Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 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 Hollywood Presbyterian Medical Center D/p Snf during CMS and state inspections, most recent first.
A resident with quadriplegia and chronic respiratory failure, who was unable to use their arms, was not provided with an adaptive call light system as required by facility policy. Instead, the resident had a standard call light remote they could not access and had to rely on making clicking sounds to call for help, which sometimes went unheard by staff. Facility staff confirmed that adaptive call light devices were available but had not been provided to the resident.
Two residents with severe cognitive and physical impairments did not receive physician-ordered hand rolls for contracture management, as evidenced by missing documentation and direct observation. Staff and nursing leadership confirmed the absence of hand rolls and incomplete records, despite care plans and facility policy requiring their use to maintain joint mobility.
A facility failed to provide and utilize proper PPE during patient showering, leading to infection control deficiencies. Staff used standard gurneys instead of appropriate shower gurneys, which had been broken for months. A resident with complex medical needs was showered without water-resistant PPE, increasing infection risks. The facility's policies on PPE and infection prevention were not followed, contributing to the deficiency.
The facility failed to ensure patient safety by using standard gurneys instead of shower gurneys designed for wet environments. This was observed during a showering session where a patient with severe medical conditions was at risk of falling due to inadequate gurney features. The facility's decision to use standard gurneys, despite broken shower gurneys, led to a deficiency in patient safety.
The facility failed to have a licensed administrator, with the CNO of GACH 1 acting as the administrator without the required license. Staff interviews revealed the CNO rarely visited, and there was no dedicated administrator since the previous one resigned. This potentially impacted the timely addressing of resident and family concerns.
Two residents did not receive prescribed passive range of motion (PROM) exercises and splint applications due to staffing issues, leading to missed treatments. The facility's policy required CNAs and charge nurses to carry out RNA programs in the absence of RNAs, but RNAs were often reassigned to CNA duties, preventing them from fulfilling their responsibilities.
The facility failed to provide sufficient nursing staff to ensure RNA program treatments were completed for two residents, resulting in missed PROM exercises and splint applications. The DON confirmed that staffing levels were inadequate, with RNAs often reassigned to CNA duties, leading to missed treatments on multiple occasions.
A facility failed to maintain a medication error rate below 5%, resulting in a 12% error rate due to late administration of medications. An LVN administered 14 medications to a resident via a G-tube, completing the task over two hours late. The DON confirmed that three medications were given more than one hour past the scheduled time, violating the facility's policy for non-time-critical medications.
A resident with chronic respiratory failure, DVT, and heart disease received three significant medications two hours late due to a timing error by an LVN. The medications, Eliquis, carvedilol, and famotidine, were crucial for managing the resident's conditions. The DON confirmed the potential adverse effects of this error.
A resident with multiple serious medical conditions was unable to reach the call light, leading to delayed assistance. Staff were observed passing by the room without responding to the activated call light. The facility's policy required prompt response to call lights, which was not adhered to in this case.
A facility failed to complete and submit the MDS upon discharge for a resident with severe medical conditions, including chronic respiratory failure and dependence on a respirator. The resident was discharged without a discharge MDS being completed, which was confirmed by the MDS Coordinator and the DON. This deficiency had the potential to negatively affect the resident's care.
A resident with multiple health issues, including a stage 4 pressure ulcer, was found to be on a Low Air Loss Mattress (LALM) set incorrectly for their weight. The LALM was set for 140 lbs, while the resident weighed 104.1 lbs. This error was confirmed by an LVN and the DON, who acknowledged that incorrect settings could compromise the mattress's effectiveness in preventing skin breakdown.
Two residents with epilepsy and anoxic brain damage were found to have only one padded side rail on their beds, despite physician orders and care plans requiring two for seizure precautions. LVNs confirmed the deficiency, and the facility's policy emphasized the need for padded side rails to ensure safety during seizures.
Two residents receiving enteral feeding in an LTC facility did not receive appropriate care. One resident's bed was not elevated as required during tube feeding, increasing the risk of aspiration. Another resident's gastrostomy tube dressing was not dated, risking infection. These deficiencies were confirmed by staff and contradicted the facility's policies.
