Above average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Westlake Convalescent Hospital during CMS and state inspections, most recent first.
A resident with chronic respiratory failure, tracheostomy, ventilator dependence, impaired cognition, and total ADL dependence was found in a room where the privacy curtain strings were tangled and the ceiling had multiple brownish stains. During an observation with the DON and maintenance staff, it was confirmed that staff were expected to check rooms weekly and that curtains should not be tangled and ceilings should be free of stains. These conditions did not comply with the facility’s homelike environment policy, which requires a safe, clean environment with privacy curtains in good condition.
A resident with chronic respiratory failure, a tracheostomy, ventilator dependence, impaired cognition, and total dependence for ADLs was observed suspended in a Hoyer lift over the bed without staff present, despite a care plan identifying fall risk and the need for assistance with all transfers. An RN found the resident alone and summoned a CNA, who stated she had left to get another staff member and acknowledged she should not have left the resident unattended. The RN and DON both stated residents should never be left unattended in a Hoyer lift and that at least two staff should assist, and facility policies required safe lifting techniques and supervision to keep the environment free from accident hazards.
Surveyors found multiple environmental deficiencies, including a loose toilet with newspaper stuffed under its base and missing caulk in an all-gender bathroom, a sink countertop pulling away from the backsplash with cracked/crumbling grout and black mold-like buildup, and deteriorated walls and baseboards in several resident rooms and shared bathrooms. Additional issues included crumbling wall material behind fallen baseboards, rusted exposed sink pipes, peeling paint, and dirt and grime buildup in bathroom corners and around sliding glass doors. The Maintenance Assistant acknowledged all observed problems, and a review of the facility’s maintenance log showed no documentation of these issues despite a policy requiring a safe, clean, and homelike environment.
The facility did not maintain a safe environment when the upper end of a stairway handrail on the right side going up from the parking lot to the first floor was found loose and easily movable during an observation with maintenance staff. The Maintenance Supervisor and Maintenance Assistant confirmed the handrail was not properly secured to the wall. Review of the facility’s “Quality of Life - Homelike Environment” P&P showed a requirement to provide a safe, clean, comfortable, and homelike environment, which was not followed in this situation.
A resident with severe cognitive impairment and multiple medical conditions was admitted without a fully completed POLST form. The form lacked required selections and signatures from the legally recognized decision maker, and was signed only by the provider. Both nursing staff and the DON confirmed that the POLST was incomplete and not in accordance with facility policy, resulting in the resident's care preferences not being properly documented.
A resident with severe cognitive impairment and complex medical needs was transferred to a general acute care hospital, but staff failed to document the transfer in the medical record. The Clinical Manager confirmed the absence of required documentation, including the resident's clinical condition and vital signs at the time of transfer, resulting in incomplete records despite facility policy requiring thorough documentation of all services and changes.
A resident with multiple stage 4 and unstageable pressure ulcers, severe cognitive impairment, and total dependence on staff did not have a comprehensive care plan developed after admission. Only a baseline care plan was created, and facility staff confirmed that no interdisciplinary team care plan was in place to address the resident's complex wound care needs, contrary to facility policy and regulatory requirements.
A resident with multiple Stage 4 and unstageable pressure ulcers did not receive weekly reassessments and documentation of their wounds as required by professional standards. The treatment nurse confirmed that scheduled weekly evaluations, including measurements and descriptions, were missed, and facility policies lacked clear guidance on reassessment frequency. This failure occurred despite the resident's high risk and dependence on staff for care.
The facility failed to provide proper catheter care for three residents, leading to potential health risks. One resident's urinary collection bag was not emptied as ordered, another's catheter bag was improperly placed above bladder level, and a third resident was not assessed for catheter removal after wound healing. These deficiencies were acknowledged by the facility's staff, highlighting risks of infection.
The facility failed to store Tuberculin PPD according to the manufacturer's recommendation, keeping it refrigerated after opening instead of at room temperature. Additionally, a vial of Latanoprost lacked an open date, and multi-dose containers of Clearlax and Reguloid were not discarded within 60 days of opening, contrary to facility policy. These deficiencies were confirmed by nursing staff and the DON.
The facility failed to follow food production recipes and fortified diet guidelines during lunch service. Fortified diets were not prepared or served to 10 residents, and six residents on a pureed diet did not receive pureed lettuce, tomato, and pickles as per the menu. Interviews revealed a lack of a written fortified diet menu and an oversight in preparing pureed items, potentially leading to meal dissatisfaction.
The facility failed to maintain safe food storage practices, with improperly labeled thawing meats and significant ice buildup in the walk-in freezer. The Dietary Supervisor confirmed the labeling errors, and the Maintenance Supervisor acknowledged the potential contamination risk from the leaking freezer.
A resident with multiple health conditions, including hemiplegia and impaired cognition, was found to have their call light out of reach, potentially preventing them from calling for assistance. The care plan required the call light to be within reach, but during an observation, it was found hanging off the bed. A CNA and the DON confirmed the deficiency, acknowledging the risk of the resident being unable to call for help.
