Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pih Health Good Samaritan Hospital D/p Snf during CMS and state inspections, most recent first.
Failure to document release of mittens and wrist restraints: A resident with AMS, dementia, and suspected toxic metabolic encephalopathy had soft wrist restraints and mittens ordered after pulling on a Foley. Staff documented the restraints were on during repeated monitoring checks and noted circulation, sensation, motor function, skin, and the resident’s calm or sleeping status, but the chart did not show the restraints were removed or released. During observation, the resident was still wearing mittens and wrist restraints, and the RN and CD confirmed the documentation did not reflect restraint release.
Missing Dialysis Emergency Kit for Resident with AV Fistula: A resident with ESRD on HD and a left upper arm AV fistula did not have a dialysis emergency kit available at bedside. During observation, the kit could not be located; an RN stated it was needed for bleeding control and that the resident could bleed out without it, while the CD said staff would call rapid response and it could take time to get gauze/equipment to stop bleeding. The CD also stated the facility did not have a policy for a dialysis emergency kit.
A resident with complex medical needs was not included in the discharge planning process until several days after admission, despite facility policy requiring early engagement. Documentation showed that multiple care management notes were completed without any indication of the resident's involvement, and the first conversation with the discharge planner occurred only after these notes had been made.
The facility failed to submit complete and accurate PBJ staffing information to CMS, resulting in reports of low weekend staffing and missing RN hours. Despite staff assertions of adequate staffing, discrepancies were noted in the PBJ reports for multiple fiscal quarters. The facility's submissions did not meet CMS requirements for accurate staffing data, impacting public information on staffing levels.
The facility failed to develop comprehensive care plans for several residents, leading to potential inadequate care. A resident's non-compliance with medication was not addressed in their care plan, while another resident's use of psychotropic medications lacked person-centered interventions. Additionally, a resident's oxygen use and another's wound care were not included in their care plans, posing risks of inadequate care.
The facility failed to transmit MDS assessments to CMS within the required timeframe for two residents. One resident, admitted with a femur fracture, and another with cellulitis and sepsis, had their assessments transmitted late due to the MDS Coordinator's ongoing training. This delay was acknowledged by the Director of the Transitional Care Unit, highlighting a deficiency in adhering to the facility's policy for timely submission.
The facility failed to complete timely and accurate discharge summaries for two residents, leading to potential communication gaps in their care. One resident's summary was delayed beyond the required 14 days, while another resident's summary inaccurately documented their discharge status after leaving AMA without proper documentation or a physician's order. These deficiencies highlight the facility's non-compliance with its discharge policy, risking continuity of care.
A resident with multiple wounds did not receive daily wound care as ordered by a physician, and there was no care plan developed to address the resident's wound care needs. The facility's policies required prompt implementation and documentation of medical orders, but these were not followed, increasing the risk of wound worsening and infection.
A facility failed to provide appropriate care for a resident with a gastrostomy tube (GT), as evidenced by missing documentation for GT site monitoring, dressing changes, and feeding tolerance checks. The resident's care plan lacked goals or person-centered interventions, and the facility's policy on enteral feeding was not consistently followed, potentially leading to complications.
The facility failed to monitor the use of psychotropic drugs for two residents, leading to the potential for unnecessary medication use. One resident was prescribed multiple antipsychotic medications without measurable target behaviors or care plan interventions, while another resident was prescribed antidepressants without monitoring orders. The lack of adherence to the facility's policy on psychotherapeutic medications was confirmed by the DTCU.
A resident with an IV catheter was not provided with appropriate infection control measures, as the IV site was not changed despite showing signs of potential infection. The facility's policy required regular assessment and change of IV sites based on clinical indications, which was not followed, increasing the risk of infection and phlebitis.