The facility failed to conduct an annual competency assessment for a Sub Acute Registered Nurse (SARN), identified as RN 2, which is necessary to ensure nursing staff have the skills to provide quality care. The last assessment was conducted in March 2023, and no assessment was on file for 2024, as confirmed by the DON. This lapse in policy adherence could potentially affect resident care quality.
The facility failed to comply with its drug disposition policy, as it did not specify the process or designate responsible personnel for disposing of discontinued medications. A nurse stated that the process did not require a witness, and the facility pharmacist confirmed the policy incorrectly referenced a regulation section.
A facility failed to clarify a physician's order for Creon, a medication for pancreatic insufficiency, as recommended by the pharmacy consultant. The order did not specify administration before meals, which is crucial for effectiveness. Despite receiving the recommendation, the order was not updated, potentially reducing the medication's effectiveness and causing discomfort for a resident.
A resident with multiple health conditions, including candida auris, experienced a breach in infection control when their condom catheter drainage bag was not properly closed, leading to urine leakage on the floor. This incident, confirmed by a CNA, highlighted poor infection control practices and was acknowledged by the DON as a potential risk for contamination and infection.
A resident with severe hand weakness and multiple medical conditions was not provided with an adaptable call light, leading to potential delays in care. Despite being able to communicate, the resident had to make a clicking noise to call for assistance. Facility staff acknowledged the deficiency, which was contrary to the facility's policy requiring assessment and provision of appropriate call light devices.
A resident with chronic respiratory failure and a tracheostomy was placed on bilateral hand mitten restraints to prevent tube removal. The facility failed to renew restraint orders daily and did not conduct required assessments from late June, leading to redness and swelling at the resident's knuckles. The DON admitted the facility's practices did not align with their policy, resulting in inadequate care and oversight.
A resident developed a stage 2 pressure injury at the facility, and the family was not informed. Additionally, the facility performed a wound debridement procedure without explaining the risks and benefits or obtaining consent from the resident's family, violating the resident's rights.
A resident with multiple diagnoses developed a stage 2 pressure injury, but the facility failed to develop a care plan, leading to the injury worsening to stage 3. The DON confirmed that the absence of a care plan delayed care and exacerbated the wound, violating the facility's wound care policy.
A facility failed to report an allegation of physical abuse involving a resident and an LVN to the Department. Despite the resident's daughter reporting the incident and requesting a meeting with the DON, Administrator, and SW, the facility did not report the allegation, justifying their inaction by stating that the daughter did not explicitly label the incident as abuse. This failure violated the facility's policies and procedures on abuse reporting.
A facility failed to thoroughly investigate an abuse allegation when a resident's daughter reported that an LVN punched the resident during tracheostomy care. The DON did not interview the resident or the CNA who witnessed the incident, and the allegation was not reported because the daughter insisted it was not abuse.
Failure to Provide Adaptive Call Light for Resident with Quadriplegia
Penalty
Summary
A deficiency occurred when a resident with quadriplegia and chronic respiratory failure, who was dependent on staff for all activities of daily living and unable to move their arms, was not provided with an appropriate adaptive call light system. Despite the resident's cognitive abilities being intact and their ability to communicate needs, the standard call light remote was placed next to the resident's head, which the resident could not access due to paralysis. The resident reported having to make clicking sounds to call for help, which sometimes went unheard by staff, resulting in delays in receiving assistance. Interviews with facility staff revealed that an adaptive call light system, such as a tap or pad that could be activated by cheek movement, was available but had not been provided to the resident. The Director of Engineering confirmed the availability of such devices and the process for installing them upon request. The Director of Nursing acknowledged that the resident should have had an adaptive call light system based on their assessment and current condition. Facility policy required that call lights be within easy reach and that adaptive devices be provided for residents with limited mobility, but this was not followed in this case.
