Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at West Pico Terrace Healthcare & Wellness Centre Lp during CMS and state inspections, most recent first.
Improper Food Texture Preparation and Service: The facility served lumpy pureed bread to residents on a pureed diet, and staff acknowledged it was not smooth or consistent with IDDSI Level 4. The facility also served minced/ground meats and vegetables to residents ordered soft and bite size instead of 1/2-inch bite-sized pieces, and one resident refused the meal, stating the food did not look good.
Failure to use gown during EBP care: A CNA provided morning hygiene care to a resident on EBP without wearing a gown. The resident had ESRD, DM, dementia, impaired cognition, and needed substantial assistance with toileting hygiene, bathing, and lower body dressing. Signage outside the room indicated EBP precautions for high-contact care, and both the LVN and CNA acknowledged that a gown should have been worn during the care.
A CNA failed to close a resident’s privacy curtain while providing morning personal care, leaving the resident in direct view of a roommate. The resident had ESRD, DM, and dementia, with moderately impaired cognition and substantial assistance needs for bathing and toileting hygiene. The LVN and DON stated the curtain should be closed during care, and facility policy requires staff to protect resident bodily privacy during personal care.
PASARR Level I Assessment Not Accurately Completed: A resident admitted with dementia, bipolar disorder, depression, and epilepsy had records showing impaired decision-making, depressive symptoms, and ongoing psychotropic medication use, yet the facility failed to ensure the PASARR Level I assessment was accurately completed. Notes also showed a physician review of the resident’s psychotropic meds via facetime, and the facility could not produce PASARR in-service education documentation.
A resident with DM, ESRD, dementia, and insulin use had a diabetes care plan that was not individualized or comprehensive. The plan included only general interventions and did not address the resident’s insulin orders, sliding-scale coverage, or the ordered hypoglycemia and hyperglycemia protocols. The RNS and DON stated the plan should have been specific and resident-centered.
A resident with ESRD, DM, muscle weakness, and moderate cognitive impairment reported that the food was not good, had no taste, and that no one had discussed food preferences with her. Other residents also said meals had no flavor and were often cold to lukewarm, and a tray tasting found the fiesta rice very bland. The DON stated food concerns were often raised in resident council, especially by new residents, and the dietary policy called for meals consistent with resident preferences and physician orders.
Insufficient Room Size in Multiple-Occupancy Bedrooms: The facility failed to ensure three multi-bed resident rooms met the required square footage per resident. A review of room measurements showed each room was below the minimum size needed for a three-bed capacity, while residents and staff interviewed stated there was enough space for belongings, movement, and care tasks. The facility also had a room waiver policy for ambulatory or semi-ambulatory residents.
The facility did not ensure that informed consent documentation for psychotropic medications was complete for two residents. Consent forms lacked the prescriber's name and did not confirm that the physician obtained consent from the resident or responsible party, despite being signed. Both the RNS and DON acknowledged the forms were incomplete and did not meet policy requirements.
The facility failed to store boxed food items off the floor, risking contamination and foodborne illnesses. Observations revealed that a box of thickened dairy drink, a box of thickened lemon-flavored water, and a 25-pound bag of sugar were placed directly on the floor. Staff acknowledged the items should be stored at least 6 inches off the floor, as per facility guidelines.
A facility failed to properly cohort a resident who tested negative for COVID-19 with another who tested positive, and did not update transmission-based precautions for a resident no longer requiring them. These actions were against facility policy and CDC guidelines, increasing infection risk.
The facility failed to update and follow up on the advance directives for two residents. One resident's POLST form was incomplete, lacking documentation of their wishes regarding CPR and other medical interventions. Another resident's AHCD was not followed up on, with no evidence that the facility requested or obtained a copy of the directive. The Director of Nursing confirmed these oversights, which were not in compliance with the facility's policy.
A facility failed to ensure a resident was free from physical restraints by not having a physician's order for bilateral bed siderails, as required by policy. The resident, with conditions like cerebral infarction and Parkinson's, was observed with siderails up, but no order or care plan was documented. The DON confirmed that siderails should have an order and care plan, as they can limit movement and be considered a restraint.
A facility failed to provide a written bed hold notification to a resident or their representative during a hospital transfer for hypotension evaluation. The Bed Hold Agreement form was incomplete, and the resident or their representative was not informed of their right to have the bed held. The facility's policy requires such notification, but it was not followed in this instance.
A facility failed to document a Change of Condition (COC) for a resident with dementia and other medical conditions, who exhibited aggressiveness and combativeness, and refused a urine sample collection. Despite the facility's policy requiring timely COC documentation, no evidence of such documentation was found, potentially delaying necessary care.