A facility failed to include a resident's advance directive in their medical chart, despite the resident having chronic respiratory failure, end-stage renal disease, and dementia. The resident lacked decision-making capacity, and the absence of the directive was confirmed by the Director of Social Services and the DON. Facility policy required advance directives to be in the clinical record, but this was not followed.
A resident with Korean as their primary language was unable to effectively communicate their needs due to the facility's failure to provide a Korean communication board within reach. Despite the care plan's directive, the board was placed in a bin by the room entrance, not at the bedside. Staff interviews confirmed the oversight, and the resident expressed difficulty in communicating with staff, often using gestures.
A resident who was ventilator-dependent and had severe cognitive impairment did not receive adequate oral care, as required by physician orders and care plans. Observations showed dry, flaky lips and crusty patches on the tongue, indicating neglect. Staff interviews confirmed the lack of consistent oral care, which is crucial to prevent infections, especially ventilator-associated pneumonia.
The facility failed to implement seizure precautions for two residents with epilepsy, as required by their care plans and physician's orders. Observations revealed that the residents' bedrails were not padded, despite the need for such precautions to prevent injury. Staff confirmed the absence of required safety measures, and the Director of Nursing acknowledged the oversight, which could lead to injuries during seizure activity.
A resident with chronic respiratory failure did not have their oxygen tubing changed weekly as required by their care plan and physician's order. Observations showed the tubing was overdue for replacement, posing a risk of infection. Interviews with staff confirmed the oversight, which was contrary to facility policies aimed at maintaining infection control.
A facility failed to ensure timely in-person visits by a physician for a resident, as required by regulations. The attending physician did not conduct an initial visit within 30 days of readmission, and subsequent visits were not alternated with a Nurse Practitioner every 60 days after the first 90 days. This resulted in incomplete care, as confirmed by the DON.
The facility failed to enforce its infection control policy, leading to deficiencies in hand hygiene and IV catheter management for two residents. A nurse did not perform hand hygiene between glove changes during skin care for a resident with severe cognitive impairment and multiple health conditions. Another resident's IV catheter was not labeled or clamped, increasing the risk of contamination. These actions violated the facility's infection prevention protocols, which emphasize hand hygiene as crucial to preventing infection spread.
A resident with multiple diagnoses, including dysphagia and severe protein-calorie malnutrition, experienced a delay in receiving a modified barium swallow study (MBSS) due to the facility's failure to follow up on insurance authorization in a timely manner. Miscommunication and errors in transportation arrangements further contributed to the delay, causing the resident to become angry and refuse meals.
Failure to Maintain Clean and Homelike Resident Room Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for one resident by not maintaining the resident’s room in accordance with its own policies. The resident, who had chronic respiratory failure, a tracheostomy, and was ventilator-dependent, had impaired cognition and was dependent on staff for all ADLs, and did not have the capacity to understand or make decisions. During an observation in the resident’s room, surveyors noted that the privacy curtain strings were tangled and the ceiling had multiple brownish stains. During the same observation, the Maintenance Staff stated that staff were supposed to check resident rooms weekly for any issues. The DON acknowledged that curtain strings were not supposed to be tangled and that there should not be stains on the ceiling in order to provide a clean and homelike environment. Review of the facility’s “Quality of Life: Homelike Environment” policy, last reviewed on 1/16/2026, indicated residents were to be provided with a safe, clean, and homelike environment characterized by cleanliness and order, with privacy curtains clean and in good condition. The observed conditions in the resident’s room did not meet these policy standards.
Resident Left Unattended in Hoyer Lift Contrary to Safety Policies
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when a resident was left unattended in a Hoyer lift. The resident had chronic respiratory failure, a tracheostomy, and was ventilator-dependent, with documented impaired cognition and dependence on staff for all ADLs, including transfers. The resident’s H&P stated the resident did not have capacity to understand or make decisions, and the care plan identified a risk for falls due to poor safety awareness, with instructions that staff assist the resident with all transfers. During observation in the resident’s room, the resident was seen suspended in a Hoyer lift over the bed with no staff present. An RN immediately called for a CNA, who reported she had left the resident in the lift while she went to call another staff member for assistance and acknowledged she was not supposed to leave the resident unattended in the Hoyer lift. The RN stated residents should not be left unattended when up in a Hoyer lift due to safety concerns. The DON stated that residents should not be left unattended when using a Hoyer lift and that it was best practice to have at least two staff assist with Hoyer lift use. Facility policies on safe lifting and resident safety/supervision indicated the facility would use appropriate techniques and devices to protect resident safety and make the environment as free from accident hazards as possible.