Failure to Provide Ordered Hand Rolls for Contracture Management
Penalty
Summary
The facility failed to ensure that two residents with significant medical conditions and physician orders for hand rolls received the appropriate services to prevent a decline in range of motion (ROM) and mobility. Both residents had orders for hand rolls to be donned at all times or as tolerated for contracture management, as documented in their care plans and physician orders. However, review of the Restorative Nursing Assistant Records (RNAR) for both residents showed multiple dates where there was no documentation that hand rolls were applied, and there was no indication in the progress notes that the residents could not tolerate the hand rolls. Resident 1 had a history of chronic respiratory failure, hemiplegia, hemiparesis, cerebral infarction, contractures in both hands, and was dependent on a ventilator and gastrostomy tube. Resident 2 had chronic respiratory failure, cerebral palsy, contracture of a joint, intellectual disabilities, and was dependent on supplemental oxygen. Both residents were assessed as having severely impaired cognitive skills and were dependent on staff for all activities of daily living. Despite these needs and the clear orders for hand roll use, observations confirmed that neither resident had the required hand rolls in place during the survey, and staff interviews confirmed that the absence of documentation meant the intervention was not provided. The facility's policy required the implementation of strategies to prevent further limitations in joint mobility, with the charge nurse responsible for ensuring RNA orders were carried out. Both the Restorative Nursing Aide and the Interim Director of Nursing confirmed that the hand rolls were not in place as ordered and that there was missing documentation for their application. The lack of adherence to physician orders and care plan interventions for ROM management constituted the deficiency identified during the survey.
Inadequate PPE Use During Patient Showering
Penalty
Summary
The facility failed to ensure proper personal protective equipment (PPE) was supplied and utilized by staff when showering a patient, leading to a deficiency in infection control protocols. During an observation, two certified nursing assistants (CNAs) were seen showering a patient on a standard gurney instead of an appropriate shower gurney, which had been broken for several months. The CNAs were standing in water, and one was not wearing shoe covers, resulting in wet clothing. The Director of Nursing Services (DNS) confirmed that the facility had been using standard gurneys due to the unavailability of shower gurneys, despite the safety concerns. Patient 1, who was being showered at the time of the observation, had a complex medical history, including neuromuscular disease, functional quadriplegia, severe scoliosis, and dependence on a mechanical ventilator. The use of a standard gurney posed a risk of cross-contamination and increased the likelihood of infection transmission due to the lack of appropriate PPE. Interviews with staff revealed that the broken shower gurneys had been out of service for four to five months, and the facility had not been able to secure replacements or rentals. The facility's policy on PPE and infection prevention emphasized the importance of using water-resistant PPE to prevent exposure to potentially infectious materials. However, the shoe covers provided were not water-resistant, and staff reported difficulties in safely transferring patients due to the wet conditions. The Clinical Educator and Infection Preventionist were unaware of the use of standard gurneys and confirmed the necessity of appropriate PPE to minimize infection risks. The facility's failure to adhere to its own policies and procedures contributed to the deficiency in infection control.
Facility Uses Inappropriate Gurneys for Showering Patients
Penalty
Summary
The facility failed to ensure the safety of fourteen patients by using standard gurneys instead of shower gurneys designed with safety features for wet environments. This practice was observed during a showering session where a patient with neuromuscular disease, functional quadriplegia, severe scoliosis, and mechanical ventilator dependence was being showered on a standard gurney. The gurney's side rails had large gaps, and there were no barriers at the head and foot, creating a risk of the patient falling. The staff members were standing in water, and one was not wearing shoe covers, increasing the risk of slipping and infection control issues. The Director of Nursing confirmed that both shower gurneys had been broken for several months, leading to the use of standard gurneys for showering patients. Despite acknowledging the safety concerns, the facility decided to continue using standard gurneys after discussions with the facility administrator. The Director of Supply Chain Operations mentioned that there was a plan to repair the broken gurneys, but they were not found when the repair engineer arrived. Attempts to rent replacements were unsuccessful, and although new gurneys were ordered, there was no estimated delivery date. The facility's Environment of Care Safety Management Plan outlines the need to minimize safety risks, but the use of standard gurneys for showering patients contradicts this plan. The operation manual for the standard gurney used emphasizes that it should not be submerged or used inappropriately, and maintenance is required after every fifth washing. The facility's failure to address the broken shower gurneys and the decision to use inappropriate equipment led to a deficiency in ensuring patient safety during showering.
Facility Lacks Licensed Administrator
Penalty
Summary
The facility failed to ensure adequate administration services as the administrator did not possess an administrator's license and there was no designated administrator for the facility. The Chief Nursing Officer (CNO) of General Acute Care Hospital (GACH) 1 was acting as the facility's administrator without the required license. The CNO's job description indicated responsibilities related to nursing operations and quality patient care, but did not include holding an administrator's license. The organizational chart showed the CNO as the administrator, but there was no posted administrator license at the facility. Interviews with staff, including the Director of Nursing (DON) and Licensed Vocational Nurses (LVNs), revealed that the CNO rarely visited the facility and there was no dedicated administrator present. The Medical Director confirmed the absence of a dedicated administrator since the previous administrator resigned, which potentially impacted the timely addressing of resident and family concerns. The facility did not provide a policy and procedure regarding administration when requested.
