Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Wilshire Skilled Nursing And Therapy during CMS and state inspections, most recent first.
Dumpster Waste Not Properly Contained: The facility failed to keep 2 of 2 roll-off dumpsters covered and failed to keep the dumpster area free of debris. Surveyors observed both dumpster lids open, and later observed broken eggshells, a partially consumed chicken drumstick, and a box resembling a pizza box on the ground near the dumpsters. The RD of Ops stated there was no policy for keeping the dumpster area clean or the lids closed, while the DS, DON, and ADM stated staff were responsible for keeping the area clean and the lids shut.
A resident with moderate cognitive impairment was not provided properly completed NOMNC and SNF ABN forms before Medicare Part A skilled coverage ended. The forms noted the resident could not understand them due to cognitive deficit, but the signature areas for the resident or representative were left blank. Interviews showed the ADON, RNC, and ADM had differing explanations about who was responsible for handling the notices and decision-making.
Failure to Promptly Resolve Missing Property Grievance: The facility did not ensure prompt follow-up on a resident’s missing cell phone grievance. A resident with moderate cognitive impairment reported the phone missing after leaving it charging, and CNAs said they reported it to nursing leadership, but the DON and Administrator stated they were not notified. The phone was later found in the medication room and returned to the resident.
Untrimmed and Dirty Nails Not Addressed: A resident with legal blindness and moderate cognitive impairment required substantial/maximal help with personal hygiene, but staff did not ensure the resident's nails were kept clean and trimmed. The resident said they asked staff to cut their nails and did not like them long, yet observations showed the nails remained long and dirty underneath. A CNA said she cleaned the nails but did not trim them and did not report the issue to the nurse, while an LPN and the DON both observed that the nails were long, broken, and in need of filing or trimming.
Failure to Follow Physician Orders for Labs, Dressing Care, and Ice Packs: A resident admitted after joint replacement surgery reported that staff did not complete ordered admission labs, surgical dressing changes, or ice pack applications. The record contained orders for CBC, CMP, prealbumin, incision cleansing and dressing changes, and ice packs for pain, but there was no documented evidence these treatments were carried out. The DON confirmed the lack of documentation, and the Administrator stated staff were expected to follow provider orders or notify the provider if unable to do so.
Shared bedrooms were not equipped to maintain full visual privacy for two pairs of residents. Surveyors observed partial privacy curtains that stopped short of the wall and large mirrors that allowed views of each resident’s sleeping area. Residents and staff stated that roommates and visitors could see into the other resident’s area, including when a resident used the shared bathroom or when care was provided.
The facility failed to store medications properly, as observed when a medication cart was left unattended with medications for two residents unsecured on top. The facility's policy requires medications to be stored safely and securely, accessible only to authorized personnel. A CMA acknowledged the carts should not be left unattended, and the DON confirmed the need for proper storage.
The facility failed to hold Resident Council meetings as scheduled, violating residents' rights to participate in such groups. The absence of an activity director and a social service person, along with the administrator's busy schedule, contributed to the failure to conduct meetings in August and September. The Resident Council president and group were unaware of the meeting schedule, and documentation for previous meetings was missing.
The facility failed to conduct scheduled activities for its residents due to the absence of an activity director, leading to unmet social and recreational needs. Residents expressed dissatisfaction, with one resident confined to their room and another desiring outdoor activities. The administrator admitted that activities did not occur due to being busy and the lack of staff.
The facility failed to maintain food safety and sanitation standards, affecting 28 residents. Expired nectar thickened tea was not removed, and the kitchen was not kept clean, with debris found in a freezer and dust on a window seal. Additionally, leftover soup was not reheated to the required 165°F, with the CDM admitting to forgetting to check the temperature, which was only 127°F.
A resident's medication, Aubagio, was held from April to September 2024 due to insurance coverage issues, but the facility failed to notify the physician as required by policy. Interviews with staff, including LPNs and the DON, confirmed the lack of documentation for physician notification, despite the medication being withheld for several months.
A facility failed to update a care plan for a resident whose smoking privileges were revoked due to safety concerns. Despite the resident no longer being allowed to smoke, the care plan continued to document them as a smoker. The oversight was identified during a review, and the corporate MDS consultant acknowledged the need for an update after being informed of the resident's current non-smoking status.
