Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Centinela Skilled Nursing & Wellness Centre West during CMS and state inspections, most recent first.
Two residents in the facility were not dressed in their own clothes, compromising their dignity and socialization potential. One resident, with conditions like hemiplegia and aphasia, was observed in a hospital gown all day, with staff only dressing them for dining or visitors. Another resident, with heart failure and aphasia, was similarly observed. The CNA and DON acknowledged the importance of dressing residents in their own clothes, as per facility policy, which was not followed.
A resident with severe cognitive impairment and difficulty swallowing was not offered dentures during meals, as observed on multiple occasions. Staff interviews confirmed the oversight, which contradicted facility policies on resident rights and quality of life.
A resident with hemiplegia and aphasia was unable to use the standard call light device due to physical limitations, as observed during a survey. Staff interviews revealed that a touch pad call light would better accommodate the resident's needs, but it was not provided, contrary to the facility's policy on accommodating resident needs.
A facility failed to provide a resident with the Notice of Medicare Non-Coverage (NOMNC) form 48 hours before the end of skilled nursing services, as required by policy. The Social Service Director admitted the form was given only one day prior, potentially affecting the resident's right to appeal. The resident, with intact cognitive skills and requiring supervision for daily activities, was not properly informed in accordance with the facility's Medicare Denial Process policy.
A resident with multiple health conditions was found to be living in a room with chipped paint on the wall next to their bed, which was not addressed in a timely manner by the facility. The issue was known to the facility's Administrator and Maintenance Director, and it was noted in the maintenance log. The facility's policy emphasizes the importance of a clean and comfortable environment, but this was not upheld for the resident.
A resident in an LTC facility, with diagnoses including chronic kidney disease and dysphagia, refused dental treatment, and the facility failed to develop a care plan addressing this refusal. The resident reported that staff did not discuss the risks and benefits of not having dentures. Both an LVN and the DON acknowledged the necessity of a care plan to set goals and interventions, as per the facility's policy on Comprehensive Person-Centered Care Planning.
A resident with ascites did not have their abdominal girth measured weekly as ordered by the physician, which is a failure to follow professional standards of practice. The resident had chronic kidney disease and psychosis, with moderately impaired cognitive skills. The DON confirmed that the measurements were not recorded, and it was the licensed nurse's responsibility to document them. This oversight could lead to negative effects such as abdominal discomfort and shortness of breath.
A resident with a Stage 3 pressure ulcer was found lying on a low air loss mattress (LALM) set incorrectly at 350 pounds, despite weighing only 100.2 pounds. The Director of Nursing (DON) and Treatment Nurse 1 (TN 1) confirmed that the LALM setting should be based on the resident's current weight to ensure effective wound management. The facility's policy indicated that the LALM should distribute body weight appropriately to prevent skin breakdown, but the responsibility to check the correct setting lay with the licensed nurses.
A resident with end-stage renal disease and heart failure did not have their fluid intake monitored and recorded as per the physician's order of a 1200 ml fluid restriction. Despite the facility's policies requiring strict documentation, the intake was not recorded in the MAR for over a month. A nurse confirmed the oversight, highlighting the risk of fluid overload due to the lack of monitoring.
A resident with dementia was prescribed Seroquel for constant screaming without proper behavioral monitoring or justification. The facility's protocol to monitor behavior for 72 hours before administering antipsychotic medication was not followed, and there was no behavioral screening log. The facility's policy requires antipsychotic drugs to be used only for specific diagnosed conditions, which was not documented in this case.
A resident with multiple health issues, including dysphagia and malnutrition, did not receive necessary dental follow-up after a recommendation for teeth extraction. Despite the resident's request and a previous dental consultation, the Social Services Director failed to arrange the required medical clearance, leading to a deficiency in care.
A resident at an LTC facility, who was cognitively intact and required substantial assistance for ADLs, was at risk for financial abuse after $11,000 went missing. Despite the care plan indicating emotional distress risk, it lacked interventions to secure belongings or prevent further loss. Interviews with staff revealed the care plan was not updated with necessary actions, contrary to the facility's policy on comprehensive care planning.
The facility failed to implement its policies on safeguarding residents' personal property and preventing abuse. A resident with chronic conditions and cognitive impairment reported her wallet containing $647 went missing. Staff interviews confirmed the facility did not secure the resident's money as required, placing her and others at risk of financial abuse and emotional harm.
