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 Veterans Home Of California - West Los Angeles during CMS and state inspections, most recent first.
Staff failed to maintain professional boundaries and protect two residents from potential financial exploitation and misappropriation of funds. One resident with atrial fibrillation, ESRD, and moderate cognitive impairment reported that a CNA proposed marriage, discussed moving the resident into her home so he could help pay rent and expenses, accepted $50 for holiday food, and shared personal phone contact and photos, contrary to facility policy prohibiting gifts, personal information sharing, and romantic or emotional relationships with residents. Another resident with DM and mild cognitive impairment bought a CNA a meal worth about $20 after a long-standing personal acquaintance, while the CNA accepted the gift and communicated with the resident via personal cell phone, with conversations reportedly focused on money. These actions violated the facility’s Professional Boundaries and Ethics and Elder Abuse Prevention and Response policies, which forbid staff from accepting anything of value from residents, sharing personal contact information, or engaging in romantic or emotional relationships.
A resident with legal blindness and severe osteoarthritis, assessed as high risk for falls, was left unsupervised in the shower room according to her preference, but without appropriate care plan interventions or supervision. The resident fell while attempting to dress after showering, resulting in multiple injuries and hospitalization. Staff interviews and record reviews confirmed that the care plan did not address the need for supervision or assistance during showering, despite the resident's known risks.
Multiple allegations of abuse involving residents with specific diagnoses were not reported to local law enforcement, the Ombudsman, the state survey agency, or the facility Administrator within the required timeframe. In one case, a resident's report of abuse at an outside medical facility was not reported as required, and in another, staff failed to notify the state survey agency after witnessing resident-to-resident abuse. Facility policies and staff training did not align with federal reporting requirements.
The facility failed to follow food safety and sanitation guidelines, including staff not wearing hair restraints, dirty ice machines, expired water filters, dishwashers not reaching required temperatures, expired food items, and improper handwashing practices. These issues posed a risk for foodborne illness among the residents.
The facility's QAPI committee failed to address the need for a Director of Dietetics, compromising food safety for 144 residents. The current ADD was overseeing dietary services without proper focus on staff competency evaluations, as noted in the QAPI Meeting Minutes.
The facility failed to ensure kitchen staff were trained and evaluated for competency in operating dishwashers, leading to dishwashers not maintaining the required temperature. This posed a risk of serving food on unclean dishes to 118 residents. Observations and interviews revealed a lack of knowledge and formal training among staff, with evaluations either not conducted or not met.
The facility failed to serve therapeutic diets according to orders for three residents, risking choking and aspiration. A resident with a cerebral infarct received a hard cookie instead of a finely chopped one, contrary to their mechanical soft diet order. Another resident with Parkinson's and dysphagia also received an improperly chopped cookie. A third resident with esophageal issues faced the same issue. Staff confirmed the discrepancies, highlighting a systemic issue with diet adherence.
A resident with serious mental health conditions was incorrectly coded in the MDS, leading to missed specialized services. The RN misinterpreted the PASRR II results, coding the resident as not having a serious mental illness. This error resulted in the resident not receiving mental health rehabilitation, ADL training, and psychotherapy or counseling.
The facility failed to implement Safe Smoking Care Plans for two residents, leading to potential safety hazards. A resident with nicotine dependence and mild cognitive impairment was observed smoking unsupervised in a non-smoking area, contrary to their care plan. Another resident, with chronic conditions, was not offered a smoking apron as required by their care plan, posing a risk of injury.
Two residents were involved in smoking-related safety deficiencies. A resident with cognitive impairment was observed smoking unsupervised in a non-smoking area, contrary to their care plan. Another resident was not offered a protective smoking apron, as required by their care plan. These actions violated the facility's policy on safe smoking practices.
The facility did not follow its policy for labeling and dating food items brought by residents, family, or visitors, leading to unlabeled and expired food being stored in the communal refrigerator. RNs and the ADON confirmed that these items should have been discarded according to the policy, which mandates immediate disposal of any unlabeled or expired food.
The facility did not ensure that two of four outside dumpsters had lids, as required to prevent pest attraction. The Chief Engineer confirmed the absence of lids, and the Chief of Plant Operations was unaware of the requirement. The FDA Food Code and the facility's policy both mandate tight-fitting lids for dumpsters.
