-contamination due to the soiled cart.
Failure to Post Complaint Investigation Results
Penalty
Summary
The facility failed to post the results of complaint investigations conducted by the California Department of Public Health (CDPH) over the past three years in areas that are prominent and accessible to residents, visitors, family members, or resident representatives. During an observation and interview with the Director of Nursing (DON), it was revealed that the survey binder available at the nursing station hallway only included the last recertification survey conducted by the CDPH. The DON acknowledged that the facility had been visited by the CDPH for complaint investigations in the past two years, but the results of these investigations were not included in the survey binder. The DON admitted that all survey results should be posted and accessible to ensure transparency and compliance with resident rights. Further interviews with the Associate Chief of Nursing (ACON) confirmed that posting survey and complaint investigation results is a federal requirement. The ACON emphasized the importance of making these results available so that residents, their representatives, and facility staff can review the facility's plan of action to prevent recurrence of the identified deficiencies. A review of the facility's admission packet, specifically the section on resident rights, indicated that residents have the right to examine the results of the most recent surveys and any plans of correction. The facility's failure to post these results constitutes a violation of this right, potentially leaving residents and their families uninformed about the facility's compliance status and past performance history.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for a resident, identified as Resident 8, by not correctly encoding the diagnosis of a psychotic disorder under Section I (Active Diagnoses). This error was discovered during a review of Resident 8's MDS, which indicated that the resident's cognitive skills for daily decision-making were severely impaired and that the resident was dependent on staff for various hygiene tasks. The MDS Nurse acknowledged that the MDS assessment was completed inaccurately, as there was a missing check mark for the psychotic disorder diagnosis, despite the resident receiving Quetiapine for psychosis. The deficiency was further highlighted during an interview with the Associate Chief Nursing Officer (ACON), who emphasized the importance of MDS accuracy for reflecting the care provided by the facility. The facility's policy and procedure on Assessment and Care Planning require the assessment to be certified for accuracy by the individuals completing any portion of it. The incorrect data transmitted to the Center for Medicare and Medicaid Services (CMS) had the potential to negatively affect Resident 8's plan of care.
Failure to Update PASRR Screening for Resident with New Psychosis Diagnosis
Penalty
Summary
The facility failed to complete and re-submit the Preadmission Screening and Resident Review (PASRR) Level I screening for a resident who had a new diagnosis of psychosis. This oversight involved a resident who was admitted with chronic respiratory failure and required a tracheostomy and gastrostomy tube. The resident was later prescribed Quetiapine for psychosis, which was manifested by pulling out tubes. Despite this new diagnosis and medication, the PASRR Level I screening was not updated to reflect the change in the resident's mental health status. During an interview and record review, the Director of Nursing (DON) acknowledged the failure to submit a new PASRR Level I screening after the resident's diagnosis of psychosis. The initial PASRR Level I screening indicated no serious mental illness and did not require a Level II evaluation. However, the resident's condition changed, necessitating a re-evaluation to determine if specialized services were needed. The PASRR reference manual requires facilities to notify the state mental health authority of significant changes in a resident's condition, which was not done in this case.
Deficiency in Care Plan for Resident Using Restraints
Penalty
Summary
The facility failed to ensure that a revised care plan was in place for a resident using non-behavioral restraints. The resident, identified as Resident 25, was admitted with a diagnosis of respiratory failure and had additional diagnoses of seizures and pneumonia. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and dependency on staff for daily activities. The care plan for the resident included the use of bilateral restraints to prevent the removal of medical tubes, with specific instructions to release the restraints for 15 minutes every two hours and to reposition them under supervision. However, the Non-Behavioral Restraint Order and Flow Sheet, which should have reflected the care plan's interventions, lacked specific instructions on the duration and frequency of restraint release and repositioning. This discrepancy was noted during a review of the resident's records and confirmed by both the MDS Nurse and a Licensed Vocational Nurse (LVN). The absence of detailed instructions on the flow sheet had the potential to result in the restraints being left on longer than necessary, which could increase the resident's discomfort. The facility's policy and procedure documents emphasized the importance of care planning and documentation, including the use of protective restraints and monitoring. Despite these guidelines, the care plan for Resident 25 was not adequately updated to reflect the necessary interventions, leading to a deficiency in the resident's care. The lack of alignment between the care plan and the restraint flow sheet was identified as a significant issue during the survey.