Failure to Provide Prescribed ROM Treatments
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain or improve the range of motion (ROM) for two residents, Resident 6 and Resident 72, as ordered by their physicians. Resident 6, who was admitted with anoxic brain injury and was dependent on a ventilator, did not receive the prescribed passive range of motion (PROM) exercises and splint applications on multiple occasions across October, November, and December 2024. The Director of Nursing (DON) confirmed that several treatments were missed, which were crucial to prevent decline in mobility and contractures. Resident 72, who was in a persistent vegetative state and also dependent on a ventilator, similarly did not receive the ordered PROM exercises and splint applications. The documentation showed that treatments were missed on several days in October, November, and December 2024. The DON confirmed these omissions and emphasized the importance of the RNA treatments in maintaining mobility and preventing contractures. The facility's policy indicated that in the absence of a Restorative Nursing Aide (RNA), Certified Nursing Assistants (CNAs) and charge nurses were responsible for carrying out the RNA program. However, RNA 1 reported that when CNAs were short-staffed, RNAs were often pulled to perform CNA duties, which prevented them from completing their RNA responsibilities. This staffing issue contributed to the failure in providing the necessary treatments to the residents.
Inadequate Staffing Leads to Missed RNA Treatments
Penalty
Summary
The facility failed to provide adequate and sufficient nursing staff to ensure that the Restorative Nursing Aide (RNA) program treatments and services were completed for two residents, as indicated on the physician's orders. This deficiency was identified through interviews and record reviews, revealing that the residents did not receive the prescribed passive range of motion (PROM) exercises and splint applications on multiple occasions. The Director of Nursing (DON) confirmed that the RNA services were not provided on specific dates in October, November, and December 2024, due to insufficient staffing levels. Resident 6, who was admitted with diagnoses including anoxic brain injury and ventilator dependency, had physician's orders for RNA to perform PROM exercises and apply elbow and knee splints. However, documentation showed that these treatments were missed on several dates across three months. The DON acknowledged that the staffing levels were inadequate, with only one or two RNAs available, which was insufficient to meet the needs of the residents. The DON also noted that RNAs were often reassigned to perform Certified Nurse Assistant (CNA) duties when CNAs called off, further impacting the ability to provide RNA services. Similarly, Resident 72, who was in a persistent vegetative state and dependent on a ventilator, had orders for PROM exercises and splint applications. The resident's RNA documentation indicated missed treatments on multiple dates in October, November, and December 2024. The DON confirmed the staffing shortages and the practice of pulling RNAs to cover CNA duties, which contributed to the missed RNA treatments. The facility's policy on staffing projections indicated that the DON and Administrator were responsible for adjusting nursing hours to meet resident needs, but the current staffing levels were insufficient to ensure the delivery of RNA services.
Medication Administration Timing Error
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 12% error rate due to three errors out of 25 opportunities. The errors were related to the administration of medications at the wrong time. During an observation, an LVN was seen preparing and administering 14 medications to a resident via a gastrostomy tube. The medications were due at 9 AM, but the administration was completed at 11:25 AM, indicating a significant delay. The Director of Nursing acknowledged that the administration of three specific medications—Eliquis, carvedilol, and famotidine—occurred more than one hour past the scheduled time, which was against the facility's policy for non-time-critical medications. The facility's policy stated that medications with a dosing schedule more frequent than once daily should be administered within one hour before or after the scheduled time. The delay in administration was attributed to the workload of the LVN, who was responsible for preparing and administering medications to an average of 10 residents, taking approximately 5 hours to complete the task.
