Above average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 West Hollywood Healthcare & Wellness Centre, Lp during CMS and state inspections, most recent first.
Failure to control resident funds and gifts: A resident with Parkinsonism, CKD, depression, muscle weakness, and bipolar disorder had intact cognition and could make decisions, yet the MR Director handled the resident’s check and deposited it into her personal account after the bank declined to cash it. The resident also acknowledged giving cash to a staff member, while the DON said staff are not allowed to cash resident checks or handle finance, the BOM said residents should access cash through the business office or social services, and the ADM stated there was no policy for gifts.
Resident Funds Misappropriated by Staff Member: A resident with Parkinsonism, CKD, depression, muscle weakness, and bipolar disorder was found to have a staff member deposit the resident’s personal check into the staff member’s personal account. The resident stated self-managing finances, denied writing the $3271 check, and the BOM said only the business office and social services manage resident funds. The MR admitted attempting to cash the resident’s check at a bank, then depositing it into a personal account after the bank declined, and the ADM later stated the MR had cashed three separate checks totaling over six thousand dollars.
Surveyors identified multiple deficiencies in food storage, labelling, and sanitation, including expired and unlabelled food items, improper cooling of hazardous foods, and unclean kitchen equipment such as the ice machine and water dispenser. Staff interviews revealed inconsistent adherence to facility policies for food safety and cleaning, and record reviews showed missing documentation for required food cooling procedures.
Staff failed to cap and secure a gastric tube after disconnecting it from a resident, leaving the tube and feeding solution on the floor, and did not promptly remove a peripheral IV catheter after therapy was completed for another resident. These actions did not follow infection control policies and were confirmed by interviews with nursing staff and the DON.
Surveyors found that a laundry room was not maintained in good repair, with cracked and dirty floors, a large hole, an open pipe, a damaged wooden platform for chemical buckets, peeling ceiling paint, and a broken door to the trash area. These deficiencies were confirmed by the Maintenance Supervisor and Administrator, and were not in compliance with facility policy.
Thirteen rooms were found to house three residents each, but the room sizes did not meet the required 80 square feet per resident, with each resident receiving between 69.7 and 73.3 square feet. Staff and residents reported adequate space for movement and care, but the facility's documentation confirmed the rooms were below the regulatory minimum.
Closet doors in nine rooms were found unhooked and nonfunctional, as nurses had removed the bottom attachments to store residents' wheelchairs due to limited space. A family member reported the issue, but no repair requests were logged, and the DON confirmed that this practice was not permitted and could lead to resident injury.
A resident with chronic medical conditions had an abnormal potassium lab result that was not promptly reported to the physician, despite facility policy requiring immediate notification. The delay in communication was confirmed through record review and staff interviews.
A resident with a stage 4 sacral pressure ulcer and complex medical history was found without a required dressing on the wound, despite physician orders and facility policy mandating daily wound care with Silvadene, Santyl, and a foam dressing. Staff interviews confirmed the dressing was missing during care, and the DON acknowledged that the wound should always be covered to prevent infection and further injury.
A resident with multiple chronic conditions received IV hydration as ordered, but the IV catheter was not removed after therapy was completed, despite facility policy and lack of a physician order to maintain access. Nursing staff and the DON confirmed the catheter should have been discontinued promptly, but it remained in place for several days.
A resident with multiple medical conditions, including CHF and acute respiratory failure, did not have their oxygen tubing changed weekly as required by facility policy, and their physician's order for oxygen therapy was incomplete, lacking clear parameters for administration. Staff confirmed these deficiencies during interviews, and facility policies supported the requirements for both timely tubing changes and complete orders.
A resident with end-stage renal disease and a history of kidney transplant failure did not have current vital signs assessed and documented within the required timeframe before being transported for dialysis. Nursing staff took vital signs several hours before departure instead of within two hours as required by facility policy and physician orders, and this information was not properly communicated to the dialysis center.
The facility failed to ensure timely follow-up and documentation of Advance Directives for four residents, despite indications that these directives were executed or intended. This deficiency involved residents with various medical conditions, including cognitive impairments, and was acknowledged by the Social Services Director.
A resident with multiple health issues refused medications for several consecutive days, but the facility failed to notify the physician or document any educational efforts. The resident expressed a preference for taking medications with food and was not informed of the risks of refusal. The facility's policies require physician notification after a certain number of refusals, which was not followed.
A facility failed to obtain necessary physician orders and informed consent for the use of bilateral bed side rails for nine residents, despite their cognitive and mobility impairments. Observations confirmed the use of side rails without proper documentation, and staff interviews revealed a misunderstanding of policy requirements, leading to potential misuse of restraints.
The facility failed to develop and implement comprehensive care plans for 12 residents, leading to deficiencies in areas such as mobility aids, medical treatments, and infection precautions. Observations showed residents using side rails without care plans, missing precautions for infection control, and improper management of medications and oxygen therapy, placing residents at risk for missed care and potential harm.
The facility failed to manage pain effectively for two residents by not following physician orders and facility policies for lidocaine patch application and removal. One resident did not receive the patch at the scheduled time, and removal times were not documented, while another resident's patches were applied inconsistently and without proper labeling. The DON acknowledged the lack of documentation and adherence to policies, placing residents at risk for untreated pain.
The facility failed to provide adequate staffing, resulting in delayed responses to call lights for several residents. Residents reported waiting 30 minutes to an hour for assistance, as CNAs were on lunch breaks and no other staff responded. The facility's policy required call lights to be answered within two minutes, which was not followed.
A facility failed to ensure its nursing staff had verified competencies necessary for resident care. A review revealed that a RN, an IPN, and two CNAs lacked documented skills competencies, as confirmed by the DSD. Facility policy requires competency assessments upon hire, annually, and as needed, but these were missing from the employee files, potentially compromising resident safety.
The facility failed to properly secure and reorder medications from emergency kits, leading to potential harm. An IV E-kit was improperly resealed, and a narcotic E-kit was not reordered promptly after use. The Emergency Kit Pharmacy Logs were incomplete, and procedures for reordering were not followed, as confirmed by the DON and an RN.
The facility failed to properly manage pharmaceutical supplies and medications, including the disposal of expired items and labeling of opened medications. Expired sterile supplies were found in storage, and opened medications lacked proper dating. Additionally, medication carts and pill cutters were not maintained in a clean and organized manner, posing risks of cross-contamination and infection.
The facility failed to provide appropriate meals for residents on renal and vegetarian diets, leading to dissatisfaction and potential nutritional inadequacies. A resident on a renal diet received chicken jambalaya instead of the prescribed meal, while residents on vegetarian diets reported limited meal variety and inappropriate options like fish sticks. The facility's dietary supervisor acknowledged the lack of a specialized vegetarian menu and the need for reassessment of dietary needs.
The facility failed to honor dietary preferences and physician-ordered diets, serving a vegan resident fish sticks and providing inadequate protein substitutes for vegetarian residents. This resulted in a deficiency in meal service, as the facility did not adhere to its policies on dietary profiles and resident preferences.