Failure to Maintain Clean, Safe, and Well-Maintained Resident Bathrooms and Rooms
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, and homelike environment in multiple resident-use areas, including bathrooms and resident rooms. Surveyors observed that the all-gender bathroom next to the nursing station had a toilet that was loose from the floor, with newspaper stuffed between the toilet and the floor and missing caulk to seal it. In the same bathroom, the sink countertop was pulling away from the backsplash with missing or cracked and crumbling grout/caulk, and there was a black mold-like buildup under the lip where the countertop met the sink bowl. The Maintenance Assistant (MA) acknowledged these conditions, explaining that recent plumbing work left the toilet not flush with the floor and confirming that the countertop and cleanliness issues existed. Additional observations showed environmental deterioration in several resident rooms and shared bathrooms. In one resident room, the baseboard near the patio sliding glass door was peeling off the wall and fell away when the curtain was moved, exposing a completely crumbled wall area; the MA confirmed this and stated there were no mice currently in the space. In the bathroom between two resident rooms, the sink was pulling away from the wall with cracked and crumbling caulk/grout, peeled paint, rust on exposed sink pipes, dirt and grime buildup in the corners, and a baseboard peeling away from the wall; the MA validated these findings. In another resident room, the baseboard near the sliding glass door was peeling away from the wall with some paint, and the corners of the sliding glass door had visible dirt and grime buildup, which the MA also confirmed. Review of the facility’s daily maintenance log over several months showed no entries documenting these environmental issues, and the facility’s policy on providing a safe, clean, comfortable, and homelike environment emphasized cleanliness and order, which contrasted with the observed conditions.
Loose Stairway Handrail Not Secured to Wall
Penalty
Summary
The facility failed to maintain a safe environment by not securing the upper end of the stairway handrail on the right side as you go up from the parking lot to the first floor. During an observation and concurrent interview with the Maintenance Supervisor and Maintenance Assistant, the top end of this handrail was found to be loose from the wall and easily movable. Both maintenance staff confirmed that the handrail was loose. Record review of the facility’s policy and procedure titled “Quality of Life - Homelike Environment,” revised 1/10/25, showed that residents are to be provided with a safe, clean, comfortable, and homelike environment, including cleanliness and order, which was not met in this instance. No specific residents or their medical conditions were mentioned in relation to this deficiency.
Incomplete POLST Documentation for Incapacitated Resident
Penalty
Summary
A deficiency occurred when the facility failed to complete the Physician Orders for Life-Sustaining Treatment (POLST) for a resident who was admitted with multiple complex medical conditions, including a stage 4 pressure ulcer, urinary tract infection, and a gastrostomy tube. The resident was determined to lack capacity to make medical decisions, as documented in both the History and Physical and the Minimum Data Set, which indicated severely impaired cognitive skills and total dependence on staff for daily activities. Upon review, the resident's POLST form was found to be incomplete. Key sections of the form, including those addressing cardiopulmonary resuscitation, medical interventions, artificially administered nutrition, and the information and signatures section, were not filled out. The form was signed only by the provider and not by the resident's legally recognized decision maker, as required when the resident lacks capacity. The responsible registered nurse confirmed that the POLST should not have been signed by the provider alone and that all sections must be completed for the document to be valid. The Director of Nursing stated that it was the responsibility of the social worker and licensed nursing staff to ensure the POLST was fully completed. Facility policy also required that the provider confirm the orders with the resident or, if incapacitated, the legally recognized decision maker before signing. The failure to complete the POLST as required resulted in the resident's medical wishes not being properly documented or available to guide care in the event of an emergency.
Plan Of Correction
F-578 Corrective Action On 9/8/25, the Director of Nursing (DON) gave the Social Service Designee (SSD) an inservice about the facility's policy on advanced directive and POLST. Reviewed the process in completing the Advanced Directive and POLST accurately and timely to avoid delay in treatment or life-sustaining procedures in the event of an emergency. On 9/8/25 and 9/11/25, the DON gave the Licensed Nurses an inservice about the facility's policy on advanced directive and POLST. Reviewed the process in completing the Advanced Directive and POLST accurately and timely to avoid delay in treatment or life-sustaining procedures in the event of an emergency. Identification of Others On 9/11/25, the DON and Medical Records Director reviewed all the other charts to review the resident's POLST. No other resident received the deficient practice. Measures to Prevent Recurrence On 9/8/25, the DON gave the SSD an inservice about the facility's policy on advanced directive and POLST. Reviewed the process in completing the Advanced Directive and POLST accurately and timely to avoid delay in treatment or life-sustaining procedures in the event of an emergency. On 9/8/25 and 9/11/25, the DON and/or gave the Licensed Nurses an inservice about the facility's policy on advanced directive and POLST. Reviewed the process in completing the Advanced Directive and POLST accurately and timely to avoid delay in treatment or life-sustaining procedures in the event of an emergency. The DON and/or designee will repeat the inservices every month for 3 months and then as needed to ensure compliance. Monitoring Performance Starting 9/11/25, the Medical Records Director and/or designee will review 5 random charts and review if the POLST is complete; weekly x 4 weeks. The Administrator, and the DON will present the recapitulations of the findings to the monthly QAPI for review and action as indicated. Identification of Others On 9/11/25, the DON and Medical Records Director reviewed all the other charts to review the resident's POLST. No other resident received the deficient practice. Measures to Prevent Recurrence On 9/8/25, the DON gave the SSD an inservice about the facility's policy on advanced directive and POLST. Reviewed the process in completing the Advanced Directive and POLST accurately and timely to avoid delay in treatment or life-sustaining procedures in the event of an emergency. On 9/8/25 and 9/11/25, the DON and/or gave the Licensed Nurses an inservice about the facility's policy on advanced directive and POLST. Reviewed the process in completing the Advanced Directive and POLST accurately and timely to avoid delay in treatment or life-sustaining procedures in the event of an emergency. The DON and/or designee will repeat the inservices every month for 3 months and then as needed to ensure compliance. Monitoring Performance Starting 9/11/25, the Medical Records Director and/or designee will review 5 random charts and review if the POLST is complete; weekly x 4 weeks. The Administrator, and the DON will present the recapitulations of the findings to the monthly QAPI for review and action as indicated.