The facility did not update the daily staffing information as required, with observations showing outdated postings lacking total hours for licensed staff. The administrator acknowledged awareness of the regulation but admitted the information was incomplete and outdated.
A CNA failed to follow proper infection control procedures by transporting urine in an uncovered hat from a resident's room to a powder room and returning the uncleaned hat to the resident's room. The resident had neuromuscular dysfunction of the bladder and an indwelling catheter. The DON confirmed that urine should be transported in a bag and the container cleaned before storage.
The facility failed to provide scheduled bathing assistance to three residents, each with specific medical conditions requiring ADL support. Despite being scheduled for regular baths, these residents missed multiple opportunities, with one resident experiencing up to 10 days between baths. The DON confirmed the absence of documentation for these missed baths, highlighting a deficiency in the facility's care provision.
The facility did not complete an annual performance review for a CMA hired in 2004. A review of employee files revealed the absence of a required annual competency review, which was confirmed by the BOM.
Dumpster Waste Not Properly Contained
Penalty
Summary
The facility failed to ensure waste was properly contained in dumpsters and failed to ensure 2 of 2 dumpsters observed were covered. The U.S. FDA Food Code, 2022, was cited for requiring outside receptacles and waste handling units for refuse and recyclables to have tight-fitting lids, doors, or covers, and to be installed and maintained to minimize debris accumulation and insect and rodent attraction and harborage. During an interview, the Regional Director of Operations stated the facility did not have a policy related to keeping the dumpster area clean or keeping the dumpsters' lids closed. An observation revealed two roll-off dumpsters at the rear of the facility adjacent to the parking lot with both lids open. Later, broken eggshells, a partially consumed chicken drumstick, and a box resembling a pizza box were observed on the ground next to the dumpsters, and the dumpsters were again observed with their lids open. The Dietary Supervisor stated she and maintenance staff were responsible for keeping the area around the dumpsters free of debris and ensuring the dumpster lids were closed, and that CNAs and housekeeping staff also used the dumpsters and were reminded to close the lid after emptying trash. The DON and Administrator stated the expectation was for the dumpster area to be kept clean and for the lids and side doors to remain shut.
Failure to Provide Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to ensure that Resident #6 was provided a Notice of Medicare Non-Coverage (NOMNC) and a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) before the end of covered Medicare Part A services. Resident #6 was admitted on 02/02/2024 and had diagnoses including unspecified disorder of adult personality and behavior and mood disorder due to known physiological condition with major depressive-like episode. The resident’s record also showed moderate cognitive impairment, including a BIMS score of 8 on a quarterly MDS and care plan documentation noting fluctuating cognitive function. The NOMNC dated 05/22/2026 stated that Medicare coverage for skilled services would end on 05/24/2026 and financial liability would begin on 05/25/2026. The form included a note from ADON-LPN #4 that the resident was unable to understand the NOMNC due to cognitive deficit, and the signature area for the resident or representative was left blank. The SNF ABN also stated that beginning on 05/25/2026 the resident may have to pay out of pocket for care if no other insurance covered the costs, and it likewise had a handwritten note from ADON-LPN #4 stating the resident was unable to understand the form due to cognitive deficit; the signature area was also left blank. During interviews, ADON-LPN #4 stated she completed the notices and that if a resident had a cognitive deficit and no representative, she explained the case to the Administrator, who would become the resident’s representative and the resident would become a trust patient. The Regional Nurse Consultant stated the Director of Skilled Services and Clinical Reimbursement was responsible for the trust designation process. The Administrator stated he assigned himself as decision maker for Resident #6, but also stated he was not officially the resident’s representative and was not legally capable of making decisions to consent to treatment; he further stated he did not sign the NOMNC on the resident’s behalf and only received notification that the resident was coming off skilled services.
Failure to Promptly Resolve Missing Property Grievance
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve a grievance involving missing personal property for Resident #27. The facility policy stated that resident/family grievances, including lost items, should be recorded on a grievance log and followed up promptly, but the Regional Director of Operations stated the facility did not have a policy for personal property or missing property. Resident #27 was admitted with diagnoses including stage 3A chronic kidney disease and morbid obesity, and a quarterly MDS showed a BIMS score of 12, indicating moderate cognitive impairment. Resident #27 stated that their phone went missing after it was left charging and they returned from a shower. A CNA reported that the resident told her about the missing phone and that she reported it to a nurse, and another CNA stated she reported the missing phone to the DON. However, the DON stated staff had not reported the missing phone to her, and the Administrator stated the missing phone had not been reported to him. The Administrator later stated the phone was found in the medication room because staff did not know who it belonged to, and Resident #27 stated the Administrator returned the phone to them, but the resident did not know when it had been found.