The facility failed to ensure safe food storage and preparation, as food brought in from outside was not dated, and there was no monitoring system for refrigerator temperatures. Expired food was not discarded, and the resident refrigerator lacked a thermometer and temperature log. The facility's policy on labeling and discarding perishable food was not followed.
The facility's Administrator failed to maintain professionalism during a recertification process, hindering an investigation into infection control practices. A resident with chronic conditions and on Enhanced Standard Precaution was observed with visitors not wearing PPE. The Administrator's confrontational behavior towards the surveyor and lack of communication about precautions led to visitor dissatisfaction and an incomplete investigation.
The facility failed to maintain an effective infection prevention and control program, with staff not donning appropriate PPE during resident care, lack of education and PPE for visitors, and unclean medication carts. Residents with indwelling catheters were not placed on Enhanced Standard Precautions (ESP), and staff lacked understanding of ESP requirements, increasing the risk of infection spread.
The facility failed to implement its Antibiotic Stewardship protocol for three residents, resulting in incomplete infection analysis for prescribed antibiotics. A resident with osteomyelitis, another with a spinal abscess, and a third with a UTI were all prescribed antibiotics without proper evaluation against usage criteria. This deficiency was identified during reviews with the Infection Preventionist Nurse.
A resident was not informed about the Enhanced Standard Precaution (ESP) measures in place, leading to confusion about her health status. Despite having ESP signage, staff failed to communicate the reasons for wearing gowns and gloves, violating the resident's rights. An LVN incorrectly stated that precautions were unnecessary, and the Infection Preventionist Nurse admitted the facility was still finalizing ESP protocols.
A resident with dementia and other health issues was not provided with necessary personal hygiene assistance after meals, leaving them with food on their clothes and bed. This failure to adhere to the care plan and facility policies compromised the resident's dignity and respect.
The facility failed to maintain comfortable noise levels, impacting two residents' ability to sleep due to staff shouting at night. Despite awareness of the issue, no corrective actions, such as staff training, were implemented, violating the facility's policy on maintaining a homelike environment.
A resident with a history of stroke, diabetes, and renal dialysis was not using a humidifier with their oxygen concentrator, leading to a failure in notifying the MD about this significant change in condition. The resident turned off the oxygen due to discomfort and lack of education on the humidifier's importance. The Infection Preventionist Nurse noted the issue and completed a Change of Condition report, but acknowledged that the nursing staff should have reported the change sooner.
A resident with cognitive impairments and multiple health conditions was found with medications improperly stored at their bedside, contrary to facility policy. The DON confirmed the resident was not approved for self-administration, highlighting a failure to ensure a hazard-free environment.
The facility failed to provide proper IV access care for two residents. One resident lacked a care plan for IV therapy, while another had a PICC line dressing improperly labeled. Additionally, a nurse did not wear required PPE during PICC line care. These actions were inconsistent with professional standards and facility policies.
Two residents in the facility did not receive prescribed oxygen therapy as per physician's orders. One resident, with multiple health conditions, was not provided with any oxygen therapy despite a physician's order. Another resident, with acute respiratory failure, received less oxygen than prescribed. The facility's policy required adherence to physician's orders for oxygen therapy, which was not followed.
A facility failed to document a post-hemodialysis assessment for a resident with end-stage renal failure, as required by professional standards. The resident, who needed maximal assistance for daily activities, did not have a post-dialysis evaluation form completed, indicating a lapse in care. An LVN confirmed that assessments should occur before, during, and after dialysis, but the facility did not maintain the necessary documentation.
The facility did not post the required daily nurse staffing hours on one occasion due to the absence of the Director of Staff and Development (DSD), who was on vacation. The posted information was outdated by two days, failing to provide residents, family, or visitors with access to current staffing hours, as mandated by federal regulations.
The facility failed to communicate pharmacist recommendations to the attending physician for two residents. One resident had a recommendation to re-evaluate duplicate antihistamine therapy, which was not documented or communicated, and the other had a recommendation to add a 'do not crush' instruction to a medication order, which was also not documented. The facility's policy required these recommendations to be acted upon and documented, which was not followed.
A resident on a kosher and fortified diet did not receive the fortified diet as ordered by the physician. During lunch service, the resident's prepackaged kosher meal was not opened to add butter, which was part of the fortified diet plan to increase caloric intake. The dietary staff failed to communicate and implement the fortified diet order, resulting in the resident not receiving the necessary additional calories.
A resident's room was found to have an uncovered overhead light with an exposed bulb, posing a potential safety risk. The Maintenance Supervisor confirmed the absence of a protective cover, which is required to prevent electrical accidents. The resident had multiple diagnoses, including hemiplegia and Alzheimer's, and required total dependence on staff for ADLs.
The facility did not meet the required 80 square feet per resident in 13 out of 34 rooms, with each room providing less than the minimum required space for three residents. Despite this, observations showed that residents and staff had enough space to move freely, and nursing staff could provide care safely. A room waiver request was submitted to address the issue.
Failure to control resident funds and gifts
Penalty
Summary
The facility failed to develop a policy and procedure for acceptance of gifts, money, or items of value from residents by staff, and failed to implement its Resident Funds policy when the Medical Records Director handled a resident’s money/check. The deficiency involved one sampled resident who was admitted and readmitted to the facility with diagnoses including parkinsonism, chronic kidney disease, major depressive disorder, muscle weakness, and bipolar disorder. The resident’s H&P stated the resident had Parkinson’s disease, chronic kidney disease, and the capacity to understand and make decisions, and the MDS indicated intact cognitive skills for self-care decisions. During interview, the resident acknowledged writing checks for monthly share of cost, a tax preparer, and transportation services, and acknowledged giving $40 cash to a staff member within the last month. The resident did not remember writing a check for $3271 and denied writing a check for that specific amount. The Medical Records Director stated the resident asked her to cash a check at the end of April 2026, that she went to the bank to cash the resident’s $3271 check, and that when the bank declined to cash it, she deposited the resident’s check through mobile banking to her personal account. The Medical Records Director stated she had received training and in-service on abuse prevention and reporting, and acknowledged that mishandling residents’ personal funds is one form of abuse. The BOM stated it was not a practice for staff to go with a resident or by themselves to cash a check on a resident’s behalf, and that the best route for residents to access cash is through the business office and social services. The DON stated staff are not allowed to deal with resident finance, are not allowed to cash a check for any reason, and that cash, funds, and finance transactions are managed by the business office or social services; the DON also stated there was no policy for gifts. The Administrator stated there was no limit if a resident wants to give money to anyone and did not believe the facility had a policy for gifts.