A resident received morphine sulfate without an active physician's order due to the facility's failure to follow its policy on unusable drugs. The medication was administered by an LVN after the order had expired, and staff interviews revealed a lack of adherence to procedures for handling expired narcotic orders.
A resident was administered morphine sulfate without a physician's order, resulting in a significant medication error. The LVN failed to verify the physician's order, which had expired, before administering the medication. The facility's policy requires that medications be administered only with a valid physician's order, and the six rights of medication administration must be followed.
The facility failed to maintain an effective infection control training program for Enhanced Barrier Precautions (EBP), leading to multiple breaches observed during a survey. Staff were unaware of EBP requirements, with only 35% trained, and new employees not receiving EBP training. The Infection Preventionist and Director of Nursing lacked coordination, and the facility's policies did not include specific EBP guidelines, compromising resident safety.
The facility failed to implement Enhanced Barrier Precautions (EBP) for several residents with wounds or MDRO, as staff did not follow proper protocols, such as wearing gowns and posting necessary signage. Additionally, staff in the Yellow Zone did not adhere to PPE requirements, including wearing N95 masks and eye protection, to prevent COVID-19 spread. These lapses in infection control measures were confirmed by the Infection Preventionist and Director of Nursing.
Two residents in the facility did not receive required neurological assessments following falls, as per physician's orders. One resident, with muscle weakness and mobility issues, missed multiple assessments after two separate falls. Another resident with cognitive impairment also missed several assessments. The facility's policy mandates such assessments for residents with head injuries or unwitnessed falls, but these were not conducted, potentially delaying the identification of neurological changes.
A facility failed to report an abuse allegation to the State Survey Agency when a male resident with dementia displayed inappropriate sexual behavior in front of a female resident with major depressive disorder and dementia. The incident, witnessed by dining hall staff, was reported to management, law enforcement, and the Ombudsman but not to the California Department of Public Health Licensing and Certification, as required by the facility's policy.
Failure to Prevent Staff–Resident Boundary Violations and Financial Exploitation
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from exploitation and misappropriation of funds by allowing CNAs to develop inappropriate personal relationships with residents, accept gifts, and share personal contact information and photos. For one resident with atrial fibrillation and end stage renal disease, admitted with a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment, the resident reported that a CNA knelt in front of him in a common area and asked him to marry her. The resident stated he agreed, that a wedding date of December 29 was discussed, and that the CNA offered to move him into her home so he could help pay rent and living expenses with money he would save by not living at the facility. The resident also reported giving this CNA fifty dollars around Thanksgiving to buy a turkey, mashed potatoes, and sweet potatoes. The facility’s social worker documented that the resident told her he was going to get married on December 29 to a nurse who had proposed to him and that he stated the proposal was serious when she asked if it might be a joke. The social worker later stated that the relationship between the CNA and the resident was “getting weird,” that the CNA had given the resident her personal phone number, and that she was sending pictures of herself to the resident, which the social worker said was not appropriate and against facility policy. The social worker also stated that although the resident was oriented to person, place, and time, he was “not great at knowing the situation,” as he wanted to move into the CNA’s house. The DON acknowledged that the resident had given the CNA fifty dollars, and the administrator stated that staff cannot receive gifts as individuals, while the facility’s Professional Boundaries and Ethics policy prohibited staff from accepting any gifts, including money or meals, from residents, from sharing personal contact information, and from engaging in sexual, romantic, or emotional relationships with residents. A second resident, admitted with diabetes mellitus with other specified complication and mild cognitive impairment, was also involved in boundary violations with another CNA. This CNA reported she had known the resident for about ten years and had previously invited him to dinner at her house, which he attended. She stated that the resident bought her a burger and fries on one occasion, which she accepted, and that she was unaware she could not accept this meal. The social worker documented that the resident admitted buying the CNA a twenty-dollar lunch and later reported that the resident’s daughter said the CNA was speaking with the resident on his personal cell phone and “talking a lot about money,” after which the resident changed his phone number. The DON stated that CNA 2 denied any prior personal relationship with the resident, while also acknowledging a gift from the resident to the CNA involving approximately twenty dollars in cash or food. These actions occurred despite facility policies on Professional Boundaries and Ethics and Elder Abuse Prevention and Response, which define financial abuse and prohibit staff from accepting anything of value from residents, sharing personal contact information, or engaging in romantic or emotional relationships with residents. Across both cases, the facility’s own policies clearly stated that employees must maintain professional relationships, set and maintain boundaries, not accept gifts or money from residents, not share personal phone numbers or other personal information, and not engage in sexual, romantic, or emotional relationships with residents, even if consensual. The documented interactions between the CNAs and the two residents—acceptance of money and meals, sharing of personal phone numbers, sending personal photos, discussion of marriage, and discussion of moving a resident into a staff member’s home—directly conflicted with these written policies. The facility’s failure to prevent or promptly address these boundary violations resulted in residents not being protected from potential financial abuse, misappropriation of property, and exploitation as defined in the facility’s Elder Abuse Prevention and Response policy.