A facility failed to develop a baseline care plan for a resident within 48 hours of admission, as required by policy. The resident, with dementia and hearing loss, lacked a documented activity care plan and a personalized treatment strategy for hearing. Staff interviews confirmed the absence of these plans, potentially affecting the resident's care and social engagement.
A facility failed to implement a comprehensive care plan for a resident with multiple diagnoses, including cerebral infarction and Parkinson's disease. The resident used bilateral bed siderails, but no care plan was developed for their use. Additionally, no care plans were created following the resident's hospitalizations for altered mental status, chest pain, and productive cough. Staff confirmed the absence of necessary care plans, which are required by facility policy.
A facility failed to update the enteral feeding care plan for a resident with severe cognitive impairment and total dependence on staff. The resident's care plan did not reflect the current physician's order for Jevity 1.5 at 65 ml/hr, instead showing an outdated order of 40 ml/hr. This discrepancy was confirmed by the RN Supervisor and the DON, who acknowledged the importance of updating care plans to ensure proper care. The facility's policy mandates regular review and revision of care plans by the interdisciplinary team.
A resident with dementia and other health issues exhibited aggressive behavior, potentially indicating a UTI. Despite physician orders to collect a urine sample, the facility failed to notify the physician after unsuccessful attempts, as required by their policy.
A facility failed to provide necessary audiology services for a resident with hearing difficulties, despite a physician's order. The resident, who had dementia and other health issues, was not referred to an audiologist as required by the facility's policy. Interviews with staff confirmed the oversight, which resulted in a significant delay in care.
A resident's exit pathway was obstructed by geri-chairs, creating a potential fire hazard and causing discomfort. Despite the resident's concerns and the facility's policies for a safe environment, the Maintenance Supervisor did not remove the obstruction. The DON acknowledged the importance of clear pathways for emergencies.
A resident with severe cognitive impairment and dysphagia had their enteral feeding bottle left unchanged for over 24 hours, contrary to facility policy. The LVN confirmed the oversight, and the DON stated that bottles should be changed daily for infection control. The facility's policy requires feeding formula and tubing changes every 24-48 hours, but this was not adhered to, risking complications.
A facility failed to change and label nasal cannula tubing and humidifier for a resident's oxygen therapy as per policy. The resident, with conditions like acute bronchospasm and pulmonary embolism, was on oxygen therapy. Staff interviews confirmed the oversight, and the facility's policy required weekly changes and labeling for infection control.
The facility failed to label an open date on a resident's ipratropium-albuterol inhalation solution, contrary to manufacturer guidelines, and left another resident's medications unattended at the bedside. The LVN acknowledged the labeling oversight, and the DON confirmed that leaving medications at the bedside is unacceptable due to potential risks. Facility policies require proper labeling and administration of medications by the nurse who prepared them.
A resident's levalbuterol inhalation solution was improperly stored, with the opened medication not used within the manufacturer's recommended timeframe. The medication was observed in a medication cart with an opened foil pouch, contrary to guidelines that require use within two weeks of opening the pouch. The resident had acute respiratory failure, CHF, and acute kidney failure, requiring moderate assistance for daily activities. The DON confirmed the importance of following manufacturer guidelines for medication effectiveness.
The facility was found deficient for not providing the required minimum square footage per resident in three multiple resident bedrooms. Despite the deficiency, observations indicated that residents had ample space to move freely, and staff reported no concerns regarding room sizes. The facility had submitted a request for a room size waiver, asserting that the room sizes did not impede resident care.
A resident with severe cognitive impairments did not receive prescribed Ciprofloxacin Otic Solution for a suspected ear infection due to it being out of stock. The delay in obtaining an alternative medication led to worsening symptoms, including severe pain and maggots in the ear, requiring hospital transfer. The facility's policies on medication availability and condition change notification were not effectively followed.
A resident with acute respiratory failure, hypertension, and dementia was not readmitted to the facility after hospitalization due to an expired bed hold. Despite an available female bed, the Admission Coordinator reserved it for another resident, violating the facility's policy. This resulted in the resident staying in the hospital longer than necessary.