Resident Funds Misappropriated by Staff Member
Penalty
Summary
The facility failed to ensure resident funds were safeguarded from misappropriation when a staff member deposited a resident’s personal check into the staff member’s personal account. The deficiency involved one resident who was admitted and readmitted to the facility with diagnoses including parkinsonism, chronic kidney disease, major depressive disorder, muscle weakness, and bipolar disorder. The resident’s H&P stated the resident had Parkinson’s disease and CKD and had the capacity to understand and make decisions. The MDS indicated intact cognitive skills for decision-making and dependence on staff for several ADLs. During observation and interview, the resident stated self-managing personal funds and finances and acknowledged writing a check for monthly SOC, but denied writing a check for the specific amount of $3271 and did not remember writing that check. The BOM reviewed the resident’s invoices and SOC and stated the resident recently wrote a check for SOC, tax preparation, and transportation, but was unaware the resident wrote a check for $3271. The BOM also stated only the business office and, to some extent, social services manage resident finances and that no other staff have access to resident funds. During interview, the MR stated the resident asked the MR to cash a check at the end of April 2026. The MR went to the bank to cash the resident’s check for $3271, but the bank declined because it could not verify ownership of the check and could not speak to the resident by phone. The MR then deposited the resident’s check into the MR’s personal account through mobile banking. The MR acknowledged this was not a normal practice and stated mishandling residents’ personal funds is a form of abuse. The ADM later stated the MR had cashed three separate checks for the resident totaling over six thousand dollars, and the facility’s policies stated staff may not act as authorized representatives of resident funds and that the facility does not condone misappropriation, exploitation, or mistreatment.
Deficient Food Storage, Labelling, and Sanitation Practices in Dietary Services
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen, as evidenced by multiple observations and interviews. Surveyors found expired food items, such as pudding and strawberries, in the kitchen refrigerator, as well as unlabelled containers of cooked foods like fish sticks, cream soup, and meatloaf. The ice machine and water dispenser trays were observed to be dirty, and the residents' outside food storage refrigerator and freezer were found to be unclean, with old and dried food present. The refrigerator temperature was above 40 degrees, and some food items, including yogurt and sausages, were not properly labelled with expiration dates or use-by instructions. Interviews with dietary staff and supervisors revealed that the required cooling down method for hazardous foods was not consistently followed. One dietary cook admitted to not using the cool down method for recently prepared meatloaf and tuna, despite having received training on the procedure. Record reviews confirmed the absence of documentation for the cooling process of several cooked items, including meatloaf, soups, and fish sticks. The Registered Dietician confirmed that dietary staff are expected to follow the cool down method and that failure to do so could result in residents consuming unsafe food. Further interviews indicated a lack of clarity and consistency regarding staff responsibilities for food labelling, discarding expired foods, and cleaning equipment. The Maintenance Supervisor stated that he cleans the ice machine and water dispenser daily and the residents' refrigerator every three days, but there were no cleaning logs or policies for the water dispenser. Facility policies required labelling, dating, and timely discarding of food, as well as routine cleaning of the ice machine, but these procedures were not consistently implemented or documented.
Failure to Maintain Infection Control for Enteral Feeding Tubes and IV Catheters
Penalty
Summary
The facility failed to implement and maintain infection control measures for two residents, resulting in deficiencies related to the handling of a gastric tube (GT) and the removal of an intravenous (IV) catheter. For one resident with a history of urinary tract infection and gastrostomy, observations revealed that the GT feeding machine was disconnected, and the GT bottle containing Jevity was left uncapped and lying on the floor, with a moderate amount of the nutritional supplement leaking onto the floor. Interviews with nursing staff and the Director of Nursing confirmed that the GT tubing should have been capped when disconnected to prevent contamination, and that failure to do so constitutes an infection control issue. Additionally, the facility did not remove a peripheral IV catheter from another resident after the completion of IV therapy. The resident, who had diagnoses including hypertension, chronic kidney disease, and diabetes, was observed with a peripheral IV line still in place two days after the physician's order for hydration had ended. Nursing staff and the Director of Nursing confirmed that IV access should be discontinued promptly after therapy is completed unless there is a physician's order to maintain it, which was not present in this case. Record reviews of facility policies indicated that staff are trained on infection control procedures, including the proper handling of enteral feeding tubes and the removal of peripheral IV catheters. However, the observed practices did not align with these policies, as the GT tubing was not capped and was left on the floor, and the IV catheter was not removed in a timely manner after therapy completion.
Failure to Maintain Laundry Room in Safe and Operable Condition
Penalty
Summary
Surveyors observed that the facility failed to maintain one of two laundry service rooms in good repair, as required by policy. The laundry room was found to have multiple areas in disrepair, including cracked and dirty floors, a large hole in the floor, an open pipe in the wall, and a wooden platform supporting chemical buckets that was rotted or water-damaged with holes and cracks. The ceiling had dark spots of unknown origin, peeling and flaking paint, and the door leading to the trash area was broken at the bottom. The floor was also noted to be several different colors, indicating possible staining or further disrepair. These findings were confirmed during interviews with the Maintenance Supervisor, who acknowledged the need for immediate repairs, and the Administrator, who agreed that repairs were necessary once estimates were obtained. The facility's own policy and procedures require the Maintenance Department to keep all areas of the building, grounds, and equipment in a safe and operable manner at all times, and to maintain the building in good repair and free from hazards. The observed conditions in the laundry room, including structural damage, unclean surfaces, and compromised containment of chemicals, represent a failure to adhere to these requirements. No information about residents' medical history or condition was provided in relation to this deficiency.
Resident Rooms Below Minimum Space Requirements
Penalty
Summary
The facility failed to ensure that 13 out of 34 resident rooms met the required minimum of 80 square feet per resident in multiple occupancy rooms, as specified by regulations. Specifically, rooms identified as 3, 4, 8, 9, 11, 14, 15, 16, 17, 18, 20, 22, and 33 were found to house three residents each, with room sizes ranging from 209 to 220 square feet, resulting in less than the required space per resident. Documentation from the facility, including a room waiver request and Client Accommodation analysis, confirmed these measurements. Observations during the survey period noted that both residents and staff had enough space to move about freely, and staff interviews indicated that care could be provided adequately in the affected rooms. The facility's policy stated an intent to provide a safe, comfortable, and person-centered environment, but the physical room sizes did not meet the regulatory standard for space per resident.
Nonfunctional Closet Doors Used for Wheelchair Storage
Penalty
Summary
The facility failed to ensure that closet doors were functional in nine resident rooms, as observed during a survey. Family members reported that closet doors were broken and that the issue had been communicated to nursing staff, but the problem remained unresolved. During an observation with the Maintenance Supervisor, it was noted that the closet doors in the affected rooms were not attached at the bottom and would swing open. The Maintenance Supervisor explained that nurses had unhooked the closet sliding doors at the bottom to store residents' wheelchairs in the closets due to insufficient space in the rooms. A review of the facility's repair request log showed no recorded requests for the repair of the closet doors in the affected rooms. The Director of Nursing confirmed that nurses were not authorized to unhook closet doors and acknowledged the potential for resident injury due to the swinging doors. The facility's policy and job description for the Maintenance Supervisor require maintaining a safe, comfortable, and sanitary environment for residents, staff, and visitors.
Failure to Promptly Notify Physician of Abnormal Potassium Level
Penalty
Summary
A deficiency occurred when the facility failed to promptly notify a physician of an abnormal laboratory result for a resident. The resident, who had a history of hypertension, chronic kidney disease, and diabetes, had a blood potassium level of 5.6 mEq/L, which was flagged as high. The laboratory result was available at 11:26 PM, but the physician was not notified until the following day at 5:50 PM. Both the Registered Nurse Supervisor and the Director of Nursing confirmed that abnormal lab results should be reported to the physician as soon as they are received, in accordance with facility policy. The resident was cognitively intact and required substantial to maximal assistance with activities of daily living. The facility's policy required licensed nurses to promptly notify the attending physician of abnormal laboratory findings by telephone or fax, with the date and time noted. Despite this, there was a significant delay in notifying the physician about the resident's hyperkalemia, as documented in the records and confirmed during staff interviews.