Failure to Individualize Care Plan for High-Risk Resident Results in Fall and Injury
Penalty
Summary
The facility failed to develop and implement a comprehensive, resident-centered care plan that addressed all of a resident's needs and preferences, specifically regarding supervision and assistance during showering. The resident, a female with legal blindness, severe osteoarthritis, and a history of falls, was admitted with declining functional abilities and was assessed as high risk for falls. Despite these risk factors, her care plan did not include interventions for her preference to be left alone in the shower room, nor did it address the need for assistance or supervision during showering. On the day of the incident, the resident was left alone in the shower room by a CNA, who waited outside the bathroom. Within minutes, the resident lost her balance while attempting to put on her robe after showering, resulting in a fall. The CNA and other staff responded after hearing a yell and a loud noise, finding the resident on the bathroom floor. The resident sustained significant injuries, including a fractured breastbone, thoracic spine fractures, a scalp bruise, and required a two-day hospital stay. Interviews with staff confirmed that the resident's legal blindness and high fall risk were known, and that the fall could have been avoided if supervision or assistance had been provided during showering. Review of the care plan and assessments showed that while the resident's fall risk and vision impairment were documented, there were no specific interventions or measurable actions addressing her preferences or the need for supervision in the shower room, directly contributing to the incident.
Failure to Timely Report Alleged Abuse to Required Authorities
Penalty
Summary
The facility failed to ensure that multiple allegations of abuse involving residents with specific diagnoses were reported to the required authorities in accordance with federal regulations. In one instance, a resident reported being abused while at an outside medical facility. The Therapeutic Activities Staff (TAS) was informed of the allegation and relayed it to the Social Worker (SW), but neither the TAS nor the SW reported the allegation to local law enforcement, the Ombudsman, the state survey agency (CDPH), or the facility Administrator within the required two-hour timeframe. Interviews with the SW, Supervising Registered Nurse (SRN), and Nurse Practitioner (NP) revealed that they did not consider the report credible enough to warrant immediate reporting, citing the resident's medical condition as a factor. The Administrator confirmed he was not notified of the allegation within the required timeframe and was unable to provide documentation of timely notification. In a separate incident, another resident was witnessed by staff abusing a fellow resident in a common area. The Registered Nurse (RN) reported the incident to the Ombudsman and local law enforcement but did not notify CDPH, following facility training that such incidents did not require reporting to the state survey agency if the abuse was caused by a resident and did not result in serious bodily injury. The facility's policy and procedure, as well as staff interviews, confirmed that the protocol did not align with federal requirements for reporting all allegations of abuse to the state survey agency, regardless of the perpetrator or injury severity. These failures resulted in delays in the investigation process by local law enforcement, the Ombudsman, and the state survey agency. The facility's census at the time was 141, and the lack of timely and comprehensive reporting of abuse allegations was confirmed through interviews, record reviews, and examination of facility policies and staff training materials.