Improper Food Texture Preparation and Service
Penalty
Summary
The facility failed to ensure that residents on a pureed diet received bread prepared in a texture that met IDDSI Level 4 requirements. During tray line observation, the pureed bread on the steam table appeared lumpy and not smooth. In a concurrent interview, the cook stated the bread was made in a food processor with butter and liquid added, and the dietary supervisor stated the facility did not add a lot of water to minimize thickener use. During a taste test, the bread was described as grainy, with small pieces of bread present and residue remaining in the mouth requiring chewing. The cook and dietary supervisor both acknowledged that the pureed bread was not smooth and did not have the consistency expected for a pureed item. The cook stated the bread needed to remain in the food processor longer and needed more liquid to make a smooth puree. The facility recipe for Pureed (IDDSI Level 4) breads stated the finished item should be smooth and free of lumps, hold its shape, and not weep. The IDDSI guidance reviewed during the survey stated Level 4 pureed foods should have no lumps, be spoonable, and maintain shape without liquid separating from the solid. The facility also failed to provide the correct texture for residents ordered a soft and bite size diet. During kitchen observation, minced or ground roast turkey and minced green beans were served to residents with soft and bite size diet orders. The dietary supervisor stated the facility did not have a soft and bite size menu and instead followed a mechanical soft diet, using ground or minced meats and vegetables for residents ordered soft and bite size. The dietary staff stated they used the food processor to make the food small and consistent, and the dietary supervisor acknowledged that serving the wrong texture could cause residents to complain and not eat. One resident observed at lunch refused to eat and stated the food did not look good and was disliked.
Failure to Use Gown During EBP Care
Penalty
Summary
The facility failed to follow infection control practices when CNA 1 provided morning care to Resident 5 without wearing a gown, even though the resident was on enhanced barrier precautions (EBP). Resident 5 had diagnoses including ESRD, DM, and dementia, and the MDS indicated moderately impaired cognition and substantial assistance needed for toileting hygiene, bathing, and lower body dressing. The resident also received dialysis, and the order summary noted instructions related to bleeding at the left femoral permcath after dialysis. During an observation, signage outside Resident 5's room indicated staff were to observe EBP during dressing, bathing/showering, hygiene, changing briefs, and toileting assistance. While CNA 1 was observed providing personal hygiene care inside the room, the CNA was not wearing a gown. LVN 3 stated the CNA should have been wearing a gown to prevent the spread of infection among residents and staff. CNA 1 stated the gown was forgotten during AM care and acknowledged that a gown should have been worn while providing care to Resident 5. The DON stated the facility uses EBP for residents with MDROs or indwelling devices and that staff are required to use gown and gloves during high-contact care activities such as dressing, bathing, showering, providing hygiene, changing linens, and assisting with toileting.
Failure to Maintain Resident Privacy During Personal Care
Penalty
Summary
The facility failed to protect a resident’s right to privacy when a CNA did not close the privacy curtain during morning personal care. Resident 5 was admitted and later re-admitted to the facility with diagnoses including ESRD, DM, and dementia. The resident’s MDS dated 1/29/2026 indicated moderately impaired cognition and that the resident required substantial assistance with toileting hygiene, bathing, and lower body dressing. During a concurrent observation and interview on 4/14/2026 at 9:28 AM, CNA 1 was observed providing morning care to Resident 5 while the privacy curtain was open and the resident was in direct view of the roommate. LVN 3 stated the curtain should have been closed completely to maintain privacy. CNA 1 stated the resident chose to have a bed bath and that he forgot to close the privacy curtain. The DON stated that during resident care the privacy curtain is closed to maintain dignity and privacy. Facility policy stated employees are to treat residents with kindness, respect, and dignity and protect resident privacy, including bodily privacy, during personal care and treatment procedures.
PASARR Level I Assessment Not Accurately Completed
Penalty
Summary
The facility failed to ensure that Resident 4’s PASARR Level I assessment was accurately completed. Resident 4 was admitted with diagnoses including unspecified dementia, bipolar disorder, depression, and epilepsy. The admission record also showed that Resident 4 had the capacity to make medical decisions, while physician progress notes stated that Resident 4’s institutionalized status limited the ability to independently seek outpatient treatment. Resident 4’s MDS dated 3/30/2026 indicated moderately impaired decision-making, little interest or pleasure in doing things, and feeling down, depressed, or hopeless nearly every day. The MDS also indicated use of a mobility device such as a walker. The care plan documented psychotropic medication use, including Vraylar for bipolar disorder, and antidepressants trazodone and Wellbutrin for depression and poor adjustment to admission. The care plan interventions included monitoring for target behavior symptoms, adverse reactions to antidepressant therapy, and changes in behavior, mood, cognition, hallucinations, delusions, social isolation, suicidal thoughts, withdrawal, and decline in ADLs. Interdisciplinary team notes dated 3/25/2026 documented that the resident was seen by a physician via facetime and that the physician reviewed the resident’s current psychotropic medications, which were continued as ordered. The facility did not produce an in-service education record with a sign-in sheet and lesson plan for the PASARR process prior to 4/17/2026. Facility policy stated that a registered nurse or physician must complete a pre-admission screening to determine whether the facility can safely meet the individual’s needs, and that PASARR would be completed in accordance with the facility’s PASARR policy.