Failure to Document Resident Transfer to Hospital
Penalty
Summary
A deficiency occurred when the facility failed to document the transfer of a resident to a general acute care hospital (GACH) in the resident's medical records. The review of the resident's records showed that there was no documentation by facility staff indicating the transfer, despite a physician's telephone order for the transfer being present. The Clinical Manager confirmed during an interview and record review that the medical records were incomplete and not accurate, specifically noting the absence of documentation regarding the resident's transfer. The resident involved had a complex medical history, including chronic respiratory failure with hypoxia, a tracheostomy, and a gastrostomy tube placement. The resident was also noted to have severely impaired cognitive skills and was totally dependent on staff for daily activities such as oral hygiene, toileting, and dressing. The resident did not have the capacity to understand or make decisions, as indicated in the history and physical and the Minimum Data Set (MDS) assessment. Facility policy and procedure documents reviewed indicated that all services provided, progress toward care plan goals, and any changes in the resident's condition should be documented in the medical record. However, in this instance, the licensed nurse did not document the resident's clinical condition, vital signs, or other pertinent information at the time of transfer. This lack of documentation resulted in incomplete medical records for the resident.
Plan Of Correction
F-628 Corrective Action On 9/10/25 and 9/11/25, the DON gave the licensed nurses an inservice about the facility's policy on discharge process. Licensed nurses must complete their discharge notes accurately and timely. Discussed that accurate and complete clinical documentation needs to be provided during resident's discharges to provide better interfacility communication and continuity of care. On 9/9/25, the Director of Nursing (DON) gave the transferring RN for Resident 1 an inservice about the facility's policy on discharge process. Discussed that accurate and complete clinical documentation needs to be provided during resident's discharges to provide better interfacility communication and continuity of care. Identification of Others On 9/11/25, the DON and Clinical Manager assessed other discharge charts. No other resident received the deficient practice. Measures to Prevent Recurrence On 9/10/25 and 9/11/25, the DON gave the licensed nurses an inservice about the facility's policy on discharge process. Licensed nurses must complete their discharge notes accurately and timely. Discussed that accurate and complete clinical documentation needs to be provided during resident's discharges to provide better interfacility communication and continuity of care. The DON and/or designee will repeat the inservices every month for 3 months and then as needed to ensure compliance. Monitoring Performance Starting 9/11/25, the Medical Records Director and/or designee will review 5 random discharge charts and review if the discharge documentation is complete; weekly x 4 weeks. The Administrator, and the DON will present the recapitulations of the findings to the monthly QAPI for review and action as indicated. The DON and/or designee will repeat the inservices every month for 3 months and then as needed to ensure compliance. Monitoring Performance Starting 9/11/25, the Medical Records Director and/or designee will review 5 random discharge charts and review if the discharge documentation is complete; weekly x 4 weeks. The Administrator, and the DON will present the recapitulations of the findings to the monthly QAPI for review and action as indicated.
Failure to Develop Comprehensive Care Plan for Pressure Ulcers
Penalty
Summary
A deficiency occurred when the facility failed to develop and implement a comprehensive care plan for a resident with multiple pressure ulcers. The resident was admitted with several stage 4 and unstageable pressure ulcers, as well as other significant medical conditions including a urinary tract infection and a gastrostomy tube. The resident was assessed as having severely impaired cognitive skills and was totally dependent on staff for daily care activities. Despite these complex needs, only a baseline care plan was created upon admission, and no comprehensive care plan was developed more than two months after admission. Interviews with facility staff confirmed the absence of a comprehensive care plan. The Clinical Manager acknowledged that while a baseline care plan was in place, there was no comprehensive care plan addressing the resident's multiple pressure ulcers. The Clinical Manager emphasized the importance of such a plan for guiding the monitoring and treatment of the wounds, noting that without it, there was no specific guidance for wound care. The Director of Nursing also confirmed that the baseline care plan is only valid for 14 days and that a comprehensive care plan should have been developed by the interdisciplinary team within that timeframe. A review of the facility's policy and procedure on comprehensive care plans indicated that care plans should be created for skin alterations, including pressure ulcers, and that goals should be realistic, measurable, and include a timeframe for re-evaluation. The failure to develop a comprehensive care plan for the resident's pressure ulcers was contrary to both regulatory requirements and the facility's own policy, resulting in a lack of documented, coordinated interventions for the resident's wound care needs.