Plan Of Correction
F609 a) 1. Resident 1 was assessed on April 10, 2025, with no injuries or emotional distress noted, including no signs of [R]. Resident was assessed and placed on close monitoring following [R] at the outside facility on March 4, 2025. Resident had no complaints, including no complaints of headache, nausea, vomiting, or body soreness. No skin issues were noted. IDT for the alleged incident that occurred at the outside facility scheduled for April 11, 2025. Resident's [R] at outside facility were postponed until investigation conducted determined it was safe to proceed. SOC341 was filed on April 10, 2025, and CDPH, LTC Ombudsman, and CHP notified. The Therapeutic Activities Staff, Social Worker, Supervising Registered Nurse, Director of Nursing, Staff Nurse Instructor, Nurse Practitioner, and Administrator were all in-serviced on April 10 and April 11, 2025, on the updated mandated reporting tree detailing all required entities to contact for elder abuse reporting, including the LTC Ombudsman, law enforcement, and the California Department of Public Health. 2. Resident 1 was immediately assessed after the alleged incident on April 4, 2025, with no injury noted. Residents 1 and 2 were immediately separated to ensure the safety of Resident 1. During immediate interviews conducted separately by Nursing and Social Work staff, Resident 1 denied any inappropriate physical contact between Resident 1 and Resident 2. Resident 1 denied any emotional distress related to the alleged event. Resident 1 was placed on close monitoring for emotional distress following the incident; none was noted. Resident 2 was placed on 1:1 nursing observation on April 4, 2025, to be in place indefinitely until IDT determines it is clinically appropriate and safe to taper. Resident 2 was assessed by psychiatric NP, and a medication change was ordered by [R] primary care physician, with daily monitoring for inappropriate behavior. Resident 1 and Resident 2 will continue to be housed in separate wings of the unit, with meals held in different dining rooms, to minimize potential contact. IDT meetings were held for both residents, and care plans updated at that time. SOC341 was sent to CDPH on April 10, 2025. RN, SRN, and Administrator were in-serviced on April 10 and April 11, 2025, on the updated mandated reporting tree detailing all required entities to contact for all elder abuse reporting, including the LTC Ombudsman, law enforcement, and the California Department of Public Health. b) The facility has determined that all residents have the potential to be affected. All incident reports and resident records from the past calendar year were audited for allegations of [R] by the Standards and Compliance manager and designee on April 10 and April 11, 2025. Through record review and audit, the facility has not found any other residents affected by the alleged deficient practice. c) An updated mandated reporting tree detailing all required entities to contact for elder abuse reporting, including the LTC Ombudsman, law enforcement, and the California Department of Public Health, was created and distributed throughout the facility, including by email, on April 10, 2025. Unit television screens were updated to include slides of the updated mandated reporting tree on April 10, 2025. The SNF Administrator in-serviced all department supervisors on April 10, 2025, and they in turn will in-service all facility staff within their respective departments on F609, facility policy, "Elder Abuse Prevention and Response," the updated mandated reporting tree, updated instructions for whom to notify in-house for any suspicion of abuse or neglect, with emphasis on notifying the facility's Abuse Coordinator and the Standards & Compliance Manager, and the SOC341 form. In-services will be complete by May 11, 2025. d) Starting April 10, 2025, the Standards & Compliance Manager and/or designee began auditing all incident reports weekly to ensure any events that could be perceived as re-reported to all required entities and agencies. In addition, in-service trainings on elder abuse prevention, response, and mandated reporter requirements will be provided annually to all staff by the Director of Staff Development and as needed. In addition, Standards & Compliance staff will conduct quarterly random reviews and interviews with facility staff throughout the facility to ensure staff understanding of the mandated reporter requirements. All findings will be reported to the SNF Administrator and facility QAPI committee for monthly review and continuous quality improvement until the QAPI committee deems compliance has been sustained. Administration will revisit and modify the plan of correction as needed. e) Corrective action will be in place on or before May 11, 2025.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to food safety and sanitation guidelines, as evidenced by multiple observations and interviews. Two kitchen staff members were observed not wearing hair restraints while in the kitchen, which is against the facility's policy to prevent food contamination from falling hair. Additionally, two of the three ice machines were found to be dirty, with visible build-up and residue, and three water filters for the ice machines were expired, which was acknowledged as a maintenance oversight. Further deficiencies were noted in the dishwashing process, where two of the three dishwashers did not reach the minimum required temperature for the wash cycle. This was confirmed by the Chief of Plant Operations, who stated that the temperature should be maintained at 150 degrees Fahrenheit. Moreover, an expired bottle of rice wine vinegar was found in dry storage, which was confirmed by a culinary specialist who acknowledged the need for disposal according to FDA guidelines. Lastly, a kitchen staff member failed to wash hands between handling dirty and clean dishes, despite wearing two pairs of gloves. This was contrary to the facility's infection control policy, which mandates proper handwashing after removing gloves. These failures posed a risk for foodborne illness among the 144 residents who rely on the facility for their meals.