Incomplete Diabetes Care Plan
Penalty
Summary
The facility failed to develop an individualized and comprehensive diabetes care plan for a resident with DM, ESRD, and dementia. The resident’s MDS indicated moderately impaired cognition, substantial assistance was needed for toileting hygiene, bathing, and lower body dressing, and the resident was receiving insulin. The diabetes care plan, initiated on 9/9/2025, included a goal for no complications related to diabetes and general interventions such as avoiding extreme temperatures, checking for skin breaks, and educating the resident and family that diabetes is a chronic disease. The care plan did not include interventions specific to the resident’s insulin use or directions for responding to abnormal blood sugar levels. Physician orders included a hypoglycemia protocol, instructions for monitoring finger sticks and vital signs every 15 minutes until stable, guidance for hyperglycemia and hypoglycemia signs and symptoms, and a sliding-scale Novolog insulin order. During interview and record review, the RNS stated the diabetes care plan was not specific and should have included the physician’s hyperglycemia, hypoglycemia, and insulin orders. The DON stated the care plan guides staff and must be individualized for the resident and diagnoses, and that without a specific individualized care plan it would not be appropriate.
Food Lacked Flavor and Was Often Served at Improper Temperature
Penalty
Summary
The facility failed to ensure food served was flavorful and/or at the proper temperature for one sampled resident. Resident 34 was admitted on 8/4/2025 and readmitted on 3/19/2026 with diagnoses including ESRD, DM, and muscle weakness. The resident's H&P dated 3/20/2026 indicated the resident was at risk for acute exacerbation, decompensation, or functional decline, and the MDS dated 3/26/2026 showed moderate cognitive impairment and that the resident required set-up assistance from staff for eating and oral hygiene. During interview, Resident 34 stated the food was not good, looked pretty but had no taste, and reported a weight loss from 150 pounds to 111 pounds. The resident also stated no one had spoken with her about food preferences. In a group interview, three of four residents stated the food had no flavor and was often cold to lukewarm. During a test tray tasting, the fiesta rice tasted very bland, and the DS stated most recipes have a bland taste although the food tasted very fresh. The DON stated the food was often brought up in resident council, especially by new residents. The facility policy stated the dietary department will provide meals consistent with residents' preferences and physician orders as indicated on the tray card.
Insufficient Room Size in Multiple-Occupancy Bedrooms
Penalty
Summary
The facility failed to ensure that three resident rooms met the required square footage per resident for multiple-occupancy bedrooms. A review of the Client Accommodations Analysis form dated 4/14/2026 showed that rooms 7, 14, and 15 measured 217.21 square feet, 217.68 square feet, and 220 square feet respectively, each with a three-bed capacity. These measurements were below the required 80 square feet per resident, which would require at least 240 square feet for a three-bed room. The report also noted that the Administrator submitted a waiver request letter on 4/14/2026 for the rooms identified in the report, stating the rooms were in accordance with the special needs of the residents and would not adversely affect health, safety, or well-being. During observations and concurrent interviews, residents in the affected rooms stated they had no problems with their rooms and that there was enough space for their personal belongings and to move around. Staff interviews with an LVN, Rehabilitation Manager, DON, and RN indicated they believed there was adequate space to perform care tasks and that residents could move in the rooms without problems. The facility policy titled Room Waiver, revised 12/01/2015, stated residents placed in waiver rooms would be screened for medical and personal needs and would be ambulatory or semi-ambulatory.
Incomplete Documentation of Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that medical records were complete and accurate for two residents by not verifying that the physician obtained informed consent prior to initiating psychotropic medications. For one resident with anxiety disorder and moderate cognitive impairment, the Verification of Informed Consent for Buspirone did not indicate the prescribing physician's name or confirm that the prescriber obtained informed consent from the resident. The form was signed by the resident but lacked documentation of the prescriber's involvement in the consent process. For another resident with major depression, dementia, and severe cognitive impairment, the Verification of Informed Consent for Mirtazapine, Quetiapine, and Buspirone did not indicate the prescriber and, although signed by the next of kin, did not confirm that the prescriber obtained informed consent from the responsible party. Both the registered nurse supervisor and the director of nursing confirmed that the consent forms were incomplete and did not meet facility policy requirements, which specify that documentation must confirm the physician obtained informed consent and that no blank spaces are left on forms.
Improper Food Storage Practices
Penalty
Summary
The facility failed to ensure that boxed food items were not stored directly on the floor, which could potentially lead to food contamination and place residents at risk for foodborne illnesses. During an observation in the dry storage area, it was noted that a box of thickened dairy drink, a box of thickened lemon-flavored water, and a 25-pound bag of sugar were stacked directly on the floor. The Cook (CK1) acknowledged that these items had been delivered earlier in the day and had not yet been placed on the racks. CK1 confirmed that the boxes should be stored at least 6 inches off the floor to prevent contamination. The Dietary Supervisor (DS1) and the Director of Nursing (DON) both stated that food should be stored in a sanitary manner, adhering to the facility's storage guidelines, which require shelving to be at least 6 inches from the floor.