Plan Of Correction
F -656 Corrective Action On 9/10/25 and 9/11/25, the DON gave the licensed nurse an inservice on how to develop and implement a comprehensive care plan for wounds. The comprehensive care plan serves as a guide in providing appropriate wound care interventions to promote healing; and avoid infection and/or worsening. On 9/10/25 and 9/11/25, the MDS Consultant gave the MDS nurses an inservice about the facility's policy on developing a comprehensive care plan. Wound care plans should be integrated in the comprehensive care plans. Identification of Others On 9/11/25, the DON and Medical Records Director reviewed other residents' wound care plans. No other resident received the deficient practice. Measures to Prevent Recurrence On 9/10/25 and 9/11/25, the DON gave the licensed nurse an inservice on how to develop and implement a comprehensive care plan for wounds. The comprehensive care plan serves as a guide in providing appropriate wound care interventions to promote healing; and avoid infection and/or worsening. On 9/10/25 and 9/11/25, the MDS Consultant gave the MDS nurses an inservice about the facility's policy on developing a comprehensive care plan. Wound care plans should be integrated in the comprehensive care plans. The DON and/or designee will repeat the inservices every month for 3 months and then as needed to ensure compliance. Monitoring Performance Starting 9/11/25, the Medical Records Director and/or designee will review 5 random charts of residents with wounds and review if they have comprehensive care plans for wounds; weekly x 4 weeks. The Administrator, and the DON will present the recapitulations of the findings to the monthly QAPI for review and action as indicated. Identification of Others On 9/11/25, the DON and Medical Records Director reviewed other residents' wound care plans. No other resident received the deficient practice. Measures to Prevent Recurrence On 9/10/25 and 9/11/25, the DON gave the licensed nurse an inservice on how to develop and implement a comprehensive care plan for wounds. The comprehensive care plan serves as a guide in providing appropriate wound care interventions to promote healing; and avoid infection and/or worsening. On 9/10/25 and 9/11/25, the MDS Consultant gave the MDS nurses an inservice about the facility's policy on developing a comprehensive care plan. Wound care plans should be integrated in the comprehensive care plans. The DON and/or designee will repeat the inservices every month for 3 months and then as needed to ensure compliance. Monitoring Performance Starting 9/11/25, the Medical Records Director and/or designee will review 5 random charts of residents with wounds and review if they have comprehensive care plans for wounds; weekly x 4 weeks. The Administrator, and the DON will present the recapitulations of the findings to the monthly QAPI for review and action as indicated.
Failure to Perform Weekly Pressure Ulcer Reassessments
Penalty
Summary
A deficiency was identified when a resident with multiple pressure ulcers did not receive care in accordance with professional standards of practice. The resident, who was admitted with several Stage 4 and unstageable pressure ulcers, was found to have not had their pressure ulcers reassessed and documented on a weekly basis as required. The treatment nurse confirmed that a scheduled weekly reassessment and documentation of the pressure ulcers, including type, location, measurement, and description, was not completed for one week. This omission was acknowledged during an interview and record review, where the nurse stated that such reassessments are necessary to determine the status and progression of the ulcers and to make any needed adjustments to the wound care plan. The resident in question had significant medical issues, including severely impaired cognitive skills, total dependence on staff for daily activities, and a history of pressure ulcers present upon admission. The baseline care plan and Minimum Data Set (MDS) documented the presence of multiple pressure ulcers and the resident's high risk for developing additional ulcers. Despite these risk factors and the need for close monitoring, the required weekly wound assessments were not consistently performed or documented. Further review of facility policies and the treatment nurse's job description revealed gaps in guidance regarding the frequency and documentation of pressure ulcer reassessments. The facility's policy did not specify the need for scheduled weekly reassessments to monitor the progression of pressure ulcers, and the job description did not require the treatment nurse to review and revise the care plan as needed for accurate wound care guidance. These omissions contributed to the failure to provide care consistent with professional standards for pressure ulcer management.