QAPI Committee Fails to Address Staffing Needs for Dietary Oversight
Penalty
Summary
The facility's QAPI committee failed to identify, prioritize, and address the staffing need for a Director of Dietetics, which is crucial for providing qualified oversight of all kitchen services. This oversight resulted in compromising food safety and posed a potential risk of severe foodborne illnesses and injuries to a medically fragile population of 144 residents. During a review of the QAPI Meeting Minutes from January to November 2024, it was noted that there was no focus on addressing the vacancy for a Director of Dietetics, which is essential for ensuring safe and sanitary food service and competent kitchen staff. Interviews with QAPI representatives, including the DON, SCM, and ADMIN, revealed that the current ADD was acting as the default overseer of dietary services alongside two Food Service Managers. Additionally, the QAPI Meeting Minutes did not mention any unmet kitchen staff competency evaluations being identified and addressed. The facility's QAPI Plan, which aims to ensure high-quality care and regulatory compliance, was not effectively implemented in this instance, as evidenced by the lack of action regarding the critical staffing need for a Director of Dietetics.
Inadequate Training and Competency Evaluation of Kitchen Staff
Penalty
Summary
The facility failed to ensure that kitchen staff were routinely trained and evaluated for competency in operating dishwashers in the satellite kitchens, specifically in B207-Food Prep and B307-Food Prep. During observations, it was noted that the dishwashers did not maintain the required minimum temperature of 150 degrees Fahrenheit during the wash cycle. Interviews with Food Service Technicians (FSTs) revealed a lack of knowledge regarding the necessary temperature requirements for the dishwashers. The Food Service Supervisor (FSS) also indicated a lack of formal training on the dishwashers, relying instead on observing others. The Chief of Plant Operations confirmed that the dishwashers should maintain a temperature of 150 degrees Fahrenheit and that staff needed to allow time between wash cycles for the temperature to rise. Further review of staff duty statements and competency checklists showed that essential functions included operating dishwashing machines, but evaluations of staff competency in this area were either not conducted or not met. The facility's policy and procedure for warewashing indicated that the Food & Nutrition Services Director or designee was responsible for training employees, and specified that wash temperatures should be between 150-160 degrees Fahrenheit. The lack of proper training and evaluation of kitchen staff's competency in operating dishwashers had the potential to result in residents being served food on unclean dishes, posing a risk of foodborne illnesses to the medically fragile population of 118 residents.
Failure to Adhere to Therapeutic Diet Orders
Penalty
Summary
The facility failed to ensure that the therapeutic diet was served in accordance with the diet order for three residents, which had the potential to cause choking and aspiration. Resident 102, who was admitted with a diagnosis of cerebral infarct, had an active order for a mechanical soft, finely chopped diet. However, during an observation, a snickerdoodle cookie on Resident 102's meal tray was found to be hard and not finely chopped as per the ordered diet. The Registered Nurse and Registered Dietitian confirmed that the cookie did not follow the ordered texture modification. Similarly, Resident 61, who had diagnoses including Parkinson's Disease and dysphagia, was also ordered a mechanical soft, finely chopped diet. An observation revealed that the snickerdoodle cookie on Resident 61's meal tray was not finely chopped, contrary to the diet order. The Food Service Supervisor confirmed that the cookie did not adhere to the finely chopped diet order. The Assistant Director of Dietetics acknowledged that all residents with a mechanical soft diet received the same type of cookie, which was not appropriate for their dietary needs. Resident 139, with diagnoses of esophageal obstruction and esophagitis, also had an active order for a mechanical soft, finely chopped diet. During an observation, the snickerdoodle cookie on Resident 139's meal tray was not finely chopped as required. The Food Service Supervisor confirmed the discrepancy, and the Assistant Director of Dietetics stated that the resources used for creating the Diet Manual included guidelines from the American Dietetic Association and the International Dysphagia Diet Standardization Initiative. Despite these resources, the facility's practice did not align with the dietary needs of the residents, as evidenced by the inappropriate serving of cookies.