Inadequate Cohorting and Precaution Updates in Infection Control
Penalty
Summary
The facility failed to ensure proper cohorting of residents in relation to COVID-19 infection control. Resident 4, who tested negative for COVID-19, was placed in the same room as Resident 29, who tested positive for the virus. Despite Resident 4's refusal to move, there was no documentation explaining the risks or the decision-making process. This practice was against the facility's policy and CDC guidelines, which recommend separating residents with confirmed infections from those without. Additionally, the facility did not update the transmission-based precaution orders for Resident 30. Although the resident was no longer on antibiotic therapy for pneumonia, the precautionary measures were not discontinued in a timely manner. This oversight was confirmed by both the RN and the Infection Preventionist, who acknowledged the failure to update the physician's order. The facility's policies and procedures were not followed, as evidenced by the lack of documentation and failure to adhere to infection control guidelines. These deficiencies had the potential to increase the risk of infection transmission among residents, staff, and visitors.
Failure to Update and Follow Up on Residents' Advance Directives
Penalty
Summary
The facility failed to ensure that the clinical records for two residents were updated according to the facility's policy and procedure. For Resident 3, the Physician Orders for Life-Sustaining Treatment (POLST) form was incomplete, lacking documentation of the resident's wishes regarding cardiopulmonary resuscitation (CPR), medical interventions, and artificially administered nutrition. Additionally, the POLST form did not have the necessary signatures from the resident or their legally recognized decision-maker, indicating whether the form had been discussed and reviewed. For Resident 29, the facility did not follow up on the resident's Advance Healthcare Directives (AHCD). Although the resident's Advance Directive Acknowledgement (ADA) form indicated that an AHCD had been executed, there was no evidence that the facility requested or obtained a copy of the actual AHCD. The Director of Nursing confirmed that the facility should have followed up to ensure the residents' wishes were documented and honored, as per the facility's policy and procedure.
Failure to Obtain Physician's Order for Bed Siderails
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints by not having a physician's order for the use of bilateral bed siderails, as required by the facility's policy and procedures. The resident, who was admitted with conditions including cerebral infarction, Parkinson's disease, Type II Diabetes Mellitus, and muscle wasting, was observed in bed with both siderails up. Despite the resident's cognitive skills being intact and requiring maximal assistance for activities of daily living, there was no documented physician's order or care plan for the use of these siderails. During an interview, the Director of Nursing acknowledged that bed siderails are used as enablers and should have a physician's order and care plan, as they can limit a resident's movement and be considered a restraint. The facility's policy, reviewed in 2024, states that bed rails are classified as a physical restraint when used to limit a resident's freedom of movement, and a detailed order by a healthcare provider is required before any restraints can be utilized. This oversight had the potential to result in entrapment and injury for the resident.
Failure to Provide Bed Hold Notification
Penalty
Summary
The facility failed to provide a written bed hold notification to a resident or their representative at the time of transfer to a hospital, which is a requirement when a resident is transferred for therapeutic leave or hospitalization. This deficiency was identified for one resident, who was transferred to a hospital for evaluation of hypotension. The resident's Admission Record indicated they were initially admitted and later readmitted with diagnoses including metabolic encephalopathy, bladder cancer, and chronic kidney failure. The Bed Hold Agreement form, which should have been completed upon transfer, was only partially filled out, with the sections regarding notification upon transfer and the 24-hour notification of bed hold decision left incomplete and unsigned. During interviews, the Registered Nurse Supervisor confirmed that the facility did not notify the resident or their responsible party of the bed hold option during or after the transfer. The Director of Nursing stated that the facility's policy is to inform residents of their right to a bed hold upon transfer. The facility's policies and procedures require written notification of the bed hold option whenever a resident is transferred to an acute care hospital or requests therapeutic leave. However, in this case, the required notification was not provided, resulting in the resident or their representative being uninformed of their right to have the bed held during the hospital stay.
Failure to Document Change of Condition for a Resident
Penalty
Summary
The facility failed to complete a Change of Condition (COC) assessment for a resident, identified as Resident 23, in accordance with its policy and procedures. Resident 23 was admitted with diagnoses including dementia, a history of transient ischemic attack, cerebral vascular accident without residuals, and hypertension. The Minimum Data Set (MDS) indicated that Resident 23 had cognitive impairment and required extensive staff assistance with activities of daily living. On a specific date, Resident 23 exhibited aggressiveness, combativeness, and refused to allow staff to collect a urine sample ordered by the physician. Despite these changes, there was no documented evidence that a COC was completed. During interviews, the Registered Nurse Supervisor and the Director of Nursing confirmed the absence of a COC documentation for Resident 23. They acknowledged that a COC is essential to monitor residents and involve the interdisciplinary team in providing necessary care. The facility's policy, reviewed in June 2024, emphasized the importance of informing residents, family, legal representatives, and physicians of changes in a resident's condition in a timely manner. The lack of a COC documentation for Resident 23 could potentially delay the care needed to address the resident's condition changes.