Failure to Dress Residents Appropriately
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident 27 and Resident 24, were dressed appropriately, which compromised their dignity and potential for socialization. Resident 27, who was admitted with conditions including hemiplegia, chronic kidney disease, and aphasia, was observed wearing a hospital gown throughout the day. Despite being dependent on staff for personal hygiene and dressing, the staff only dressed Resident 27 when taken to the dining room or when visitors were present. The Certified Nursing Assistant (CNA) acknowledged that dressing the resident daily would aid in socialization and prevent feelings of depression. The Director of Nursing (DON) confirmed that there was no policy for keeping residents in hospital gowns during the day and emphasized the importance of dressing residents in their own clothes. Similarly, Resident 24, who had diagnoses including heart failure, dysphasia, and aphasia, was also observed wearing a hospital gown throughout the day. The resident required substantial assistance from staff for personal hygiene and dressing. The CNA noted that dressing Resident 24 in personal clothing was important for fostering a sense of togetherness with other residents. The DON recognized that not dressing the resident was a dignity issue and could lead to feelings of sadness. The facility's policies indicated that residents should be dressed in their own clothes, yet this was not adhered to, leading to the identified deficiency.
Failure to Provide Dentures During Meals
Penalty
Summary
The facility failed to ensure that a resident was offered his dentures before eating, which could potentially affect his ability to chew food effectively. The resident, who was admitted with diagnoses including heart failure, dysphasia, and aphasia, had a severely impaired cognition and required substantial assistance with personal hygiene and transfers. Observations on multiple occasions revealed that the resident was not provided with his dentures during meals, both in his room and in the dining room. Interviews with staff, including a CNA and the DON, confirmed that the resident required feeding assistance and should have been offered his dentures to aid in chewing and eating. The facility's policies on resident rights and quality of life emphasized the importance of providing an environment that meets individual needs and treating cognitively impaired residents with dignity. However, the staff failed to adhere to these policies by not ensuring the resident had access to his dentures during meals.
Inadequate Call Light Device for Resident
Penalty
Summary
The facility failed to provide an appropriate call light device for one of the residents, identified as Resident 27, which could potentially delay the resident's ability to call for assistance. Resident 27 was admitted with diagnoses including hemiplegia, chronic kidney disease, and aphasia, which affected their ability to communicate and perform certain physical tasks independently. The Minimum Data Set (MDS) assessment indicated that Resident 27 was dependent on staff for personal hygiene, showering, dressing, and transfers, and was usually understood by others. However, during an observation, Resident 27 was unable to grasp and press the standard call light button to request assistance. Interviews with facility staff, including an LVN and the DON, revealed that Resident 27 would benefit from a touch pad call light device, which would be easier for the resident to use given their physical limitations. The LVN emphasized the importance of having the appropriate call light device to ensure timely assistance, especially in emergencies such as falls or choking. The DON acknowledged that Resident 27 did not have the correct call light device and confirmed the necessity of a touch pad call light to accommodate the resident's needs. The facility's policy on accommodating resident needs highlighted the importance of evaluating and providing adaptive devices to support residents' independence and dignity, which was not adhered to in this case.
Failure to Provide Timely Notice of Medicare Non-Coverage
Penalty
Summary
The facility failed to provide the Notice of Medicare Non-Coverage (NOMNC) form to a resident 48 hours prior to the end of skilled nursing services, as required. This deficiency was identified during an interview and record review involving the Social Service Director (SSD) and Resident 205. The SSD acknowledged that the NOMNC form was given to Resident 205 only one day before the end of Medicare Part A skilled services, which was contrary to the facility's policy of providing the notice 48 to 72 hours in advance. This lapse in procedure potentially compromised the resident's right to appeal the decision regarding financial coverage. Resident 205, who was admitted to the facility with diagnoses including chronic obstructive pulmonary disease, alcoholic liver disease, and diabetes mellitus, had intact cognitive skills for daily decision-making and required supervision for certain activities of daily living. The facility's policy, titled Medicare Denial Process, mandates that Medicare beneficiaries be properly notified when they no longer meet the requirements for covered skilled services. However, the SSD's failure to adhere to this policy resulted in Resident 205 not being properly informed in a timely manner, thus affecting the resident's ability to exercise their right to appeal.
Failure to Maintain Homelike Environment Due to Chipped Paint
Penalty
Summary
The facility failed to provide a homelike environment for one of its residents, identified as Resident 34, due to the presence of chipped paint on the wall next to the resident's bed. This issue was observed during a survey, where it was noted that the chipped paint could negatively impact the resident's quality of life. Resident 34, who has diagnoses including aphasia, chronic kidney disease, and atherosclerotic heart disease, was found to require substantial assistance with personal hygiene, showering, and dressing. Despite the resident's inability to make decisions, the Minimum Data Set indicated that Resident 34 was usually able to understand others. The deficiency was acknowledged by the facility's Administrator during an observation and interview, where it was confirmed that the chipped paint was known and needed repair. The Maintenance Director also confirmed that the need for painting had been reported in the maintenance log nearly a month prior to the survey. The facility's policy on Resident Rights emphasizes the importance of providing an environment that meets individual resident needs, which includes maintaining a clean and comfortable living space. However, the failure to address the chipped paint in a timely manner resulted in a deficiency in providing a homelike environment for Resident 34.