Untrimmed and Dirty Nails Not Addressed
Penalty
Summary
The facility failed to ensure that Resident #3's nails were kept clean and trimmed. Resident #3 was admitted with diagnoses including legal blindness and sequelae of cerebral infarction, and the quarterly MDS indicated the resident had moderate cognitive impairment and required substantial/maximal assistance with personal hygiene. The care plan included an intervention for staff to check nail length on bath days and report concerns to the nurse, and the nail care record documented nail care 61 times between 05/12/2026 and 06/10/2026, although the record did not specify what care was provided. During observation and interview, Resident #3's nails on both hands were noted to be untrimmed and dirty underneath, and the resident stated they had asked staff to cut their nails but staff did not do it and that they did not like their nails being long. On a later observation, the nails were still long and the resident again stated they had not been trimmed. CNA #7 stated she had cleaned the resident's nails but did not trim them and had not reported the nail length to the nurse, despite documenting the task as completed. An LPN observed that the nails should have been filed and noted a broken and chipped left thumb nail. The DON measured the nails and stated they were long and broken, and that her expectation was for nails to be trimmed during showers when softened and kept shorter if the resident wanted them shorter.
Failure to Follow Physician Orders for Labs, Dressing Care, and Ice Packs
Penalty
Summary
The facility failed to ensure staff followed physician orders for laboratory testing, dressing changes, and ice pack application for Resident #50. The resident was admitted on 02/28/2025 with a history of aftercare following joint replacement surgery and discharged on 03/02/2025. The resident’s record showed a BIMS score of 15 on the five-day MDS, indicating intact cognition. The resident stated during interview that facility staff did not draw ordered laboratory tests, change the surgical dressing, or provide ice packs as ordered during the stay, and that the resident abruptly left the facility due to concerns about safety and lack of care. The resident’s order summary included admission laboratory testing for CBC, CMP, and prealbumin; cleansing the surgical incision twice daily with peroxide and changing the dressing daily and PRN; and applying ice packs every four hours and PRN for pain. Review of the clinical record and facility documentation showed no evidence that the ordered laboratory tests, dressing changes, or ice pack applications were completed. The DON reviewed the record and stated there was no documented evidence the orders were completed, and that admission laboratory orders were expected to be completed within 72 hours. The Administrator stated staff were expected to carry out physician orders or notify the provider if unable to do so, and that failure to carry out ordered treatments represented a failure in care.
Shared Bedrooms Did Not Provide Full Visual Privacy
Penalty
Summary
The facility failed to ensure that shared resident bedrooms were designed and equipped to maintain full visual privacy when privacy was needed. The Regional Director of Operations stated the facility did not have a policy related to resident privacy, while the Resident’s Rights and Family Handbook stated residents have the right to privacy, including private telephone calls, meetings, and mail. Surveyors identified four residents affected by privacy curtain concerns in two shared bedrooms. For Residents #43 and #35, both with diagnoses including anxiety and depression, observation of their shared room showed a partial privacy curtain that separated the beds only partway across the room and stopped about 4 feet before the opposite wall. A large mirror on the wall opposite the beds allowed a view of each resident’s sleeping area, and there was no wrap-around capability to block visibility. Resident #43 stated that when leaving the room, they lowered their head and looked at their wheelchair wheels so they would not look at their roommate. Resident #35 was not available for interview. For Residents #24 and #14, both with shared-room privacy concerns and diagnoses including schizophrenia, anxiety, and depression, observation showed the same room setup with a partial curtain that did not fully close off the sleeping areas and a large mirror that allowed a view of both residents’ sleeping areas. Resident #24 stated they could see their roommate’s bedroom area whenever entering or exiting the shared bathroom. CNA #7, CMA #8, the DON, and the Administrator all stated that the curtain placement, mirror placement, and room layout allowed residents and visitors to see into the roommate’s area, and that privacy could not be fully provided in these rooms as configured.