Failure to Implement Baseline Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, as required by their policy and procedures. Specifically, the facility did not address the inclusion of activity programs tailored to the resident's interests and cognitive, physical/functional, and social abilities. This omission was identified during a record review and interviews with facility staff, who acknowledged the absence of a documented activity care plan for the resident. The lack of an activity care plan meant that staff were unaware of the resident's activity preferences, which could affect the resident's social engagement and overall well-being. Additionally, the facility did not outline a personalized treatment strategy for the resident's hearing loss within the required timeframe. The resident, who was admitted with diagnoses including dementia, generalized weakness, and adult failure to thrive, was noted to have moderate difficulty with hearing and severely impaired vision. Despite a physician's order for an audiology consult, the facility did not implement a care plan to address the resident's hearing needs. Interviews with staff confirmed that the resident was hard of hearing, requiring staff to speak loudly and close to the resident's ear. The absence of a care plan for the resident's hearing loss potentially impacted the delivery of necessary care and services.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident, identified as Resident 10, which resulted in a deficiency. Resident 10 was admitted with multiple diagnoses, including cerebral infarction, Parkinson's disease, Type II Diabetes Mellitus, and muscle wasting and atrophy. Despite these conditions, the facility did not develop a care plan for the use of bilateral bed siderails, which were observed in use during a facility tour. Additionally, there were no care plans developed following Resident 10's hospitalizations due to altered mental status, chest pain, and productive cough with generalized weakness. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, confirmed the absence of care plans for the use of siderails and for the resident's changes of condition that led to hospitalizations. The facility's policy requires comprehensive, person-centered care planning, which should be reviewed and revised with the onset of new problems or changes in condition. The lack of a care plan for these critical aspects of Resident 10's care had the potential to negatively impact the resident's health and safety.
Failure to Update Enteral Feeding Care Plan
Penalty
Summary
The facility failed to update the enteral feeding care plan for Resident 22, who was admitted with diagnoses including cerebrovascular accident, dysphagia, and heart failure. The resident's Minimum Data Set indicated severely impaired cognition and total dependence on staff for various activities, including eating. A physician's order dated 1/16/25 specified that Jevity 1.5 should be administered at 65 ml/hr via a gastrostomy tube. However, the care plan, initiated on 10/9/24, still reflected an outdated order of 40 ml/hr, which was not aligned with the current physician's order. During a review, the Registered Nurse Supervisor confirmed that the care plan had not been updated to reflect the current enteral feeding order, acknowledging that this oversight could lead to the resident not receiving proper care. The Director of Nursing also confirmed that care plans should be updated with any changes in the resident's care, medication, or enteral feeding. The facility's policy on comprehensive person-centered care planning requires that care plans be reviewed and revised by the interdisciplinary team after each assessment and upon changes in the resident's condition.
Failure to Notify Physician of Unsuccessful Urine Sample Collection
Penalty
Summary
The facility failed to notify the physician when they were unable to collect a urine sample for urinalysis, culture, and sensitivity (UA and C&S) for a resident, as per the physician's orders. The resident, who was admitted with diagnoses including dementia, a history of transient ischemic attack, cerebral vascular accident without residuals, and hypertension, exhibited aggressive and combative behavior during activities of daily living care. This behavior was potentially indicative of a urinary tract infection (UTI), for which the physician had ordered a urine sample to be collected via straight catheter. Despite the facility's process requiring three attempts to collect the urine sample before notifying the physician, there was no documented evidence that the physician was informed after the unsuccessful attempts. The Director of Nursing confirmed that the urine sample should have been collected as soon as possible and that the physician should have been notified if the sample could not be collected after three consecutive shifts. The facility's policy indicated that the attending physician should be notified of refusal of treatment based on the resident's condition and potential serious consequences, but this was not adhered to in this case.
Failure to Provide Audiology Services as Ordered
Penalty
Summary
The facility failed to provide necessary outside services as required by physician orders for a resident, identified as Resident 6, who was admitted with diagnoses including dementia, generalized weakness, and adult failure to thrive. The physician's order dated 11/23/2024, indicated a need for an audiology consult due to the resident's hard of hearing condition. However, there was no documented evidence that the referral to an audiologist was made, despite the facility's policy and procedures requiring such referrals to be coordinated by the Director of Social Services. Interviews with facility staff, including a CNA, Registered Nurse Supervisor, and the Social Services Director Interim, confirmed that the referral was not made, and it had been 13 weeks since the order was given. The deficiency was further highlighted during interviews with the Director of Nursing, who stated that the facility's process involved notifying social services of the order, who would then notify the audiologist. The failure to notify the audiologist resulted in a delay in care and evaluation for Resident 6, who had moderate difficulty with hearing and severely impaired vision. This delay had the potential to negatively affect the delivery of necessary care and services for the resident, as confirmed by the staff interviews and the facility's policy review.