MDS Coding Error Leads to Missed Specialized Services
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) was completed for a resident, identified as Resident 119, which had the potential to result in negative outcomes due to missed specialized services. Resident 119 was admitted with diagnoses including schizotypal disorder, obsessive-compulsive personality disorder, and anxiety disorder. A Preadmission Screening and Resident Review II (PASRR II) indicated that Resident 119 required specialized services due to a medical and/or mental health condition. However, during a review of the MDS, it was found that item A1500 was incorrectly coded as 0, indicating no serious mental illness, when it should have been coded as 1, indicating the presence of a serious mental illness. The error was attributed to a misinterpretation of the PASRR II results by Registered Nurse (RN) 2, who incorrectly coded the MDS. The Director of Nursing (DON) confirmed the coding error during an interview. As a result of this incorrect coding, the resident did not receive three out of seven recommended specialized services, including mental health rehabilitation, activities of daily living training, and psychotherapy or counseling, as confirmed by the Social Worker (SW).
Failure to Implement Safe Smoking Care Plans
Penalty
Summary
The facility failed to implement Safe Smoking Care Plans for two residents, leading to potential safety hazards. Resident 89, who has nicotine dependence and mild cognitive impairment, was observed smoking in a non-smoking area without supervision. Despite the care plan indicating that Resident 89 should be escorted to a designated smoking area under supervision, staff allowed the resident to smoke unsupervised and in inappropriate locations. Additionally, a staff member was observed escorting Resident 89 to a non-smoking area and providing a cigarette and lighter, contrary to the care plan directives. Resident 142, diagnosed with high blood pressure, chronic kidney disease, and tobacco use, was observed smoking without being offered a smoking apron, which was a requirement in the resident's care plan to prevent injury. The Charge Nurse confirmed that Resident 142 should have been offered a smoking apron while smoking. These oversights in implementing the care plans had the potential to cause severe injuries from fires and burns to the residents, other residents, staff, and visitors.
Failure to Implement Smoking Safety Measures
Penalty
Summary
The facility failed to implement measures to prevent smoking accidents for two residents, leading to potential safety hazards. Resident 89, who has nicotine dependence and mild cognitive impairment, was observed smoking in a non-smoking area without supervision. Despite the care plan indicating that Resident 89 should be escorted to a designated smoking area under supervision, staff allowed the resident to smoke in unauthorized areas. This was confirmed by multiple observations and interviews with staff, who acknowledged the resident's need for supervision and the requirement to use designated smoking areas. Additionally, Resident 89 was escorted by staff to smoke in a non-smoking area, contrary to the facility's policy and the resident's care plan. A CNA admitted to providing the resident with a cigarette and lighter before reaching the designated smoking area. The facility's policy clearly prohibits smoking in non-designated areas, yet this was not adhered to, as evidenced by the resident's repeated smoking in front of the building and the burning of a wheelchair cushion. Resident 142, diagnosed with high blood pressure, chronic kidney disease, and tobacco use, was observed smoking without a protective smoking apron, despite the care plan's directive to offer one. The resident confirmed not being offered an apron, and the charge nurse acknowledged the oversight. The facility's policy emphasizes promoting safe smoking practices, yet the failure to provide a smoking apron to Resident 142 represents a lapse in adhering to these safety measures.
Failure to Follow Safe Food Handling Protocols
Penalty
Summary
The facility failed to adhere to its policy regarding the labeling and dating of food items brought in by residents, family, or visitors, which are stored in the communal refrigerator. During observations, it was noted that an opened jar of pickles and a container of dairy-free lemon ice cream were found in the refrigerator without labels or dates. Registered Nurses on Unit C2 confirmed that these items should have been discarded according to the facility's policy, which mandates that any food or beverage not labeled with a resident's name and date should be immediately discarded. Additionally, expired food items were found in the communal refrigerator, including a container wrapped in a plastic bag and two brown plastic bags duct-taped closed, all with old dates. The Assistant Director of Nursing and a Registered Nurse acknowledged that these items should have been thrown away. The facility's policy clearly states that all perishable foods must be labeled with the resident's name and the date stored, and any unlabeled or expired items should be discarded immediately. The failure to follow these protocols posed a risk of residents consuming expired or improperly stored food.