Failure to Maintain Physician-Ordered Dressing on Sacral Pressure Ulcer
Penalty
Summary
The facility failed to follow physician orders and provide appropriate wound care for a resident with a stage 4 sacral pressure ulcer. The resident, who had a history of sepsis, osteomyelitis of the sacrum and coccyx, and a recent skin graft to the sacrococcyx area, was admitted and readmitted with significant medical needs. Physician orders and the resident's care plan required the application of Silvadene and Santyl ointments, cleansing with normal saline, and the use of a foam dressing to the sacral wound. However, during wound care observation, the resident's sacral pressure injury was found without a dressing in place. Staff interviews confirmed that the dressing was not present during morning care and that CNAs were instructed not to remove dressings, with responsibility for replacement falling to the charge nurse or RN supervisor if a dressing became soiled or detached. Record reviews further indicated that the facility's policies and the treatment nurse's job description required adherence to prescribed wound care treatments to prevent infection and promote healing. Despite these protocols, the resident's wound was left uncovered, contrary to both physician orders and facility policy. The DON and treatment nurses acknowledged that the wound should always be covered to prevent infection and further injury, and that the absence of a dressing was not in accordance with established procedures.
Failure to Timely Remove IV Catheter After Completion of Therapy
Penalty
Summary
The facility failed to remove a resident's intravenous (IV) catheter after the completion of ordered IV hydration therapy. The resident, who had a history of hypertension, chronic kidney disease, and diabetes, was cognitively intact and required substantial assistance with activities of daily living. Physician orders specified that IV hydration was to be administered until a specific date and time, after which there was no order to maintain the IV access. Despite this, observation revealed that the peripheral IV line remained in place on the resident's forearm two days after the hydration therapy was completed. Interviews with nursing staff and the Director of Nursing confirmed that facility policy required IV catheters to be discontinued promptly after therapy unless there was a physician's order to keep the access. There was no documentation of such an order for this resident. The facility's policy and procedures also indicated that peripheral IV catheters should be removed safely and aseptically by a competent nurse when therapy is completed. The failure to remove the IV catheter as required constituted a deficiency in following professional standards for IV administration.
Failure to Provide Safe and Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide necessary respiratory care services for a resident by not changing the resident's oxygen tubing weekly as required by facility policy and by maintaining an incomplete physician's order for oxygen therapy. During observation, the resident was found using a nasal cannula with a date label indicating it had not been changed within the required seven-day period. Staff interviews confirmed that the tubing should have been changed weekly to maintain infection control, and failure to do so could lead to infection. Additionally, a review of the resident's physician order for oxygen therapy revealed that the order lacked specific parameters, such as whether the oxygen was to be administered routinely or as needed, and did not provide clear instructions for when to start or stop oxygen. Both the RN Supervisor and the DON acknowledged that the order was incomplete and that oxygen, considered a medication, requires a complete and clear order to ensure safe administration. The facility's policies confirmed the need for weekly tubing changes and complete physician orders for oxygen therapy.
Failure to Assess and Document Pre-Dialysis Vital Signs Prior to Transport
Penalty
Summary
Facility staff failed to ensure that a resident requiring dialysis received care consistent with professional standards by not assessing and documenting the resident's current vital signs immediately prior to transport to the dialysis center. Record reviews showed that the resident's pre-dialysis vital signs were taken more than four hours before the resident left for dialysis on multiple occasions, despite facility policy and physician orders requiring that vital signs be taken within two hours of departure. Interviews with nursing staff and the Director of Nursing confirmed that vital signs are necessary to determine the resident's appropriateness for dialysis and to identify any potential complications before transport. The resident involved had a history of end-stage renal disease, dependence on renal dialysis, and kidney transplant failure, and required substantial assistance with activities of daily living. The care plan for this resident included monitoring vital signs and reporting abnormalities prior to dialysis. Facility policy and the care coordination agreement with the dialysis provider both required that current vital signs be communicated to the dialysis staff and that residents be assessed for medical stability before transport. Despite these requirements, the facility did not consistently follow these protocols, resulting in a failure to properly assess the resident's condition prior to dialysis treatments.
Failure to Follow Up on Advance Directives
Penalty
Summary
The facility failed to ensure that residents were informed, offered, or followed up regarding Advance Directives (ACHD) in a timely manner for four of the 18 sampled residents. This deficiency was identified through interviews and record reviews, revealing that the facility did not have copies of the ACHDs for Residents 43, 3, 48, and 58, despite indications that these residents had executed or intended to execute such directives. The absence of these documents in the residents' medical records could potentially lead to conflicts with the residents' healthcare wishes. For Resident 43, the admission records indicated a diagnosis of urinary tract infection, sepsis, and paroxysmal atrial fibrillation. The Minimum Data Set (MDS) showed that Resident 43 had mildly impaired cognitive skills and required assistance with activities of daily living. Despite choosing the option that an ACHD had been executed, there was no follow-up or documentation by the Social Services Department to obtain a copy of the ACHD. The Social Services Director (SSD) acknowledged the lack of follow-up and documentation. Similarly, Resident 3, who had diagnoses including hemiplegia, Parkinson's disease, and Alzheimer's disease, was noted to have moderately impaired cognitive skills and total dependence on staff for daily activities. Although the ACHD assessment indicated that an ACHD had been executed, there was no documentation or follow-up to obtain a copy. The SSD admitted to not following up or documenting the ACHD. For Residents 48 and 58, similar issues were noted, with the SSD failing to follow up on the residents' ACHD status or document any actions taken, despite the residents' intentions to execute or provide ACHDs.
Failure to Notify Physician of Medication Refusal
Penalty
Summary
The facility failed to notify the physician when a resident continued to refuse her medications, which was identified as a deficiency during a survey. The resident, who was admitted with diagnoses including metabolic encephalopathy, hypertension, a history of falling, and muscle weakness, had moderately impaired cognitive skills and required assistance with activities of daily living. Despite multiple consecutive days of medication refusals documented in the Medication Administration Record (MAR), there was no evidence in the Progress Notes that the physician was notified or that any education was provided to the resident regarding the risks of not taking her medications. During an interview, the resident expressed her dislike for taking medications without food and mentioned that nurses did not inform her of the risks associated with refusal. The Director of Nursing confirmed that the physician should be notified of medication refusals and that documentation should include the reason for refusal and any education provided. The facility's policy and procedure on medication administration and refusal of treatment require that the prescriber be notified after a certain number of doses are refused, but this was not adhered to in this case.