Obstructed Exit Pathway Poses Safety Risk
Penalty
Summary
The facility failed to maintain a safe and functional environment for a resident by not ensuring that the exit pathway was clear of geri-chairs and clutter. This deficiency was identified during an observation and interview with the resident, who expressed concerns about the obstruction caused by six geri-chairs outside her door. The resident, who was admitted with conditions such as pneumonia, acute respiratory failure, and hemiplegia following a cerebral infarction, required maximal to total assistance for activities of daily living. Despite the resident's intact cognitive skills, she felt uncomfortable and unsafe due to the blocked exit pathway, which also obstructed her view to the outside. The Maintenance Supervisor acknowledged the placement of the geri-chairs outside the resident's room due to recent rains and was aware of the resident's complaint but had not moved the equipment. The Director of Nursing confirmed that the exit pathway should be clear in case of emergencies such as fire or earthquake, and acknowledged that a blocked pathway might make residents feel unsafe. The facility's policies emphasized providing a safe and hazard-free environment, and staff were instructed to notify supervisors of any unsafe situations. However, these policies were not adhered to in this instance, leading to the deficiency.
Failure to Change Enteral Feeding Bottle Within 24 Hours
Penalty
Summary
The facility failed to ensure that a resident's enteral feeding bottle was changed after 24 hours, as required by the facility's policy and procedures. Resident 22, who was admitted with diagnoses including cerebrovascular accident, dysphagia, and heart failure, was observed with a feeding tube that had not been changed within the 24-hour timeframe. The resident's care plan indicated the need for monitoring for signs or symptoms of infection and adherence to physician orders for feeding. However, during an observation, it was noted that the feeding bottle was dated from the previous day, exceeding the recommended hang time. Licensed Vocational Nurse (LVN) 1 confirmed that the tube feeding had been hanging for more than 24 hours, acknowledging that this could lead to infection. The Director of Nursing (DON) stated that staff are expected to change enteral feeding bottles daily for infection control, following the manufacturer's instructions. The facility's policy indicated that feeding formula and tubing should be changed every 24-48 hours, depending on manufacturer guidelines. Despite this, the feeding bottle for Resident 22 was not changed within the specified time, posing a risk of tube feeding-associated complications.
Failure to Change and Label Oxygen Therapy Equipment
Penalty
Summary
The facility failed to provide necessary respiratory care services for a resident by not adhering to its policy on changing nasal cannula (NC) tubing and humidifier for oxygen therapy. The resident, who was admitted with conditions including acute bronchospasm, pulmonary embolism, Type II Diabetes Mellitus, and chronic kidney disease, required oxygen therapy. The physician's order specified that the NC tubing and humidifier should be changed every Monday, labeled, and dated. However, during an observation, it was found that the NC tubing and humidifier bottle lacked a written label with the date, and the staff was unaware of when it was last changed. Interviews with the staff, including a Licensed Vocational Nurse (LVN) and a Registered Nurse (RN), confirmed the oversight. The RN stated that the NC tubing and humidifier should be changed every seven days and labeled with the date. The Director of Nursing (DON) reiterated that the equipment should be replaced weekly and labeled for infection control purposes. The facility's policy on oxygen therapy, reviewed in 2024, also indicated that the humidifier and tubing should be changed every seven days and labeled. This deficiency had the potential to cause complications associated with oxygen therapy.
Medication Labeling and Administration Deficiencies
Penalty
Summary
The facility failed to properly label the open date on a resident's ipratropium-albuterol inhalation solution, which is necessary to ensure the medication is used within the manufacturer's recommended timeframe. During an observation, it was noted that the medication was stored in a medication cart with an opened foil pouch, but without a label indicating when it was first opened. The Licensed Vocational Nurse (LVN) acknowledged that the medication should have been labeled upon opening. The manufacturer's guidelines specify that once removed from the foil pouch, the vials should be used within two weeks. The facility's policy also requires that medications be labeled with the date opened and adhere to the manufacturer's expiration guidelines. Additionally, the facility did not ensure that a resident's medications were not left unattended at the bedside. During an observation, a medication cup containing various medications was found on a resident's bedside table. The resident confirmed the medications were left there, and the LVN admitted that it was not acceptable to leave medications at the bedside. The Director of Nursing (DON) stated that medications should not be left unattended as it poses a risk of other residents taking them, potentially leading to accidents or interactions with other medications. The facility's policy requires that medications be administered by the nurse who prepared them and that any refusal by a resident should be documented, with attempts made to administer the medication again.