Failure to Document Release of Mittens and Wrist Restraints
Penalty
Summary
The facility failed to document the removal or release of mittens and soft wrist restraints for one sampled resident. The resident was admitted with altered mental status and had a history of dementia and suspected toxic metabolic encephalopathy. The history and physical stated the resident was pulling on a Foley catheter, so restraints were continued until the Foley was removed. The resident’s record included a physician order for non-violent restraints consisting of soft left wrist, soft right wrist, mitten left hand, and mitten right hand. The restraint monitoring documentation showed the restraints were on during multiple assessments, including at 12:00 AM, 2:02 AM, 4:02 AM, and 6:04 AM, and staff documented the resident’s condition, circulation, sensation, motor function, skin, position, and that the resident was calm or sleeping. However, the documentation did not indicate that the restraints were removed or released during those assessments. During observation at 12:15 PM, the resident was seen with mittens on both hands and restraints on both wrists. The CNA stated the resident had restraints because he was a fall risk and was also being monitored on video and had a bed alarm. When the restraint monitoring assessment was reviewed with the RN, the box for documenting removal of the restraints was not checked. The Clinical Director stated that if staff did not document removing or releasing the mittens and wrist restraints, it was not done, and stated releasing the restraints would allow the nurse to assess circulation. The Director of Quality stated the electronic medical record needed to be modified because of issues with the restraint monitoring documentation tool.
Missing Dialysis Emergency Kit for Resident with AV Fistula
Penalty
Summary
Provide safe, appropriate dialysis care/services for a resident who requires such services was not met for Resident 34 when the facility failed to ensure a hemodialysis emergency kit was available at the bedside for the resident’s left upper arm arteriovenous fistula. Resident 34 was admitted with diagnoses including anemia and acute falls, and the H&P documented end stage renal disease on hemodialysis Tuesday, Thursday, and Saturday, along with leukopenia, thrombocytopenia, colon cancer, and a goal to maintain hemoglobin greater than 7 with transfusions as needed. The MDS indicated the resident could make himself understood and understand others, and the Adult Assessment/Intervention documented the fistula on the left upper arm. During a concurrent observation and interview in the resident’s room, a dialysis emergency kit could not be located. The RN stated the resident needed a dialysis emergency kit near the bedside in case of bleeding from the fistula and stated the resident could bleed out if there was no kit to stop the bleeding. The RN said she would get a dialysis emergency kit for the resident. The Clinical Director stated staff would call a rapid response, that it might take time to get gauze/equipment to stop bleeding, and that the resident could continue to bleed until pressure could be applied. The Clinical Director also stated the facility did not have a policy for a dialysis emergency kit.
Resident Not Included in Discharge Planning Process
Penalty
Summary
The facility failed to ensure that a resident was included in the discharge planning process, as required by policy. Review of the resident's medical record revealed that, although the resident had a complex medical history including end stage renal disease on hemodialysis, peripheral artery disease, and multiple amputations, there was no documentation of any conversation with the resident regarding discharge planning until several days after admission. The first documented interaction between the discharge planner and the resident occurred only after four prior care management progress notes had been completed, none of which indicated the resident's involvement in the discharge planning process. During an interview, the Director of Case Management and Social Services confirmed that it is important for discharge planners to meet with residents within one to two days of admission to ensure their preferences are incorporated into the discharge plan. The facility's policy also requires care management staff to engage the patient or their representative in the discharge planning process and to consider their preferences. The lack of early engagement with the resident meant that the resident's needs and preferences may not have been fully considered during the initial stages of discharge planning.