Improper Use of Bed Side Rails Without Physician Orders or Consent
Penalty
Summary
The facility failed to ensure that nine sampled residents were free from the use of physical restraints, specifically bilateral bed side rails, without obtaining the necessary physician's orders and informed consent as per the facility's policy and procedures. The residents involved had various medical conditions, including cognitive impairments, mobility issues, and other health diagnoses that required assistance with activities of daily living. Despite these needs, the facility did not have documented physician orders or informed consent for the use of side rails, which were observed to be in use for all nine residents. For Resident 43, the facility did not have a physician's order or informed consent for the use of bilateral bed side rails, and the resident's bed rail assessment indicated that side rails were not necessary. Similarly, Resident 48's care plan included the use of side rails for turning and repositioning, but there was no physician's order or informed consent documented. Observations confirmed that these residents were unable to lower the side rails independently, indicating a potential misuse of the rails as restraints. The Director of Nursing (DON) and other staff members, including an LVN, were interviewed and confirmed the use of side rails without the required orders or consent. The DON stated that side rails did not need a physician's order as they were not considered restraints, despite the facility's policy indicating otherwise. This misunderstanding and lack of adherence to policy resulted in the improper use of side rails, potentially compromising the residents' safety and dignity.
Deficiencies in Care Planning and Implementation
Penalty
Summary
The facility failed to develop and implement individualized comprehensive care plans for 12 residents, leading to several deficiencies. For instance, residents requiring bilateral upper bed side rails as mobility enablers did not have corresponding care plans, despite observations showing the side rails in use. This oversight was noted for multiple residents, including those with cognitive impairments and physical limitations, who required assistance with daily activities such as toileting, bathing, and bed mobility. Additionally, the facility did not implement care plans for specific medical treatments and precautions. One resident receiving Venofer IV therapy for iron deficiency lacked a care plan for this treatment, and another resident requiring transmission-based precautions due to a risk of infection was not placed under the necessary precautions. Observations revealed that staff were not using personal protective equipment as required, increasing the risk of infection. The facility also failed to manage medications and oxygen therapy appropriately. A resident was found with medications at their bedside despite not being approved for self-administration, and another resident's oxygen therapy was not set up according to the physician's orders. These lapses in care planning and implementation placed residents at risk for missed care, worsening medical conditions, and potential harm.
Inadequate Pain Management for Two Residents
Penalty
Summary
The facility failed to provide adequate pain management for two residents, Resident 9 and Resident 58, by not adhering to physician orders and facility policies regarding the application and removal of lidocaine patches. Resident 9, who was admitted with diagnoses including aftercare following joint replacement surgery and major depressive disorder, had a care plan indicating the need for pain management. However, the facility did not administer the lidocaine patch at the scheduled time of 9:00 a.m. and failed to document the removal time of the patch, which was observed to be left on beyond the prescribed 12-hour period. Similarly, Resident 58, who had diagnoses including metabolic encephalopathy and a history of falling, also experienced deficiencies in pain management. The resident's care plan required the application of a lidocaine patch for 12 hours on and 12 hours off, but the facility did not document the removal times, and the patches were applied at inconsistent times, deviating from the scheduled 9:00 a.m. application. Observations revealed that the patches were not labeled with the date and time of application, as required by the facility's policy. The Director of Nursing acknowledged the lack of specific documentation regarding the application and removal of the patches. The facility's policies on pain management and transdermal drug delivery were not followed, as evidenced by the absence of documentation on the Medication Administration Record (MAR) and the failure to label the patches correctly. These deficiencies placed both residents at risk for experiencing untreated pain and discomfort.
Delayed Response to Call Lights Due to Insufficient Staffing
Penalty
Summary
The facility failed to provide sufficient staffing to meet the needs of its residents, as evidenced by the delayed response to call lights for four out of five sampled residents. Residents 8, 18, 50, and 53 reported waiting between 30 minutes to an hour for assistance after activating their call lights. This delay occurred because the certified nursing assistants (CNAs) assigned to these residents were on lunch breaks, and no other CNAs responded to the call lights. The residents also reported hearing staff conversing outside their rooms without addressing the call lights. Resident 8 was admitted with diagnoses including obesity, osteoarthritis, and generalized muscle weakness, requiring moderate assistance for activities of daily living (ADLs). Resident 18 had monoplegia of the lower leg, spinal stenosis, and generalized muscle weakness, also requiring moderate assistance for ADLs. Resident 50 was diagnosed with bronchitis, obesity, and congestive heart failure, needing moderate assistance for ADLs. Resident 53 had diabetes mellitus, acute respiratory failure, and generalized muscle weakness, requiring minimal assistance for ADLs. The facility's policy required call lights to be answered promptly, within two minutes, which was not adhered to, as confirmed by the Director of Staff and Development.
Lack of Verified Competencies in Nursing Staff
Penalty
Summary
The facility failed to ensure that its nursing staff possessed the necessary competencies to provide safe and effective care to residents. During an interview and record review, it was found that four out of nine sampled nursing staff members, including a Registered Nurse, an Infection Prevention Nurse, and two Certified Nursing Assistants, lacked verified skills competencies. The Director of Staff and Development confirmed that these competencies were missing from the employee files. According to the facility's policy and procedures, competency assessments should be conducted upon hire, annually, and as needed, and should be documented in the employee files. The absence of these assessments indicates a failure to adhere to the facility's policy, potentially compromising resident safety.
Failure to Secure and Reorder Emergency Kits
Penalty
Summary
The facility failed to ensure proper pharmaceutical services by not securely sealing the emergency kits (E-kits) and not reordering medications used from these kits. In one instance, an Intravenous (IV) E-kit located in a medication storage closet was improperly resealed with a red zip-tie, which allowed it to be opened without cutting the tie. The Director of Nursing (DON) confirmed that the E-kit was not properly secured and should have been replaced by the pharmacy within 48 hours of opening. Additionally, the Emergency Kit Pharmacy Log inside the E-kit was incomplete, missing entries for the pharmacist taking the order and the serial number, which the DON acknowledged should have been filled out by the nurse when removing medication. In another instance, a narcotic E-kit in a medication cart was found with a red zip-tie, indicating it had been opened. The E-kit pharmacy log showed that a medication was removed, but the required reordering of a new E-kit was not completed promptly. The Registered Nurse (RN) stated that the procedure required the nurse to reorder a new E-kit as soon as possible, with a refill needed within 72 hours of opening. The facility's policy and procedures outlined the steps for documenting medication use and reordering E-kits, but these were not followed, leading to potential harm due to the unavailability of medications in emergencies.
Deficiencies in Pharmaceutical Management and Cleanliness
Penalty
Summary
The facility failed to ensure proper disposal and management of pharmaceutical supplies and medications, as observed during a survey. An open sterile central line dressing kit, along with expired sterile needles, alcohol pads, and a saliva collection kit, were found in the IV medication storage closet. A registered nurse confirmed the expiration of these supplies and acknowledged that they should not have been present. The facility's policy requires that equipment and supplies for medication administration be clean and orderly, and that expired items be removed and disposed of appropriately. Additionally, the facility did not adhere to proper labeling and usage protocols for medications. Opened bottles of acidophilus and bismuth subsalicylate were found without dates indicating when they were opened, contrary to the facility's policy that requires dating upon opening. Furthermore, a foil pack of ipratropium Bromide and albuterol sulfate solution was found open beyond the manufacturer's recommended two-week usage period. The facility's policy mandates that nurses check expiration dates before administering medications and remove expired medications from active supply. The survey also revealed issues with cleanliness and organization of medication carts and equipment. Pill cutters in two medication carts were observed with residue from previous uses, and the carts themselves were cluttered with various items. Both a registered nurse and a licensed vocational nurse acknowledged that pill cutters should be cleaned after each use to prevent cross-contamination. The infection preventionist nurse confirmed that maintaining cleanliness of medication carts and equipment is essential to prevent infection transmission, as outlined in the facility's general guidelines for medication administration.