Failure to Provide Adequate Hair Care for a Resident
Penalty
Summary
The facility failed to ensure that a resident's hair was shampooed twice a week as required, leading to the resident's hair becoming matted and having an abundance of dandruff. The resident, who was admitted with chronic respiratory failure, sepsis, a tracheostomy, and encephalopathy, was in a persistent vegetative state and dependent on staff for all activities of daily living (ADLs), including personal hygiene. Observations on a specific date revealed the resident's hair condition, and interviews with staff confirmed that hair care was supposed to be provided on shower days, which occurred twice a week. The Certified Nursing Assistant (CNA) acknowledged that the resident's hair looked dirty and emphasized the importance of washing and combing the hair to prevent dryness, dandruff, and tangling. The Associate Chief Nursing Officer (ACNO) confirmed that hair care was part of the resident's ADLs and should have been performed on shower days to maintain hygiene and prevent scalp infection. The facility's policy on hair and scalp care indicated that shampooing should be part of the bathing program, and the condition of the hair and scalp should be observed, with cream rinse used if the hair is tangled.
Failure to Label Oxygen Tubing for Infection Control
Penalty
Summary
The facility failed to ensure that the corrugated oxygen tubing for a resident was labeled with a date of change, which is a critical step for infection control. This deficiency was identified during an observation and interview with a respiratory therapist who noted that the tubing was not dated, making it unclear when it was last changed. The resident in question, who was admitted with chronic respiratory failure and had a tracheostomy, was dependent on staff for all activities of daily living and was receiving oxygen therapy continuously. The lack of labeling on the oxygen tubing posed a potential risk for respiratory infection. Interviews with the Director of Nursing and the Associate Chief Nursing Officer confirmed that it is the facility's policy to label all respiratory equipment with a date of change. The Director of Nursing highlighted that a clogged oxygen tubing could result in inadequate oxygen delivery, potentially causing shortness of breath. The facility's policy and procedure document indicated that all equipment should be changed as needed or when visibly dirty and dated, but this was not adhered to in the case of the resident's oxygen tubing.
Failure to Address Pharmacy Consultant's Recommendation for Medication Review
Penalty
Summary
The facility failed to ensure that a pharmacy consultant's recommendation regarding a resident's medication regimen was acknowledged and acted upon. Specifically, the pharmacy consultant recommended a review and justification for the restarting of Quetiapine, a psychotropic drug, for a resident. This recommendation was not followed through by the Director of Nursing (DON), who was responsible for addressing such recommendations with the resident's physician. The facility's policy required that the attending physician address the consultant pharmacist's recommendation by their next scheduled visit, but this was not done. The resident involved had a history of chronic respiratory failure with a tracheostomy and a gastrostomy tube. The resident was receiving Quetiapine for psychosis manifested by pulling out tubes, but there was no documentation in the psychiatric progress notes to support the diagnosis of psychosis or the use of Quetiapine. The failure to address the pharmacy consultant's recommendation placed the resident at risk for unnecessary medication administration, as there was no documented justification for the medication's use.