Inaccurate PBJ Staffing Data Submission
Penalty
Summary
The facility failed to submit complete and accurate Payroll Based Journal (PBJ) staffing information to the Centers for Medicare Services (CMS), which is essential for the appropriate care of residents. During the first fiscal quarter of 2024, the PBJ report indicated excessively low weekend staffing data. In the second fiscal quarter, the report showed no Registered Nurse (RN) hours for four or more days within the quarter. The third fiscal quarter revealed a one-star staffing rating and again triggered excessively low weekend staffing. These deficiencies were identified through a review of the CMS PBJ Staffing Report and the CMS Submission Reports for the respective quarters. Interviews with facility staff revealed a lack of understanding regarding the discrepancies in the PBJ reports. The Director of the Transitional Care Unit (DTCU) stated that staffing at the facility had been adequate, with at least one RN on every shift, and that the facility was supported by a General Acute Care Hospital's staffing office. The Director of Strategic Partnerships (DSP), responsible for submitting the PBJ reports, also expressed confusion, stating that the files submitted appeared fine and did not show any staffing issues. Both directors suggested that the information reported on the PBJ Staffing Data Report was inaccurate. The CMS Electronic Staffing Data Submission Payroll-Based Journal Long-Term Care Facility Policy Manual requires facilities to submit complete and accurate staffing information based on payroll and other verifiable data. The facility's failure to meet these requirements resulted in the provision of incomplete and inaccurate staffing information to the public. The CMS Staffing Data PBJ Submission website emphasizes the importance of staffing data in assessing the quality of care in nursing homes, and the deficiencies in the facility's submissions could impact the public's understanding of the facility's staffing levels.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive, resident-centered care plans for four of ten sampled residents, leading to potential inadequate care and services. For Resident 111, the facility did not create a care plan to address the resident's non-compliance with taking prescribed medications, including Septra DS, Pepcid, and Aspirin. Despite the resident's history of medication refusal, no care plan was in place to manage this issue, as confirmed by both the Registered Nurse and the Director of the Transitional Care Unit. Resident 115's care plan lacked person-centered interventions for the use of psychotropic medications, despite the resident's diagnoses of schizophrenia, bipolar disorder, and depression. The resident was prescribed Lexapro, Zyprexa, and Quetiapine, but the care plan did not include goals or interventions related to these medications. The Director of the Transitional Care Unit acknowledged the absence of a care plan addressing these issues, which could lead to inadequate care and monitoring. For Resident 163, the facility did not develop a care plan with measurable goals and interventions to monitor oxygen use, despite the resident's need for oxygen due to interstitial lung disease. The care plan did not reflect the resident's oxygen therapy, which was crucial for their care. Similarly, Resident 166's care plan did not include interventions for multiple wounds, despite active wound care orders. The lack of a comprehensive care plan for these residents posed a risk of inadequate care and potential harm.
Untimely Transmission of MDS Assessments
Penalty
Summary
The facility failed to ensure timely transmission of Minimum Data Set (MDS) assessments to the Center for Medicare Services (CMS) for two residents. Resident 3 was admitted with a right femur fracture and discharged after two weeks. The MDS assessments for Resident 3, including the admission and discharge assessments, were completed but transmitted late to CMS. Similarly, Resident 4, admitted with cellulitis and sepsis, had their entry and admission MDS assessments transmitted late. The MDS Coordinator acknowledged the delay, stating that the assessments were transmitted beyond the 14-day window required after completion. The Director of the Transitional Care Unit confirmed the untimely submission of MDS assessments, attributing the delay to the MDS Coordinator's ongoing training. The facility's policy mandates that MDS assessments be completed and transmitted within specific timeframes to ensure timely updates to CMS. The failure to adhere to these timelines was identified as a deficiency, with the potential to delay services for the affected residents.
Deficient Discharge Documentation for Two Residents
Penalty
Summary
The facility failed to timely and accurately complete discharge summaries for two residents, leading to potential gaps in their continuing care. For Resident 8, the discharge summary was not completed within the required 14 days after discharge. The resident was admitted with chest pain and discharged to a telemetry unit for anemia and hyperkalemia treatment. The discharge summary, completed late, listed generalized muscle weakness and moderate risk for falls as diagnoses, but the delay in completion posed a risk for communication gaps between medical providers. Resident 9's discharge summary was inaccurate and lacked a final summary of the resident's status. The resident, admitted with right foot osteomyelitis and Type II diabetes mellitus, was documented as discharged home with home health services. However, the resident left the facility Against Medical Advice (AMA) without a physician's discharge order or proper documentation, including the removal of a PICC line and wound vac. The discharge summary did not reflect the resident's actual discharge status, and there was no signed AMA form or documentation of the resident's condition prior to leaving. The facility's policy requires a physician's order before discharge and proper documentation of the patient's status and discharge instructions. The lack of adherence to these procedures for both residents resulted in incomplete and inaccurate discharge documentation, which could have impacted the continuity of care. The Director of the Transitional Care Unit acknowledged these deficiencies, highlighting the importance of timely and accurate discharge summaries to ensure effective communication and care continuity.