Inadequate Dietary Accommodations for Renal and Vegetarian Diets
Penalty
Summary
The facility failed to adhere to the dietary requirements and preferences of its residents, leading to dissatisfaction and potential nutritional inadequacies. One resident on a renal diet, which requires careful management of fluid, electrolyte, and mineral intake, was served chicken jambalaya instead of the prescribed baked chicken and rice. This substitution was inappropriate for a renal diet due to the presence of tomatoes and sausage, which are not suitable for individuals with kidney disease. The resident expressed dissatisfaction with the meal, and their family noted that the food was not appropriate for a renal diet. Additionally, residents on vegetarian and vegan diets reported a lack of variety in their meal options. One vegan resident was mistakenly served fish sticks, while another vegetarian resident frequently received fish sticks as a meal option, despite their dietary preferences. The facility's dietary supervisor acknowledged the limited vegetarian options and the absence of a specialized menu for vegetarian diets. Attempts to introduce plant-based alternatives were unsuccessful, as residents did not find them palatable. The facility's policies and procedures for menu planning and dietary accommodations were not effectively implemented, resulting in meals that did not meet the nutritional needs and preferences of the residents. The dietary supervisor and facility administrator recognized the need to reassess and evaluate the residents' dietary needs in collaboration with a registered dietitian to ensure compliance with dietary requirements and resident satisfaction.
Failure to Honor Dietary Preferences and Provide Adequate Nutrition
Penalty
Summary
The facility failed to provide meals that adhered to the dietary preferences and physician-ordered diets of its residents, leading to a deficiency in meal service. Resident 69, who was on a vegan diet, was served fish sticks during lunch, which contradicts the vegan dietary restrictions that exclude all animal products, including fish. Despite the resident's dietary profile indicating a preference for plant-based foods and a dislike for meats and dairy, the dietary staff continued to serve fish sticks, believing the resident liked them. This inconsistency in meal service was further compounded by the resident's significant weight loss over two weeks, as noted in the nutrition progress notes. Additionally, two residents, identified as vegetarians, were served fish sticks as an alternative protein source, which provided significantly less protein than the regular menu options of beef paprika and roasted pork chop. The facility's dietary supervisor acknowledged the lack of a set menu for vegetarian diets and admitted that the protein content of the fish sticks was not equivalent to the meat options provided to other residents. This inadequate substitution resulted in a lower protein intake for the vegetarian residents, which could potentially affect their nutritional status. The facility's policies on dietary profiles and resident preferences were not effectively implemented, as evidenced by the repeated serving of inappropriate meal options. The dietary manager's failure to update and adhere to the residents' dietary preferences and physician orders contributed to the deficiency. The lack of suitable vegetarian and vegan meal options, as well as the improper substitution of protein sources, highlighted the facility's inability to meet the nutritional needs and preferences of its residents.
Deficient Food Storage and Labeling Practices
Penalty
Summary
The facility failed to ensure safe and sanitary food storage and preparation practices, as observed during a survey. Food brought in from outside the facility, including leftovers stored in the resident refrigerator, was not dated, and there was no monitoring system for refrigerator temperatures. Expired food was not discarded, which could potentially lead to harmful bacteria growth and cross-contamination. During an observation, it was noted that the resident refrigerator lacked a thermometer and a temperature documentation log. Various food items, including plastic bags, a lunch box, and to-go containers, were found without labels or dates, and some exceeded the storage period for outside food. During an interview with the Dietary Supervisor and Administrator, it was revealed that the nursing staff were responsible for checking food labels and dates, but there was no clear explanation for the absence of a thermometer in the freezer. The facility's policy indicated that food brought in by visitors should be labeled with the resident's name and date received, and perishable food should be discarded after two hours at bedside or after 48 hours if refrigerated. However, these procedures were not followed, leading to the deficiency.
Administrator's Unprofessional Conduct Impedes Infection Control Investigation
Penalty
Summary
The facility failed to ensure that the Administrator maintained professionalism and appropriate behavior during the recertification process, which impeded the completion of an investigation. This deficiency placed residents at risk for the spread of infections and delays in care. The report highlights an incident involving Resident 278, who was admitted with chronic kidney disease, type 2 diabetes mellitus, and chronic obstructive pulmonary disease. The resident was on Enhanced Standard Precaution (ESP) due to a history of multidrug-resistant organisms, but there was no physician's order for ESP, and visitors were observed entering the resident's room without wearing the required personal protective equipment (PPE). During an observation and interview, the Administrator approached the surveyor in a confrontational manner, interrupting the surveyor and displaying unprofessional behavior in front of staff, residents, and visitors. The Administrator's actions included speaking loudly, pointing a paper close to the surveyor's face, and angrily questioning the surveyor about the facility's policies. This behavior led to a visitor confronting the surveyor, expressing dissatisfaction with the facility's lack of communication regarding the precautions and the absence of PPE near the resident's room. The report also describes a telephone interview with the district office supervision, where the Administrator continued to interrupt and speak loudly, claiming to be passionate. During the formal exit conference, the Administrator wore an inappropriate outfit and interrupted the surveyor multiple times, further demonstrating a lack of professionalism. The facility's policy on Enhanced Standard Precautions was reviewed, indicating the need for clear communication and signage for infection control, which was not adequately followed in this case.
Infection Control Deficiencies in PPE Use and Education
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not donning appropriate personal protective equipment (PPE) when required. For instance, a Licensed Vocational Nurse (LVN) was observed wearing gloves but not a gown while disconnecting a resident from a gastrostomy tube, despite the resident being on Enhanced Standard Precautions (ESP). Additionally, a Certified Nursing Assistant (CNA) did not wear any PPE while assisting another resident, who was supposed to be on ESP, due to a lack of updated signage and readily available PPE. The facility also failed to provide necessary education and PPE to visitors of residents on ESP. In one case, visitors entered a resident's room without being informed about the precautions or offered PPE, as the facility relied on phone notifications prior to visits. Furthermore, residents with indwelling catheters, such as those undergoing hemodialysis, were not placed on ESP, contrary to the facility's policy and CDC guidelines. This oversight was partly due to a lack of understanding among staff about the requirements for ESP. Additional deficiencies included unclean medication carts and pill cutters, which were observed with residue and clutter, posing a risk of cross-contamination. A Registered Nurse (RN) also failed to don a gown while providing care for a resident with a peripherally inserted central catheter (PICC), despite the presence of signage indicating the need for gown and glove use during such procedures. These practices collectively increased the potential for cross-contamination and the spread of infection within the facility.