Failure to Develop Care Plan for Dental Service Refusal
Penalty
Summary
The facility failed to ensure that a care plan was developed for a resident who refused dental services, which is a communication tool for patient care between nurses. This deficiency was identified for one out of six sampled residents, referred to as Resident 2. The absence of a care plan for the refusal of dental services had the potential to place Resident 2 at risk for not receiving appropriate interventions to prevent discomfort when eating. Resident 2 was admitted to the facility with diagnoses including chronic kidney disease, dysphagia, and aortic aneurysm. The resident's Minimum Data Set indicated intact cognition and required supervision for personal hygiene and transfers. During interviews, it was revealed that Resident 2 refused dental treatment as documented in the dental record titled Elite Mobile Dental. The resident expressed that staff did not review the risks and benefits of not having dentures, which would have made chewing food easier. Both the Licensed Vocational Nurse and the Director of Nursing acknowledged the need for a care plan when dental treatment is refused, emphasizing the importance of setting goals and interventions to prevent mouth infections and to educate the resident on the risks and benefits of treatment. The facility's policy on Comprehensive Person-Centered Care Planning required that care plans be developed and updated based on assessed needs, but this was not followed in Resident 2's case.
Failure to Measure Abdominal Girth as Ordered
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice by not measuring the abdominal girth weekly as per the physician's order. This deficiency was identified for a resident diagnosed with ascites, a condition where fluid accumulates in the abdomen. The resident's medical history included chronic kidney disease and psychosis, and they had fluctuating capacity to understand and make decisions. The Minimum Data Set indicated that the resident had moderately impaired cognitive skills for daily decision-making and required supervision for personal care tasks. The Director of Nursing confirmed during an interview and record review that the abdominal girth measurements were not recorded on the specified dates in September and October. It was the responsibility of the licensed nurse to perform these measurements and document them in the Treatment Administration Record. The facility's policy emphasized the importance of following physician orders to maintain the resident's highest practicable wellbeing. The failure to measure the abdominal girth as ordered could lead to negative effects such as abdominal discomfort, weakness, and shortness of breath.
Incorrect LALM Setting for Resident with Pressure Ulcer
Penalty
Summary
The facility failed to ensure that a low air loss mattress (LALM) was set and maintained at the correct setting for a resident with a Stage 3 pressure ulcer on the sacral area. The resident, who was totally dependent on staff for personal hygiene and at risk of developing pressure ulcers, was observed lying on a LALM set at 350 pounds, despite weighing only 100.2 pounds. This incorrect setting was identified during an observation and interview with the Director of Nursing (DON), who acknowledged that the setting should be based on the resident's current weight to ensure effective wound management. The facility's policy and procedure for mattress resources indicated that the LALM should distribute the resident's body weight appropriately to prevent skin breakdown. However, the DON and Treatment Nurse 1 (TN 1) confirmed that the responsibility to check the correct setting of the LALM lay with the licensed nurses. The incorrect setting of the LALM could result in delayed wound healing and worsening of the resident's pressure ulcer, as it would cause extra pressure on the bony prominence and discomfort for the resident.
Failure to Monitor Fluid Restriction for Dialysis Resident
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident with end-stage renal disease and heart failure by not monitoring and recording the resident's daily fluid intake as per the physician's order. The resident, who had a fluctuating capacity to understand and make decisions and required maximum assistance with daily activities, was on a 1200 ml fluid restriction due to their medical condition. However, the facility did not document the fluid intake in the Medication Administration Records (MAR) for over a month, from September to October 2024. During an interview, a registered nurse acknowledged the oversight and emphasized the importance of adhering to the fluid restriction to prevent complications such as fluid overload, swelling, and shortness of breath. The facility's policies on intake and output recording and fluid restrictions required strict monitoring and documentation of fluid intake for residents with such orders, but these were not followed in this case, leading to the deficiency.