Improper Storage of Medications
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored properly, as observed during a survey. The Storage of Medications policy, dated January 2022, mandates that medications and biologicals be stored safely, securely, and properly, accessible only to authorized personnel. However, during an observation on November 22, 2024, medication cart #1 on the west hall was found unattended with medications belonging to two residents left on top of the cart. Specifically, a diabetic medication, metformin 500 mg, for one resident, and clonidine 0.1 mg and sevelamer 800 mg for another resident, were observed unsecured. A Certified Medication Aide (CMA) acknowledged that medication carts should not be left unattended, and the Director of Nursing (DON) confirmed that all medications should be stored properly.
Failure to Hold Resident Council Meetings
Penalty
Summary
The facility failed to ensure that Resident Council meetings were held as scheduled, which is a violation of residents' rights to organize and participate in such groups. The facility's Resident Rights and Family Handbook indicated that Resident Council meetings were to be held monthly, as documented in the September 2024 Activity Calendar. However, the Resident Council president, who assumed the role four weeks prior, was unaware of the meeting schedule. The facility administrator, responsible for the Resident Council in the absence of an activity director, admitted that no meetings were held in August 2024 due to the lack of a Resident Council president and could not confirm if a meeting took place in July 2024 due to missing documentation. On the day a meeting was scheduled, the Resident Council group expressed uncertainty about when the next meeting would occur and could not recall the last meeting date. The administrator acknowledged that the scheduled meeting did not occur due to the absence of an activity director and their own busy schedule. The facility had been without an activity director for about a month and a social service person for two to three weeks, contributing to the failure to hold the meetings.
Failure to Conduct Scheduled Activities for Residents
Penalty
Summary
The facility failed to ensure scheduled activities were held for its residents, leading to a deficiency in meeting the social and recreational needs of the residents. The facility's Resident Rights and Family Handbook promised a full program of activities, but observations and interviews revealed that activities were not taking place as scheduled. The September 2024 Activity Calendar listed activities such as exercise and cup pong, but these were not observed to occur. Interviews with residents and staff confirmed that the facility had not had an activity director for about a month, and no one else had taken over the responsibility of conducting activities. Several residents expressed dissatisfaction with the lack of activities. One resident with muscle weakness and multiple sclerosis stated they used to participate in activities but now stayed confined to their room. Another resident with acute kidney failure and type two diabetes mellitus mentioned that it had been close to a month since they had an activity director. A third resident with major depressive disorder and anxiety expressed a desire to go outside and participate in activities. The administrator acknowledged the absence of an activity director and admitted that scheduled activities did not occur due to being busy and the lack of staff to conduct them.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure proper food safety and sanitation practices in the kitchen, affecting the quality of care for 28 residents. During an inspection, it was observed that expired food items, specifically nectar thickened tea, were not removed from circulation. The Certified Dietary Manager (CDM) acknowledged that the thickener was expired and explained that it was not frequently used, leading to a whole case being overlooked. Additionally, the kitchen's cleanliness was compromised, with dark areas and debris found on the bottom floor of a freezer and a large amount of brown dust and debris on the window seal behind the dishwasher. The window blinds were also broken, indicating a lack of maintenance and adherence to the cleaning schedule. Furthermore, the facility did not adhere to proper food reheating standards. A bowl of leftover soup was microwaved and placed on a hall tray cart without reaching the required internal temperature of 165 degrees Fahrenheit. The CDM admitted to forgetting to check the temperature, and upon verification, the soup was found to be at only 127 degrees Fahrenheit. These lapses in food safety and sanitation practices highlight the facility's failure to comply with professional standards, potentially compromising resident safety and well-being.
Failure to Notify Physician of Medication Hold
Penalty
Summary
The facility failed to notify a physician when a medication was held for a resident diagnosed with muscle weakness and multiple sclerosis. The medication, Aubagio, was prescribed to be taken daily but was placed on hold starting in April 2024 due to insurance not covering the cost. Despite the facility's policy requiring physician notification when a medication is withheld, there was no documentation that the physician was informed of the medication being on hold. The medication was not administered from April through September 2024. Interviews with facility staff, including LPNs and the DON, revealed that the medication was held due to its cost and lack of insurance coverage. The DON confirmed placing the hold order but found no documentation of physician notification. A form from the pharmacy indicated that the nurse was supposed to call the physician, but there was no record of this communication. The physician had signed monthly orders indicating the medication was on hold, but there was no evidence of direct notification about the insurance issue.