Failure to Implement Antibiotic Stewardship Protocol
Penalty
Summary
The facility failed to implement its protocol for Antibiotic Stewardship for three residents, leading to a deficiency in monitoring antibiotic use. Resident 178, who was admitted with conditions including diabetes mellitus, end-stage renal failure, and hemodialysis dependence, was prescribed ceftriaxone sodium and daptomycin for osteomyelitis. However, the Infection Screening Evaluation (ISE) for these antibiotics lacked the necessary infection analysis results to determine if the antibiotic usage criteria were met. This oversight was confirmed during a review with the Infection Preventionist Nurse (IPN) and acknowledged by the Director of Nursing (DON). Resident 278, admitted with diagnoses such as diabetes mellitus, muscle weakness, and a spinal abscess, was prescribed daptomycin via a peripherally inserted central catheter (PICC). Similar to Resident 178, the ISE for Resident 278's antibiotic treatment was incomplete, missing the infection analysis result needed to confirm if the antibiotic usage criteria were met. This deficiency was also identified during a review with the IPN. Resident 13, with a history of diabetes mellitus, major depressive disorder, and essential hypertension, was prescribed ciprofloxacin for a urinary tract infection. The ISE for this antibiotic was also found to be lacking the infection analysis result necessary to verify if the antibiotic usage criteria were met. The facility's policy on Antibiotic Stewardship, which mandates tracking antibiotic use against McGeer's Criteria, was not followed, leading to the potential for antibiotic resistance and adverse events.
Failure to Inform Resident About Health Status and Precautions
Penalty
Summary
The facility failed to ensure that a resident's right to be informed about their health status and care was honored, leading to a deficiency in the delivery of necessary care and services. Resident 43, who was admitted with diagnoses including urinary tract infection, sepsis, and paroxysmal atrial fibrillation, was observed to have an Enhanced Standard Precaution (ESP) signage posted outside her door. Despite this, Resident 43 was not informed about the reason for the precautionary measures, such as staff wearing gowns and gloves during care. The resident expressed confusion and concern about her health status, indicating that no explanation was provided by the nursing staff. During interactions with the staff, including a Licensed Vocational Nurse (LVN) and an Infection Preventionist Nurse (IPN), it was revealed that there was a lack of communication and education regarding the ESP protocols. The LVN incorrectly informed the resident that there was no need for gowns and gloves, contradicting the posted signage. The IPN acknowledged that staff should educate residents about transmission-based precautions and admitted that the facility was still in the process of finalizing their ESP protocols. This lack of communication and proper protocol implementation violated the resident's rights as outlined in the facility's policy and procedures on resident rights.
Failure to Provide Personal Hygiene Assistance
Penalty
Summary
The facility failed to enhance a resident's dignity and respect by not providing necessary personal hygiene and assistance. Resident 1, who was admitted with diagnoses including unspecified dementia, moderate protein-calorie malnutrition, and heart failure, required moderate assistance for activities of daily living (ADLs) due to severely impaired cognitive skills. The resident's care plan indicated a need for extensive assistance with personal hygiene and oral care. However, on a specific date, the ADL log did not show any record of care or assistance provided to the resident during dinner. An observation on the same day revealed Resident 1 lying in bed with food scattered over their clothes and bed. During an interview, CNA 8 confirmed that the resident was not assisted after eating, and food was not removed from the resident's clothes and bed. The facility's policies emphasized providing care that promotes dignity, respect, and a homelike environment, yet these were not adhered to in this instance, potentially affecting the resident's psychosocial well-being.
Failure to Maintain Comfortable Noise Levels
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment for residents by not ensuring that noise levels were kept at a comfortable level, particularly during the night. This deficiency was identified for two residents who reported being unable to sleep due to staff shouting and yelling across the hallway at night. Both residents had moderately intact cognition and required varying levels of assistance with activities of daily living. The issue was raised during a resident council meeting, and previous complaints had been documented in the resident council minutes. Despite the noise issue being brought to the attention of the nursing department, there was no evidence that corrective actions, such as staff in-service training, were implemented. Interviews with the Activity Director and the Director of Staff and Development confirmed that the noise issue was acknowledged but not addressed through staff training. The facility's policy on maintaining a comfortable environment emphasized the importance of comfortable noise levels, yet this was not adhered to, leading to the deficiency.
Failure to Notify MD of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the Medical Director about a significant change in condition for a resident who was not using a humidifier with their oxygen concentrator. This oversight was identified during an observation and interview with the resident, who reported turning off the oxygen due to discomfort and a lack of education on the importance of the humidifier. The resident's medical history includes hemiplegia, hemiparesis following a stroke, diabetes mellitus, and dependence on renal dialysis. The resident was moderately impaired and required assistance with activities of daily living. The Infection Preventionist Nurse noted the resident's non-use of the humidifier and completed a Change of Condition report, acknowledging that the nursing staff should have reported the change sooner. The facility's policy requires prompt notification of the resident, their physician, and family members in the event of a significant change in condition. The failure to notify the Medical Director in a timely manner had the potential to place the resident at risk for dry mucous membranes, which could lead to skin breakdown and infection.
Improper Medication Storage Poses Risk to Resident Safety
Penalty
Summary
The facility failed to maintain an environment free from risks and hazards for a resident by not ensuring that medications were properly stored according to the facility's policy and procedures. Specifically, a resident was found with an opened Desitin cream inside their bedside drawer and eyedrops on top of the bedside table, despite not being approved for self-administration of medications. This oversight was observed during a room inspection and confirmed by the Director of Nursing (DON), who acknowledged that the resident was not allowed to keep medications at the bedside. The resident involved had a history of metabolic encephalopathy, acute respiratory failure, acute kidney failure, and pneumonia, and required maximal to total assistance for daily activities. The facility's policy stated that medications should only be accessible to authorized personnel and that bedside storage is only permitted when it does not pose a risk to confused residents. The presence of these medications at the bedside increased the risk of accidents, under or overdosing, and medication diversion, potentially jeopardizing the health and safety of the resident and others.
Deficiencies in IV Access Care and PPE Use
Penalty
Summary
The facility failed to provide appropriate intravenous (IV) access care for two residents, as per professional standards and facility policy. For Resident 277, the facility did not develop or implement a care plan for the resident's IV therapy, despite the resident having an order for Venofer intravenous solution for iron deficiency. The resident's medical history included hypertensive heart disease with heart failure, muscle weakness, difficulty walking, and anemia. The absence of a care plan was confirmed by the Infection Prevention Nurse during an interview. For Resident 278, the facility did not properly label the peripherally inserted central catheter (PICC) line dressing with the date, time, and initials of the staff member who changed it. The resident had a history of diabetes mellitus, muscle weakness, discitis in the lumbar region, and malignant neoplasm of the breast. The resident was on IV antibiotic therapy and had a PICC line, which required dressing changes every seven days. During an observation, it was noted that the dressing was only labeled with the date and initials, lacking the time of change. Additionally, Registered Nurse 1 failed to wear the required personal protective equipment (PPE) while providing care for Resident 278's PICC line. The nurse did not don a gown as required by the Enhanced Standard Precautions, which were clearly indicated on the signage outside the resident's room. This oversight was acknowledged by the nurse during an interview, where it was confirmed that the facility's policies and procedures were not followed in these instances.