Failure to Maintain Proper Dumpster Lids
Penalty
Summary
The facility failed to ensure that two of four outside dumpsters had lids, which is a requirement to prevent attracting pests and rodents. During an observation and interview with the Chief Engineer in the loading dock area, it was confirmed that the dumpsters did not have lids. The Chief of Plant Operations was unaware of the need for lids on the dumpsters. A review of the U.S. Food and Drug Administration's Food Code from 2022 indicated that outside receptacles used with materials containing food residue must have tight-fitting lids. Additionally, the facility's policy on trash removal, dated March 7, 2024, stated that dumpster lids should remain closed.
Unauthorized Administration of Morphine Sulfate
Penalty
Summary
The facility failed to adhere to its policy and procedure for handling unusable drugs, resulting in the unauthorized administration of morphine sulfate to a resident without an active physician's order. The resident, who was admitted with osteoarthritis of the hip, had a physician's order for morphine sulfate that had expired. Despite this, a dose of morphine sulfate was signed out and administered by a Licensed Vocational Nurse (LVN) after the order had ended. Interviews with facility staff revealed a breakdown in communication and procedure. The LVN stated that expired narcotic orders should prompt the medication nurse to notify the Charge Nurse, who would then either obtain a new order or ensure the narcotics were taken to the pharmacy for destruction. The Pharmacy Manager confirmed that medications without active orders should not remain in active stock. The facility's policy on expired and unusable medications clearly stated that such drugs should be segregated and not administered, yet this protocol was not followed, leading to the deficiency.
Unauthorized Administration of Morphine Sulfate
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a Licensed Vocational Nurse (LVN) administered morphine sulfate without a physician's order. The resident, who was admitted with a diagnosis of osteoarthritis of the hip, had a previous physician's order for morphine sulfate that expired on 10/12/24. However, on 10/18/24, LVN 1 signed out and administered a dose of morphine sulfate to the resident without verifying an active physician's order, as required by the facility's policy and procedure. Interviews with the Registered Nurse (RN) and Supervisor Registered Nurse (SRN) confirmed that the LVN did not follow the protocol of checking the physician's orders before administering medication. The facility's policy mandates that medications are administered only on the order of a physician, and the six rights of medication administration must be adhered to. LVN 1 admitted to administering the medication because the resident was in pain but failed to verify the physician's order, leading to the unauthorized administration of morphine sulfate.
Inadequate Infection Control Training on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection control training program, specifically regarding Enhanced Barrier Precautions (EBP), which are designed to reduce the transmission of multidrug-resistant organisms. The deficiency was identified during a survey where multiple instances of breaches in EBP were observed. Certified Nursing Assistants (CNAs) were seen providing personal hygiene and toileting assistance to residents without wearing the required gowns, and there was a lack of signage on residents' doors to indicate their EBP status. Interviews with staff revealed a lack of awareness and training regarding EBP, with some staff only receiving training on the day of the survey. The facility's Infection Preventionist (IP) and Director of Nursing (DON) were responsible for overseeing the infection prevention program, but there was a lack of coordination and communication regarding EBP implementation. The IP relied on floor staff and the wound care nurse to determine which residents should be on EBP, while the DON confirmed that the IP and nurses should collaborate on these decisions. However, the training provided was insufficient, as only 35% of nursing staff and providers were trained in EBP, and new employees did not receive EBP training as part of their orientation. The facility's policies and procedures did not include a specific policy related to EBP, and the training program did not cover all necessary staff, such as environmental services and therapy/rehabilitation staff. The lack of a comprehensive training program and clear policies led to staff being unable to demonstrate infection control competency, potentially compromising the safety of the medically-compromised resident population.