Failure to Update Resident's Smoking Status in Care Plan
Penalty
Summary
The facility failed to update the care plan for a resident who was previously identified as a smoker. The resident, who had diagnoses including muscle weakness and multiple sclerosis, had their smoking privileges revoked due to serious safety concerns. Despite this change, the resident's care plan, revised after the revocation, still documented them as a smoker and did not reflect the updated status that the resident was no longer allowed to smoke. The oversight was identified during a review of the resident's care plan, which was not updated to indicate the cessation of smoking privileges. The corporate MDS consultant, responsible for resident care plans, acknowledged the discrepancy upon review and noted that the care plan had not been updated to reflect the resident's current non-smoking status. The Director of Nursing confirmed that the resident's smoking privileges had been revoked on a specific date, but this information was not incorporated into the care plan in a timely manner.
Failure to Update Daily Staffing Information
Penalty
Summary
The facility failed to ensure that the posted staffing information was updated daily as required. Observations on multiple days revealed that the staffing board at the beginning of hall 200 displayed outdated information, including an incorrect census and missing total hours for licensed staff. On 09/17/24, the board showed a census of 29 and lacked RN hours. By 09/18/24, the board still had the previous day's date and did not include total hours for any discipline. On 09/19/24, the board on both halls 100 and 200 still displayed the date of 9/17/24 and lacked the required total hours for licensed staff. The administrator acknowledged awareness of the staffing posting regulation, which mandates the inclusion of staff names, their assigned halls, and shift details. However, during an observation on 09/19/24, the administrator admitted that the posted information was incomplete and outdated, and they were unaware of the specific requirements for the posted staffing information.
Infection Control Breach in Urine Handling
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices were followed during the handling and transportation of urine. Specifically, a CNA was observed transporting urine in an uncovered hat from a resident's room down the hall to a powder room, where the urine was disposed of in a toilet. The CNA then placed the hat in a plastic bag and stored it in a cabinet in the resident's room without cleaning it. This action was contrary to the facility's protocol, which required urine to be transported in a bag and the container to be cleaned before being returned to the resident's room. The incident involved a resident with neuromuscular dysfunction of the bladder, who had an indwelling catheter. The CNA admitted to not using a bag for transporting the urine and not rinsing the hat before returning it to the resident's room. The CNA also mentioned it was their first time using a hat for urine transport, as they usually used a urinal. The DON confirmed that the correct procedure was to transport urine in a bag and clean the container before storage in the resident's room.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to provide adequate bathing assistance to three residents who required help with activities of daily living (ADLs). Resident #1, diagnosed with hemiplegia and fibromyalgia, was scheduled to receive baths on Mondays, Wednesdays, and Fridays but missed five out of 13 scheduled opportunities. Resident #2, with hemiplegia and hemiparesis following a cerebral infarction, also missed seven out of 13 scheduled bathing opportunities. Both residents reported inconsistencies in receiving their scheduled baths. Resident #3, who had acute and chronic diastolic heart failure and chronic kidney disease, was scheduled for baths twice a week but reported that it could be up to 10 days between baths. The Director of Nursing (DON) confirmed that all bathing documentation was maintained electronically and acknowledged the lack of documentation for the missed bathing dates. This indicates a failure in the facility's system to ensure that residents received the necessary assistance with their personal hygiene needs.
Failure to Conduct Annual Competency Review for CMA
Penalty
Summary
The facility failed to conduct a nurse aide performance review every 12 months for a certified medication aide (CMA) who was hired on January 30, 2004. During a review of employee files, it was found that there was no record of an annual competency review for this CMA. The Business Office Manager (BOM) confirmed the absence of this documentation during an interview on June 13, 2024.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wildewood Skilled Nursing And Therapy | 2.4 mi | ★★★★★ | 0 | 0 |
| Tuscany Village Nursing Center | 3.4 mi | ★★★★★ | 7 | 0 |
| Northwest Nursing Center | 3.6 mi | ★★★★★ | 0 | 0 |
| Ignite Medical Resort Edmond, Llc | 4.1 mi | ★★★★★ | 19 | 0 |
| The Lodge At Brookline | 4.1 mi | ★★★★★ | 0 | 0 |
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