Failure to Justify Antipsychotic Medication Use for a Resident with Dementia
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of dementia was free from the use of antipsychotic medication without proper justification. Resident 49, who was admitted with diagnoses including dementia, urinary tract infection, cerebral ischemia, and muscle weakness, was found to be severely cognitively impaired and required maximal assistance with daily activities. Despite not exhibiting any physical behavioral symptoms directed towards others, the resident was prescribed Seroquel, an antipsychotic medication, for psychotic features manifested by constant screaming. The Director of Nursing (DON) acknowledged that the protocol before administering antipsychotic medications was to monitor a resident's behavior for 72 hours, which was not followed in this case. The original order for Seroquel was placed for dementia, and later revised to indicate psychotic features as the reason for its use. However, there was no behavioral screening log to monitor the resident's behavior, and the facility's policy stated that antipsychotic drugs should not be given unless necessary to treat a specific diagnosed condition documented in the clinical record. This oversight had the potential to result in the use of unnecessary psychotropic drugs for the resident.
Failure to Follow Up on Dental Services for a Resident
Penalty
Summary
The facility failed to ensure a dental services follow-up for a resident, leading to a deficiency in care. The resident, who was admitted with diagnoses including metabolic encephalopathy, dysphagia, protein-calorie malnutrition, and iron deficiency, was cognitively intact and required assistance with daily activities, including eating and oral hygiene. Despite experiencing a toothache a month prior and expressing a desire to see a dentist for dentures, the resident did not receive the necessary follow-up for dental services after a recommendation for teeth extraction was made in August. Interviews revealed that the Social Services Director (SSD) was responsible for arranging the medical clearance needed for the dental procedure but failed to do so. The SSD acknowledged the oversight and the potential consequences of not following up on dental services, such as discomfort and difficulty eating. The Director of Nursing (DON) confirmed that the Social Services Department was responsible for ensuring dental services and acknowledged the lack of follow-up for the resident. The facility's policy indicated that the Social Services Staff was responsible for arranging dental appointments, but this was not adhered to in this case.
Failure to Implement Comprehensive Care Plan for Financial Abuse Risk
Penalty
Summary
The facility failed to develop and implement a comprehensive and patient-centered care plan for a resident following allegations of financial abuse, where the resident was missing $11,000. The resident, who was cognitively intact and required substantial assistance for activities of daily living, was admitted with diagnoses including hypertensive heart disease, peripheral vascular disease, and chronic obstructive pulmonary disease. Despite the resident's care plan indicating a risk for emotional distress related to financial abuse, it lacked specific interventions to secure the resident's belongings or prevent further financial loss. Interviews with facility staff, including the Director of Nursing, MDS Coordinator, and Social Services Director, revealed that the care plan was not updated with necessary interventions to address the financial abuse risk. The facility's policy on comprehensive person-centered care planning emphasized the need for interdisciplinary care to meet residents' needs, but the care plan did not reflect this standard. The Social Services Director noted that without documented interventions, it is assumed that necessary actions are not being implemented, highlighting a gap in the care plan's execution.
Failure to Safeguard Resident's Personal Property and Prevent Financial Abuse
Penalty
Summary
The facility failed to implement its policies and procedures regarding the safeguarding of residents' personal property and the prevention of abuse, neglect, and theft. Specifically, the facility did not follow its Theft and Loss Policy, which mandates that residents' personal property be safeguarded and any missing property be investigated and documented. Resident 1, who had chronic kidney disease, chronic obstructive pulmonary disease, and a cognitive communication deficit, reported that her wallet containing $647 went missing. Despite the facility's policy requiring that residents' money and valuables be taken to the business office for safekeeping, Resident 1's wallet was not properly secured, leading to its loss. Interviews with staff, including a Certified Nurse Assistant, Licensed Vocational Nurse, Social Service Director, and Director of Nursing, confirmed that the facility did not take appropriate measures to safeguard Resident 1's money, which could have led to emotional distress and potential safety risks for the resident. Additionally, the facility did not adhere to its Abuse Prevention, Screening, and Training Program, which prohibits any form of resident abuse, neglect, misappropriation of property, and exploitation. The policy defines financial abuse as the deliberate misplacement, exploitation, or wrongful use of a resident's belongings or money without consent. The failure to secure Resident 1's wallet and the subsequent loss of $647 placed Resident 1 and other residents at risk of financial abuse and emotional harm. The facility's inaction in safeguarding residents' property and investigating the loss demonstrates a significant lapse in following established protocols designed to protect residents from abuse and neglect.
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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 Inglewood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Osage Healthcare & Wellness Centre | 0 mi | — | 25 | 0 |
| Inglewood Health Care Center | 0.8 mi | — | 28 | 0 |
| Century Villa, Inc | 1.3 mi | — | 12 | 0 |
| Primrose Post-acute | 1.5 mi | — | 5 | 0 |
| Hawthorne Healthcare & Wellness Centre, Lp | 1.5 mi | — | 17 | 0 |
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