Significant Medication Timing Errors in LTC Facility
Penalty
Summary
The facility failed to prevent significant medication errors for a resident during medication administration observations. Specifically, a licensed vocational nurse administered 14 medications to a resident at 11:25 AM, which were scheduled for 9 AM. Among these, three medications were identified as significant: Eliquis, carvedilol, and famotidine. The Director of Nursing confirmed that these medications were administered two hours late, which constituted a significant wrong time error. The resident involved had a complex medical history, including chronic respiratory failure with hypoxia, acute embolism, deep vein thrombosis, hypertension, and atherosclerotic heart disease. The physician's orders specified that Eliquis and carvedilol were to be administered twice daily via a gastrostomy tube, and famotidine was prescribed for gastrointestinal bleeding. The Director of Nursing acknowledged that the irregular administration of these medications had the potential to adversely affect the resident's health condition.
Failure to Ensure Timely Response to Call Light
Penalty
Summary
The facility failed to ensure that the call light device was within reach and answered in a timely manner for Resident 65, who was admitted with multiple serious medical conditions including chronic respiratory failure, polyneuropathy, and neuromuscular dysfunction of the bladder. The resident was observed with the call light placed on the bedside table, out of reach, and reported that staff did not always respond when she called for help. The resident expressed difficulty in pressing the call light due to a lack of strength and resorted to yelling for assistance, which was not always effective. During observations, staff members were seen passing by the resident's room without responding to the activated call light. A CNA acknowledged the call light was not within reach and suggested that the resident would benefit from an adaptable call light. The facility's policy required call lights to be answered promptly, within five minutes, and emphasized the importance of ensuring call lights are accessible to residents at all times. The Director of Nursing confirmed that staff should not pass by a room with an active call light and that the facility had alternative methods for residents unable to use standard call lights.
Failure to Complete and Submit Discharge MDS
Penalty
Summary
The facility failed to complete and submit the Minimum Data Set (MDS) upon discharge for a resident, identified as Resident 62. This resident was admitted with serious medical conditions including chronic respiratory failure, cachexia, a tracheostomy, gastrostomy, dependence on a respirator, and dysphagia. The resident had severely impaired cognitive skills and was dependent on assistance for various daily activities. The last MDS assessment for Resident 62 was completed on 7/18/2024, and the resident was discharged on 9/25/2024 without a discharge MDS being completed or submitted. During a review of the resident's electronic health record, it was confirmed by the MDS Coordinator that the discharge MDS was missed and should have been completed and submitted within 14 days of discharge. The Director of Nurses also confirmed that the MDS assessment should have been completed within one week of discharge and submitted to CMS within 14 days. The failure to complete and submit the MDS in a timely manner was identified as a deficiency, with the potential to negatively affect the provision of necessary care and services for the resident.
Incorrect LALM Settings for Resident at Risk of Pressure Ulcers
Penalty
Summary
The facility failed to maintain the correct settings on a Low Air Loss Mattress (LALM) for a resident, identified as Resident 10, who was at risk for pressure ulcers. Resident 10 was admitted with multiple diagnoses, including anoxic brain damage, neuromuscular dysfunction, epilepsy, and a stage 4 pressure ulcer in the sacral region. The resident's care plan included the use of a LALM to aid in wound management and prevent further skin breakdown. However, during an observation, it was found that the LALM was set incorrectly for a weight of 140 lbs, while Resident 10 weighed 104.1 lbs. This discrepancy was confirmed by LVN 5, who acknowledged that the LALM should have been set at a level appropriate for 105 lbs. The Director of Nursing (DON) confirmed that the LALM settings were determined by the resident's weight and that incorrect settings could render the mattress ineffective in preventing skin breakdown. The manual for the LALM indicated that settings should be adjusted based on the patient's height and weight to ensure comfort and effectiveness. The failure to adjust the LALM settings according to Resident 10's actual weight had the potential to compromise the resident's skin integrity and exacerbate existing pressure ulcers.
Failure to Implement Seizure Precautions for Residents
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for two residents diagnosed with epilepsy and anoxic brain damage. Both residents were required to have two padded side rails on their beds as a precaution against injury during seizures, as per their physician's orders and care plans. However, observations revealed that each resident only had one padded side rail, contrary to the prescribed seizure precautions. Licensed Vocational Nurses confirmed the deficiency during interviews, acknowledging the importance of having two padded side rails to prevent injuries during seizures. The facility's policy on seizure management and precautions emphasized the necessity of padded side rails to ensure resident safety during seizure activity. Despite this policy, the facility did not comply with the prescribed safety measures for the two residents, leaving them at risk of injury. The Director of Nursing also confirmed the importance of padded side rails for residents with a history of seizures, highlighting the oversight in implementing the necessary precautions as outlined in the residents' care plans and physician's orders.