Failure to Implement Non-Pharmacological Interventions Before Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure consistent indication and identification of behavior, as well as the implementation of non-pharmacological interventions, before administering Quetiapine, a psychotropic drug, to a resident. The resident, who was admitted with chronic respiratory failure and a gastrostomy tube, was prescribed Quetiapine for psychosis manifested by pulling out tubes. However, the Director of Nursing (DON) confirmed that there was no documentation of the resident's behavior or attempted behavioral interventions prior to the initiation of Quetiapine. Furthermore, the resident's psychiatric progress notes did not indicate a diagnosis of psychosis, and the facility lacked evidence of a pattern of behavior that would justify the use of the medication. Interviews with the Director of Staff Development (DSD) and the Associate Chief Nursing Officer (ACON) revealed that pulling out tubes was not considered a specific behavior of a resident with psychotic features. The DSD acknowledged that the use of Quetiapine was unnecessary and could lead to adverse effects, including chemical imbalance and cardiac complications. The ACON stated that the facility should have employed less restrictive measures, such as hand mittens or one-on-one monitoring, before resorting to psychotropic medication. The facility's policy required that alternative interventions be attempted and documented before administering psychoactive medications, which was not adhered to in this case.
Medication Administration Errors Due to Delayed Dosing
Penalty
Summary
The facility failed to ensure that the medication error rate was less than 5%, resulting in medication errors. During an observation of 27 medication administration opportunities, two routine medications were not administered at their scheduled times. Licensed Vocational Nurse 1 (LVN 1) observed that a nebulizer medication, levalbuterol, was not administered to a resident at the scheduled time of 7:00 a.m. as per the Medication Administration Record (MAR). LVN 1 acknowledged that not administering routine medications at the scheduled time could lead to medication errors. Similarly, Licensed Vocational Nurse 2 (LVN 2) observed that another nebulizer medication, albuterol/ipratropium, was not administered to a different resident at the scheduled time of 7:00 a.m. The Director of Respiratory Therapy (DRT) confirmed that both medications were administered after their scheduled times, as indicated by a red box on the MAR. The DRT acknowledged that this delay could result in medication errors, overmedicating residents, and a lack of communication between staff. The facility's policy on medication administration requires that medications be charted immediately after administration, which was not adhered to in these instances.
Improper Storage of Intravenous Medication
Penalty
Summary
The facility failed to ensure that an intravenous medication, Amikacin, was refrigerated as required by its labeling. During an observation and interview, a registered nurse identified that the medication, which was scheduled to be administered at 9:00 p.m., was improperly stored in the intravenous medication cart instead of being refrigerated. The nurse acknowledged that the medication should have been refrigerated and noted that improper storage could lead to the medication being ineffective or expired. The facility's policy on medication storage mandates that drugs be stored under proper conditions, including temperature control.
Room Size Deficiency Identified in Facility
Penalty
Summary
The facility failed to meet the minimum square footage requirement for a resident room, specifically room [ROOM NUMBER], which was intended to accommodate two residents. The required size for such a room is 160 square feet, but the room was measured to be only 155 square feet. This discrepancy was identified during an observation conducted by the Director of Nursing (DON) and the Maintenance Supervisor (MS). The facility had previously submitted a room waiver request to address this issue, indicating that the room was slightly below the required size. During the survey, the DON confirmed that the room was unoccupied and did not have ventilator or tracheostomy access. The facility had been submitting annual waiver requests for this room due to its size deficiency. Despite the room's size not meeting the regulatory requirements, the DON stated that there was no harm to resident safety or well-being. Observations made over the course of the survey indicated that the room sizes did not adversely affect the health or safety of residents.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 7,194 citations issued within 25 miles in the last 12 months — including the 35 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
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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 Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Costa Del Sol Healthcare | 0.6 mi | ★★★★★ | 8 | 0 |
| East Los Angeles Doctors Hosp | 0.7 mi | ★★★★★ | 7 | 0 |
| Infinity Care Of East Los Angeles | 2 mi | ★★★★★ | 11 | 0 |
| Hollenbeck Palms | 2.2 mi | ★★★★★ | 21 | 0 |
| Maywood Skilled Nursing & Wellness Centre | 2.3 mi | ★★★★★ | 25 | 0 |
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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 July 2026) and official state health department websites.