Plan Of Correction
F-686 Corrective Action On 9/10/25, the DON gave the Treatment nurses an inservice about the facility's policy on reassessing wounds weekly. Wound sites will be reassessed weekly and documented timely. On 9/10/25, the DON gave the licensed nurse an inservice about the facility's policy on reassessing wounds weekly. Wound sites will be reassessed weekly and documented timely. Identification of Others On 9/11/25, the DON and Treatment nurse reviewed other residents' weekly wound assessments and documentation. No other resident received the deficient practice. Measures to Prevent Recurrence On 9/10/25, the DON gave the Treatment nurses an inservice about the facility's policy on reassessing wounds weekly. Wound sites will be reassessed weekly and documented timely. On 9/10/25, the DON gave the licensed nurse an inservice about the facility's policy on reassessing wounds weekly. Wound sites will be reassessed weekly and documented timely. The DON and/or designee will repeat the inservices every month for 3 months and then as needed to ensure compliance. Monitoring Performance Starting 9/11/25, the DON and/or designee will review 5 random charts of residents with wounds and review if they have completed their weekly wound assessment; weekly x 4 weeks. The Administrator, and the DON will present the recapitulations of the findings to the monthly QAPI for review and action as indicated.
Deficient Catheter Care in LTC Facility
Penalty
Summary
The facility failed to provide proper care for residents with indwelling catheters, leading to potential health risks. For one resident, the staff did not empty the urinary collection bag as ordered by the physician. The resident reported that the bag had not been emptied since the previous day, and a CNA confirmed that the bag was full and had not been checked or emptied during the current shift. The Director of Nursing acknowledged this as a deficient practice, noting the potential for infection. Another resident's urinary catheter bag was improperly maintained above the level of the bladder, contrary to the facility's policy. An LVN confirmed the incorrect placement and acknowledged the risk of urinary tract infection due to potential backflow of urine. The Director of Nursing reiterated that the catheter bag should be placed below the bladder level to prevent infection. A third resident had an indwelling catheter placed for wound management, but there was no assessment for its removal after the wound had healed. An LVN stated that the catheter was no longer appropriate as the resident's pressure sore had resolved. The Director of Nursing confirmed that the resident should have been assessed for catheter removal to avoid unnecessary infection risk.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store Tuberculin purified protein derivative (Tuberculin PPD) according to the manufacturer's recommendation. During an observation, a vial of Tuberculin PPD was found in the medication refrigerator with an open date of 5/29/2024, despite the manufacturer's instructions to store it at room temperature after opening. This oversight was confirmed by RN 2, who acknowledged the discrepancy between the storage practice and the manufacturer's guidelines. Additionally, the facility did not adhere to proper labeling and disposal protocols for other medications. An open vial of Latanoprost was found without an open date, and multi-dose containers of Clearlax and Reguloid were not discarded within the 60-day period after opening, as required by the facility's policy. LVN 5 and LVN 6 confirmed these lapses during interviews, and the Director of Nursing reiterated the importance of following the facility's policy and manufacturer's recommendations to ensure medication efficacy.
Failure to Follow Fortified and Pureed Diet Guidelines
Penalty
Summary
The facility failed to ensure that staff followed food production recipes and fortified diet guidelines during lunch service. Specifically, fortified diets, which are designed to increase caloric intake for residents who cannot consume adequate calories or protein, were not prepared or served to 10 residents who were on such diets. During a tray line observation, it was noted that the dietary aide communicated the fortified diet orders, but the staff member serving the food did not add any additional food items as per the fortified menu. Interviews with the dietary aide and the dietary supervisor revealed that there was no written fortified diet menu, and extra butter or gravy, which are typically added to increase calorie density, were not included in the meals served that day. Additionally, the facility did not adhere to the menu for residents on a pureed diet. Six residents on a pureed diet did not receive pureed lettuce, tomato, and pickles with their meal as specified in the menu. During the tray line observation, it was found that only pureed hamburger, bread, and corn were served. An interview with the dietary supervisor and the staff member serving the food confirmed that there was a mistake, and the pureed items were not prepared or served as required. This oversight had the potential to result in meal dissatisfaction for residents on a pureed diet.
Deficiencies in Food Storage and Freezer Maintenance
Penalty
Summary
The facility failed to ensure safe and sanitary food storage practices, as observed during a survey. Two previously cooked and frozen roast pork items were found thawing in the walk-in refrigerator without a pull-out or thaw date, and a large turkey was labeled with the wrong thaw date. The Dietary Supervisor confirmed that the roast pork was removed from the freezer to thaw but was not dated correctly, and the turkey was mislabeled. The facility's policy requires all foods stored in the refrigerator or freezer to be covered, labeled, and dated, which was not adhered to in these instances. Additionally, the walk-in freezer had significant ice buildup on the ceiling, condenser, and pipes, with icicles hanging above the food. A large pan filled with solid ice and water was observed, indicating a leak from above. The floor of the freezer was slippery with ice. The Dietary Supervisor acknowledged the issue and stated that an outside company was expected to fix it. The Maintenance Supervisor was informed of the problem and recognized the potential for contamination from the leaking water. The facility's sanitation policy requires equipment to be maintained in good repair, which was not the case here.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach for a resident, identified as Resident 22, which could potentially prevent the resident from calling for assistance when needed. Resident 22 was admitted with multiple diagnoses, including hemiplegia, blindness in one eye, and dependence on a wheelchair, and had moderately impaired cognition. The resident required substantial assistance with daily activities, including toileting and personal hygiene. The care plan for Resident 22 specified that the call light should be kept close and within reach to ensure the resident could call for help. During an observation, it was noted that Resident 22's call light was hanging off the bed and not within reach, and the resident was unable to locate it. A CNA confirmed the call light was not accessible and acknowledged the potential risk of the resident being unable to call for help. The Director of Nursing also stated that call lights should always be within reach to prevent residents from being unable to call for assistance. The facility's policy indicated that call lights should be easily accessible to residents when they are in bed or confined to a chair.