Failure to Provide Prescribed Oxygen Therapy
Penalty
Summary
The facility failed to provide necessary respiratory care services for two residents, Resident 3 and Resident 10, as per their physician's orders. Resident 3, who was admitted with conditions including hemiplegia, Parkinson's disease, and Alzheimer's disease, had a physician's order for oxygen at 2 liters per minute via nasal cannula to maintain oxygen saturation above 93%. However, observations on multiple occasions revealed that Resident 3 was not receiving the prescribed oxygen therapy, and there was no oxygen machine or nasal cannula present in the room. The Director of Nursing (DON) confirmed that the facility was not implementing the care plan regarding oxygen therapy for Resident 3. Resident 10, who was admitted with acute respiratory failure and heart failure, also had a physician's order for oxygen at 2 liters per minute via nasal cannula to maintain oxygen saturation above 93%. During an observation, Resident 10 was found to be receiving oxygen at only 1.5 liters per minute, which was below the prescribed amount. The DON acknowledged that the oxygen machine was not set to the correct level as per the physician's order. The facility's policy and procedure for oxygen therapy, which was reviewed earlier in the year, indicated that oxygen should be administered according to physician's orders. The failure to adhere to these orders for both residents had the potential to deny them the necessary oxygen needed for their health and well-being.
Failure to Document Post-Dialysis Assessment
Penalty
Summary
The facility failed to provide appropriate post-hemodialysis care for a resident, identified as Resident 46, who required hemodialysis treatment due to end-stage renal failure. The deficiency was identified when the facility did not assess and document the resident's condition for complications after hemodialysis treatment, as required by professional standards of practice. The resident, who had a history of diabetes mellitus and generalized muscle weakness, was dependent on hemodialysis and required maximal assistance for activities of daily living. The facility's records showed that the post-dialysis evaluation form for a specific date was missing, indicating a lapse in the required assessment process. During an interview, a Licensed Vocational Nurse (LVN 3) confirmed that residents scheduled for hemodialysis were supposed to be assessed before leaving the facility, during the treatment by the hemodialysis staff, and upon returning to the facility. The nurse stated that the nursing staff was responsible for assessing the resident and documenting the assessment to ensure the resident tolerated the hemodialysis without complications. The facility's policy on dialysis care required all documentation concerning dialysis services to be maintained in the resident's medical record, which was not adhered to in this instance.
Failure to Post Daily Nurse Staffing Hours
Penalty
Summary
The facility failed to comply with the federal requirement to post daily actual hours worked by the nursing staff in an area accessible to the public. On May 25, 2024, an observation at the nurse's station revealed that the posted nurse staffing hours were dated May 23, 2024, indicating that the information had not been updated for two days. During an interview on May 27, 2024, the Director of Staff and Development (DSD) admitted that the facility was unable to update and post the nursing hours due to his absence on vacation. The facility's policy and procedures require daily posting of the facility name, current date, and total number and actual hours worked by all licensed and unlicensed nursing staff responsible for resident care per shift. This failure resulted in the actual hours worked by the staff not being readily accessible to residents, family, or visitors, potentially leading to inadequate staffing.
Failure to Communicate Pharmacist Recommendations
Penalty
Summary
The facility failed to communicate the consultant pharmacist's recommendations from the Medication Regimen Review (MRR) to the attending physician for two residents, Resident 15 and Resident 53. For Resident 15, the pharmacist recommended re-evaluating the use of cetirizine and loratadine due to potential duplicate therapy, with instructions to document the rationale if the medications were to be continued. However, the Director of Nursing (DON) confirmed that there was no documentation in Resident 15's progress notes regarding the pharmacist's recommendation, and the Nurse Practitioner was unaware of the duplicate antihistamine therapy or the pharmacy recommendation. For Resident 53, the pharmacist recommended adding a 'do not crush' instruction to the Fosamax order. The DON confirmed that this recommendation was not documented in the resident's progress notes, and the 'do not crush' instruction was missing from the active physician's orders. The facility's policy required that recommendations be acted upon and documented by the facility staff and/or the prescriber, which was not followed in these cases.
Failure to Provide Fortified Diet as Ordered
Penalty
Summary
The facility failed to provide a fortified diet as ordered by the physician for a resident who was on a kosher and fortified diet. During an observation of lunch service, it was noted that the resident received a prepackaged kosher meal that was heated in the microwave but did not have butter added to it, which was part of the fortified diet order. The dietary staff responsible for preparing the trays did not communicate or implement the fortified diet order for the resident, resulting in the absence of additional calories intended to prevent weight loss. The dietary supervisor confirmed that the fortified diet orders were not followed for the resident, as the prepackaged kosher meals were not opened to add butter, which was the facility's method of fortifying meals. The resident's dietary profile indicated a preference for kosher food and a need for a fortified diet due to weight loss. The facility's policy on fortified diets emphasized the importance of increasing caloric intake by adding items like butter, but this was not executed for the resident, leading to a deficiency in meeting the resident's nutritional needs.
Uncovered Overhead Light Poses Safety Risk
Penalty
Summary
The facility failed to maintain patient care equipment in safe working condition, as evidenced by an uncovered overhead light with an exposed bulb in the room of a resident. This deficiency was identified during an observation of the resident's room, where it was noted that the overhead light lacked a protective cover. The Maintenance Supervisor confirmed the absence of the cover and acknowledged that the light should always have a protective cover to prevent potential electrical accidents. The resident involved in this deficiency was admitted to the facility with multiple diagnoses, including hemiplegia and hemiparesis following a cerebral infarction, Parkinson's disease, dysphagia, and Alzheimer's disease. The resident's cognitive skills for daily decision-making were moderately impaired, and they required total dependence on staff for activities of daily living. The facility's policy and procedures indicated that adequate lighting should be provided to promote a safe and comfortable environment, which was not adhered to in this instance.
Room Size Deficiency in Multiple Resident Rooms
Penalty
Summary
The facility failed to ensure that 13 out of 34 rooms met the required 80 square feet per resident in multiple resident rooms. Specifically, rooms numbered 3, 4, 8, 9, 11, 14, 15, 16, 17, 18, 20, 22, and 33 did not meet this requirement, with each room providing less than the minimum required space per resident. The Client Accommodation Analysis revealed that these rooms, intended for three residents each, ranged from 69.7 to 73.3 square feet per resident, falling short of the 240 square feet total required for three-bedroom accommodations. Despite these deficiencies, observations indicated that both residents and staff had enough space to move freely, and nursing staff had adequate space to provide care safely. The facility had submitted a room waiver request to address this issue.
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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) |
|---|---|---|---|---|
| Kennedy Care Center | 0.3 mi | ★★★★★ | 12 | 0 |
| Sharon Care Center | 1.1 mi | ★★★★★ | 57 | 0 |
| La Brea Rehabilitation Center | 1.2 mi | ★★★★★ | 8 | 0 |
| Guardian Rehabilitation Hospital | 1.4 mi | ★★★★★ | 17 | 0 |
| Beverly Hills Rehabilitation Centre | 1.5 mi | ★★★★★ | 3 | 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.