Inadequate Implementation of Infection Control Measures
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for four of thirteen sampled residents, which is a measure to reduce the transmission of germs between residents. The Infection Preventionist (IP) stated that EBP should be used for residents with wounds, indwelling devices, or colonization with Multidrug Resistant Organisms (MDRO). However, multiple staff members, including Licensed Vocational Nurses (LVNs) and Certified Nursing Assistants (CNAs), did not follow these precautions. For instance, Resident 6, who tested positive for MDRO, did not have the required signage on their door, and staff did not wear gowns when providing care. Similarly, Resident 7, with a stage 2 pressure ulcer, and Resident 9, with a vascular wound, also lacked proper signage and staff adherence to EBP. Additionally, the facility failed to ensure that staff in the Yellow Zone, a designated area to limit the spread of COVID-19, wore the necessary personal protective equipment (PPE). Laundry Staff 1 was observed in the Yellow Zone without an N95 mask or eye protection, despite the requirement for all staff to wear these items in the area. The Director of Nursing (DON) and the Infection Preventionist confirmed that all staff, regardless of their role, should adhere to these PPE requirements to prevent the spread of COVID-19. The facility did not provide a policy related to the use of Enhanced Barrier Precautions during the survey, and the staff's lack of adherence to infection control measures was evident. The CMS Quality and Safety & Oversight Group memo and the facility's own policy on infection control emphasize the importance of these precautions, yet the facility's implementation was inconsistent, leading to potential risks of infection spread among residents, staff, and visitors.
Failure to Conduct Neurological Assessments Post-Fall
Penalty
Summary
The facility failed to implement physician's orders for neurological assessments for two residents after they sustained falls. Resident 1, who was admitted with diagnoses including generalized muscle weakness and abnormalities of gait and mobility, experienced two falls. After the first fall on July 1, 2024, the physician ordered neurological checks for 72 hours post-fall. However, three scheduled assessments were missed. Following a second unwitnessed fall on July 27, 2024, 15 scheduled neurological assessments were not conducted. The Charge Registered Nurse confirmed these omissions during a review of the Neurological Check Flow Sheets. Resident 2, admitted with cognitive impairment, also did not receive the required neurological assessments following a fall. The physician's order dated June 26, 2024, specified neurological checks per protocol for 72 hours. However, seven scheduled assessments were missed. The Quality Assurance Supervising Registered Nurse acknowledged that the licensed staff should have conducted these checks as ordered. The facility's policy and procedure for Accident/Fall Prevention and Neurological Assessment require that residents with head injuries, unwitnessed falls, or impaired neurological responses undergo neurological assessments. These assessments are to be documented in the health care record, including initiation, results, changes from baseline, and completion of the assessment period. The failure to conduct these assessments as per the physician's orders and facility policy could potentially delay identifying changes in the residents' neurological status.
Failure to Report Abuse Allegation to State Agency
Penalty
Summary
The facility failed to report an abuse allegation to the State Survey Agency involving two residents. Resident 2, a male with a history of dementia and behavior disturbance, was observed by two dining hall staff members engaging in inappropriate sexual behavior in front of Resident 1, a female with a history of major depressive disorder and dementia. This incident occurred in the dining hall and was witnessed by staff, yet the facility did not report the incident to the California Department of Public Health (CDPH) Licensing and Certification, citing that both residents had dementia. The facility's Standards and Compliance Manager acknowledged that the incident was reported to management, law enforcement, and the Ombudsman office, but not to CDPH Licensing and Certification. The facility's policy on Elder Abuse Prevention and Response mandates reporting such incidents to Licensing and Certification, the Ombudsman, and local law enforcement. The failure to report this incident to the appropriate state agency resulted in undue emotional distress for Resident 1 and posed a potential risk for other residents.
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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) |
|---|---|---|---|---|
| Brentwood Health Care Center | 3 mi | ★★★★★ | 10 | 0 |
| New Vista Post-acute Care Center | 3.1 mi | ★★★★★ | 45 | 0 |
| Westwood Post Acute Care | 3.1 mi | ★★★★★ | 6 | 0 |
| Berkley East Healthcare Center | 3.4 mi | ★★★★★ | 14 | 0 |
| Santa Monica Health Care Center | 3.4 mi | ★★★★★ | 5 | 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 June 2026) and official state health department websites.