Failure to Include Advance Directive in Resident's Medical Chart
Penalty
Summary
The facility failed to ensure that a current copy of a resident's advance directive was included in the resident's medical chart. This deficiency was identified for a resident who was admitted with chronic respiratory failure, end-stage renal disease, and dementia. The resident's physician history and physical indicated that the resident lacked the capacity to understand and make decisions, and the Minimum Data Set assessment showed moderately impaired cognition and dependence on multiple helpers for daily activities. During interviews, the Director of Social Services acknowledged that the resident's advance directive was not found in the clinical record, despite an acknowledgment form indicating its existence. The Director of Nursing confirmed that the advance directive should have been in the resident's chart to guide staff in honoring the resident's medical decisions. The facility's policy required that advance directives be placed in the clinical record when provided by the resident or their representative, but this was not adhered to in this case.
Failure to Provide Accessible Communication Tools for Non-English Speaking Resident
Penalty
Summary
The facility failed to accommodate the communication needs of a resident whose primary language is Korean. The resident, admitted with conditions such as osteomyelitis, type 2 diabetes, and muscle weakness, required a Korean communication board to effectively communicate with staff. Despite the care plan indicating the need for a visual communication board at the resident's bedside, the board was found in a folder placed in a bin secured to the wall by the entrance of the resident's room, out of the resident's reach. This oversight was confirmed during observations and interviews with staff, including a Licensed Vocational Nurse and the Social Services Director, who acknowledged the importance of having the communication board accessible to the resident. Interviews with the resident, facilitated by translation services, revealed that the resident experienced difficulty communicating with staff due to the language barrier, often resorting to gestures. The Director of Nursing also confirmed that the communication board should have been near the resident's bedside to ensure easy access and facilitate communication. The facility's policy on accommodating communication deficits emphasized the need for care plans to reflect accurate and current assessments related to communication needs, which was not adhered to in this case.
Failure to Provide Oral Care for Ventilator-Dependent Resident
Penalty
Summary
The facility failed to provide adequate oral care for a resident who was completely dependent on staff for all activities of daily living, including oral hygiene. The resident, who had severe cognitive impairment and was dependent on a ventilator due to chronic respiratory failure, was observed with dry, flaky lips and off-white crusty patches on the tongue, indicating a lack of oral care. Despite physician orders and care plans specifying the need for oral care every shift to prevent infection, observations and staff interviews revealed that oral care was not consistently provided. Interviews with staff, including a CNA, a respiratory therapist, the Director of Staff Development, and the Director of Nursing, confirmed that the resident had not received proper mouth care for some time. The facility's policy required oral care to maintain oral hygiene and prevent infections, especially important for residents on ventilators to avoid ventilator-associated pneumonia. The deficiency was identified through observations and staff admissions that oral care was neglected, putting the resident at risk for infection.
Failure to Implement Seizure Precautions for Residents
Penalty
Summary
The facility failed to implement necessary seizure precautions for two residents, both diagnosed with epilepsy, which placed them at risk for injury. Resident 2, who was severely cognitively impaired and dependent on staff for all activities of daily living, had a care plan that required padded side rails as a precaution against seizures. However, during an observation, it was noted that Resident 2's bedrails were not padded, contrary to the physician's orders and the care plan. Licensed Vocational Nurse 4 confirmed the absence of padding and acknowledged that it was required to protect the resident from harm. Similarly, Resident 20, who had moderate cognitive impairment and required substantial assistance for daily activities, also had a care plan that included seizure precautions such as padded side rails. Observations revealed that Resident 20's bedrails were not padded, and there were no pillows or wedge pillows in place as required. Licensed Vocational Nurse 1 confirmed the lack of padding despite having documented that the precautions were in place. The Director of Nursing acknowledged the failure to implement the physician's orders, which could lead to injuries during seizure activity. The facility's policy emphasized the importance of implementing interventions to reduce accident risks, which were not followed in these cases.