Improper Storage of Levalbuterol Inhalation Solution
Penalty
Summary
The facility failed to properly store a resident's levalbuterol inhalation solution medication according to manufacturer guidelines. The medication, which is used to prevent or relieve symptoms of lung disease, was observed in a medication cart with an opened foil pouch. The medication box was labeled with the date it was first opened, but the manufacturer's guidelines specify that once the foil pouch is opened, the vials should be used within two weeks, and individual vials should be used within one week once removed from the pouch. This discrepancy was noted during an observation and interview with an LVN, who confirmed the date labeled was when the medication was first opened. The resident involved had been admitted with diagnoses including acute respiratory failure, congestive heart failure, and acute kidney failure. The resident's cognitive skills for daily decisions were mildly impaired, and they required moderate assistance from staff for activities of daily living. The Director of Nursing acknowledged that manufacturer guidelines must be followed to ensure medication effectiveness. The facility's policy indicated that medications should be dated when opened and used within the manufacturer's recommended timeframe, which was not adhered to in this case.
Room Size Deficiency in Resident Bedrooms
Penalty
Summary
The facility failed to provide the required minimum square footage per resident in multiple resident bedrooms, as mandated by federal regulations. Specifically, three resident rooms were identified as not meeting the minimum requirement of 80 square feet per resident. Room 7, Room 14, and Room 15 were each found to have less than the required space for three residents, with measurements of 217.21, 217.68, and 220 square feet respectively, whereas the regulation requires at least 240 square feet for a three-bedroom. This deficiency was identified during a recertification survey, where it was noted that the facility had previously submitted a request for a room size waiver, indicating that the rooms did not pose any risk to resident care. Observations and interviews conducted during the survey period revealed that residents had ample space to move freely within the rooms, and there was sufficient space for nursing staff to provide care. The maintenance supervisor demonstrated the method used to measure the rooms, which involved measuring from the window to the door for length and from the wall to the start of the closet for width. Despite the room size deficiency, staff interviews indicated no concerns regarding the room sizes, and the Vice President of Operations confirmed the facility's request for a continued room waiver, asserting that the room sizes did not impede resident care.
Failure to Provide Timely Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services as ordered for a resident with severe cognitive impairments and multiple diagnoses, including cerebral palsy and severe intellectual disabilities. The resident was prescribed Ciprofloxacin HCI Otic Solution for a suspected ear infection, but the medication was not administered for two days due to it being out of stock at the pharmacy. The delay in obtaining an alternative medication, Ofloxacin Otic Solution, contributed to the resident's condition worsening. The resident experienced increased redness, swelling, and severe pain on the right side of the face, along with a cream-colored foreign body in the right ear, which was later identified as maggots. This condition necessitated the resident's transfer to a General Acute Care Hospital for further evaluation. The facility's Director of Nursing acknowledged the delay in medication administration and the lack of timely follow-up with the pharmacy and physician. The facility's policies on unavailable medications and change of condition notification were not effectively followed, leading to a failure in ensuring the resident's needs were met. The Director of Nursing admitted that the ENT specialist should have been informed after the resident's repeated ear infections, and the nursing staff should have identified the worsening symptoms sooner.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the readmission of a resident after hospitalization, resulting in a deficiency. A resident, who was admitted with acute respiratory failure, hypertension, and dementia, was not allowed to return to the facility after a hospital stay. The resident's bed hold had expired, and the facility's Admission Coordinator informed the family that no female beds were available, despite the facility's census indicating otherwise. This led to the resident remaining in the hospital longer than necessary. The facility's policy stated that residents eligible for Medi-Cal/Medicaid should be readmitted to their previous room or the first available bed in a semi-private room if their hospital stay exceeded seven days. However, the Admission Coordinator admitted to reserving an available female bed for another resident, who also exceeded the bed hold period. This action was contrary to the facility's policy, which contributed to the resident's extended hospital stay and potential impact on her psychosocial wellbeing.
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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) |
|---|---|---|---|---|
| Pavilion On Pico Healthcare & Wellness Centre, Lp | 0.1 mi | ★★★★★ | 27 | 0 |
| Flower Villa, Inc | 0.6 mi | ★★★★★ | 19 | 0 |
| Miracle Mile Healthcare Center, Llc | 0.7 mi | ★★★★★ | 46 | 0 |
| Beverly Hills Rehabilitation Centre | 1 mi | ★★★★★ | 3 | 0 |
| Guardian Rehabilitation Hospital | 1.1 mi | ★★★★★ | 17 | 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.