Failure to Administer Prescribed Wound Care
Penalty
Summary
The facility failed to ensure that a resident received the prescribed wound care treatment, which was crucial for promoting the healing of wounds. The resident, who was admitted with diagnoses including failure to thrive, had specific wound care orders from a physician that were not documented as being carried out daily. These orders included painting wounds on various parts of the lower extremities with Betadine and covering certain wounds with Optifoam. However, during interviews and record reviews, it was revealed that there was no evidence of these treatments being administered as ordered. Additionally, there was no care plan developed for the resident that included person-centered goals and interventions for wound care. Both the registered nurse and the Director of the Transitional Care Unit acknowledged the lack of documentation and care planning. The facility's policies required that diagnostic and therapeutic orders be implemented promptly and documented daily, but these procedures were not followed, leading to an increased risk of wound worsening and potential infection for the resident.
Failure to Provide Appropriate GT Care and Documentation
Penalty
Summary
The facility failed to provide appropriate care for a resident receiving nutrition through a gastrostomy tube (GT), which is a flexible tube surgically inserted through the abdomen into the stomach for feeding, fluid, and medication administration. The resident, who was admitted with diagnoses including schizophrenia, bipolar disease, and a history of aphasia, was to receive continuous tube feeding at a specified rate. However, the resident's GT feeding care plan lacked goals or person-centered interventions. Additionally, the facility's Patient Safety Coordinator (PSC) and Director of Transitional Care Unit (DTCU) identified missing documentation for GT care, including site skin monitoring, dressing changes, and feeding tolerance checks on multiple dates. The PSC and DTCU noted that licensed nurses did not thoroughly complete the Assessment and Intervention Flowsheets for GT care, which are standard nursing procedures that do not require a physician's order. The facility's policy on enteral feeding indicated that the enterostomy site should be evaluated for patency before initiating feeding, but this was not consistently documented. The lack of documentation suggests that the necessary care and monitoring were not performed, potentially leading to complications such as infection.
Failure to Monitor Psychotropic Drug Use
Penalty
Summary
The facility failed to ensure that two residents, identified as Residents 113 and 115, were free from unnecessary use of psychotropic drugs. For Resident 115, who was admitted with diagnoses including schizophrenia and bipolar disease, there were no measurable target behaviors documented for the use of three antipsychotic medications: Lexapro, Zyprexa, and Quetiapine. The resident's care plan lacked goals or interventions for antipsychotic medication use, and the Minimum Data Set indicated severely impaired cognitive skills without hallucinations or delusions. The Director of Transitional Care Unit (DTCU) confirmed the absence of orders for monitoring specific targeted behaviors related to these medications, which hindered the evaluation of their effectiveness. Similarly, Resident 113, admitted with conditions such as uncontrolled Type II diabetes and a psych disorder, was prescribed Wellbutrin XL and Prozac for depression. However, there were no orders for monitoring specific targeted behaviors related to these medications. The DTCU acknowledged the lack of monitoring orders, which also impeded the assessment of medication effectiveness. The facility's policy required consent and documentation of side effects for psychotherapeutic medications, but these were not adhered to in these cases.
Failure to Implement Infection Control Measures for IV Site
Penalty
Summary
The facility failed to implement proper infection control measures for a resident who had an intravenous catheter (IV) in place. The resident, who was admitted with diagnoses including failure to thrive, was observed with an IV in their left arm that had not been changed since its insertion. The IV site was noted to have a pinkish-red color with dried blood surrounding it, indicating potential issues with the site. During observations and interviews, it was revealed that the IV should have been changed when it was not functioning properly, could not be flushed, or showed signs of redness or pinkness. The facility's policy required IV sites to be assessed every four hours for signs of phlebitis, infiltration, or infection, and to be changed as clinically warranted. However, the IV for this resident was not changed in accordance with these guidelines, posing a risk for infection and phlebitis.
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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.
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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) |
|---|---|---|---|---|
| Burlington Convalescent Hospital | 0 mi | ★★★★★ | 0 | 0 |
| Mid-wilshire Health Care Cntr | 0.2 mi | ★★★★★ | 36 | 1 |
| Angels Nursing Health Center | 0.4 mi | ★★★★★ | 0 | 0 |
| Bonnie Brae Skilled Nursing | 0.5 mi | ★★★★★ | 9 | 0 |
| California Post Acute | 0.6 mi | ★★★★★ | 52 | 2 |
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