Failure to Change Oxygen Tubing as Per Care Plan
Penalty
Summary
The facility failed to adhere to the care plan and physician's order for Resident 2, who required oxygen therapy due to chronic respiratory failure and other conditions. The care plan specified that the resident's oxygen tubing should be changed every seven days to prevent infection and maintain cleanliness. However, observations revealed that the oxygen tubing had not been changed as scheduled, with the tubing dated 6/14/2024, indicating it was overdue for replacement by the time of the surveyor's observation on 6/21/2024 and 6/22/2024. Interviews with the respiratory therapist and the Director of Nursing confirmed that the tubing should have been changed weekly, and the failure to do so posed a risk of infection. The facility's policy and procedure documents supported the requirement for regular changes to maintain infection control. Despite these guidelines, the oversight in changing the oxygen tubing as per the care plan and physician's order resulted in a deficiency, highlighting a lapse in the facility's adherence to prescribed care protocols.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that a physician completed in-person visits in a timely manner for a resident, as required by regulations. Specifically, the attending physician did not conduct an initial comprehensive visit within 30 days after the resident's readmission. Instead, a Nurse Practitioner (NP) completed the History and Physical (H&P) assessment. This oversight was confirmed during an interview with the Director of Nursing (DON), who acknowledged that the attending physician was required to perform the initial visit personally. Additionally, the facility did not adhere to the required schedule of alternating physician and NP visits every 60 days after the first 90 days of the resident's admission. The resident's progress notes from November 2023 to March 2024 were all completed by an NP, with no documented visits from the attending physician. The DON confirmed that the attending physician had not visited the resident since November 2023, which could lead to incomplete care. The facility's policy mandates that the attending physician must visit residents at least once every 30 days for the first 90 days and then at least every 60 days thereafter, with alternate visits by an NP allowed only after the initial 90 days.
Infection Control Deficiencies in Hand Hygiene and IV Management
Penalty
Summary
The facility failed to enforce its infection prevention and control policy, resulting in deficiencies related to hand hygiene and intravenous catheter management for two residents. For Resident 29, who was admitted with severe cognitive impairment and multiple health conditions including sepsis and chronic kidney disease, the facility did not ensure proper hand hygiene between glove changes during skin care procedures. Licensed Vocational Nurse 2 was observed changing gloves multiple times without performing hand hygiene, which is against the facility's policy and increases the risk of spreading infectious microorganisms. Resident 10, who had intact cognition and required assistance with daily activities, was receiving intravenous antibiotic treatment. The facility failed to label the intravenous catheter with the date of insertion and did not clamp the needleless lock system after use. This oversight was confirmed by Registered Nurse 1, who acknowledged that the open system could lead to cross-contamination. The Director of Nursing also confirmed that the facility's protocol requires labeling and clamping to prevent contamination. The facility's policy emphasizes hand hygiene as the primary means to prevent infection spread, stating that gloves do not replace the need for handwashing. The policy outlines specific instances when hand hygiene should be performed, such as between glove changes and after contact with a resident's skin or contaminated equipment. The failure to adhere to these protocols for both residents highlights a significant lapse in maintaining a safe and sanitary environment, as required by the facility's infection prevention and control policies.
Failure to Timely Follow Up on Insurance Authorization for MBSS
Penalty
Summary
The facility failed to follow up on insurance authorization for a modified barium swallow study (MBSS) in a timely manner for a resident, leading to a delay in service. The resident, who had multiple diagnoses including hemiplegia, COPD, dysphagia, and severe protein-calorie malnutrition, was admitted with a g-tube for feeding. Despite a physician's order for an MBSS, the facility did not ensure the authorization process was completed promptly, causing the resident to become angry and refuse meals. The resident's appointment for the MBSS was initially scheduled, but due to miscommunication and errors in transportation arrangements, the appointment was missed. The facility's business office assistant (BOA) faced difficulties in obtaining the necessary authorization from the insurance company, experiencing a runaround between the insurance company and the medical group. Despite multiple follow-up attempts, the authorization process was delayed, and the resident was not informed of the status in a timely manner. The resident expressed frustration and anger due to the delay in receiving the MBSS, which was necessary for evaluating the removal of the g-tube. The resident's refusal to eat the provided puree diet and the ongoing issues with the authorization process contributed to the resident's deteriorating mental state and increased agitation. The facility's failure to follow its own policy and procedures for timely follow-up on authorizations led to a significant delay in the resident's care and exacerbated the resident's distress.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 7,017 citations issued within 25 miles in the last 12 months — including the 36 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Rehabilitation Center Of Los Angeles | 0 mi | ★★★★★ | 0 | 0 |
| Bonnie Brae Skilled Nursing | 0.1 mi | ★★★★★ | 9 | 0 |
| Angels Nursing Health Center | 0.2 mi | ★★★★★ | 0 | 0 |
| Mid-wilshire Health Care Cntr | 0.4 mi | ★★★★★ | 35 | 0 |
| Pih Health Good Samaritan Hospital D/p Snf | 0.6 mi | ★★★★★ | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.