Deficiencies in Enteral Feeding Care
Penalty
Summary
The facility failed to ensure appropriate treatment and services for two residents who were fed by enteral means. For one resident receiving nutrition via a gastrostomy tube (GT), the head of the bed was not elevated more than 30 degrees while the tube feeding was on, contrary to the physician's order and care plan which required the head of the bed to be elevated between 30 to 45 degrees. This oversight was confirmed during an observation and interview with a Licensed Vocational Nurse (LVN), who acknowledged the risk of aspiration if the head of the bed was not properly elevated. Another resident's gastrostomy tube dressing was not dated, which is a deviation from the facility's policy requiring dressings to be dated and initialed by the nurse. This practice is crucial to ensure that dressing changes are not skipped, which could lead to complications such as infections. During an observation and interview, an LVN confirmed the absence of a date and initials on the dressing, acknowledging the potential for missed dressing changes. The Director of Nursing (DON) confirmed the importance of maintaining the head of the bed elevation to prevent aspiration and the necessity of dating and initialing dressing changes to prevent infections. The facility's policy and procedure documents also emphasize these practices to reduce risks associated with enteral feeding tubes, highlighting the facility's failure to adhere to its own guidelines.
Failure to Conduct Annual Competency Assessment for RN
Penalty
Summary
The facility failed to complete an annual competency assessment for a Sub Acute Registered Nurse (SARN), identified as RN 2, which is required to ensure that nursing staff have the necessary skills and knowledge to provide quality care to residents. During a review of RN 2's employee file, it was discovered that the last competency assessment was conducted on 3/21/2023, and no assessment was on file for 2024. This oversight was confirmed by both the Human Resources representative and the Director of Nursing (DON), who acknowledged that the competency assessments are supposed to be conducted annually. The facility's policy mandates that all nursing staff undergo an annual competency assessment to validate their ability to perform nursing tasks effectively. The DON stated that these assessments are crucial for ensuring that staff can perform essential nursing skills, such as medication administration and suctioning, which are critical for resident care. The absence of a current competency assessment for RN 2 indicates a lapse in the facility's adherence to its own policies and procedures, potentially affecting the quality of care provided to residents.
Deficiency in Drug Disposition Policy Compliance
Penalty
Summary
The facility failed to ensure compliance with their policy on drug disposition, specifically regarding the process of returning or destroying unused medications. During an interview, a registered nurse stated that a nurse performs the disposition of discontinued medications that are not controlled substances, and this process did not require a witness. A review of the facility's policy, last revised in August 2019, indicated that discontinued medications should be disposed of in compliance with state and federal laws, but the policy did not specify the process or designate the person responsible for performing the drug disposition. Additionally, the facility pharmacist confirmed that the policy incorrectly referenced a California Code of Regulations section for drug disposition, which should have been section 72371 instead of 73369.
Failure to Clarify Creon Administration Timing
Penalty
Summary
The facility failed to clarify the physician's orders for Creon, a medication used to treat pancreatic insufficiency, as recommended by the facility's pharmacy consultant during the monthly medication regimen review. This deficiency involved a resident who was taking Creon for pancreatic insufficiency, a condition where the pancreas does not produce enough digestive enzymes. The physician's order for Creon did not specify that it should be administered before meals, which is crucial for its effectiveness. The resident, who was readmitted to the facility with multiple diagnoses including chronic respiratory failure, type 2 diabetes, and morbid obesity, was receiving Creon three times a day. However, the medication administration record did not indicate whether Creon was given before meals, as recommended by the pharmacy consultant. The Director of Nursing confirmed that the physician's order had not been updated to include this important detail, despite the recommendation being received on 11/14/2024. The facility's policy requires that recommendations from the pharmacy consultant be acted upon within two weeks, but this was not done in this case. The Director of Pharmacy stated that the recommendation should have been fulfilled promptly to ensure the medication's effectiveness. The failure to clarify the order as recommended had the potential to reduce the effectiveness of Creon and cause stomach discomfort for the resident.
Infection Control Breach Due to Improper Catheter Management
Penalty
Summary
The facility failed to observe proper infection control measures for a resident using a condom catheter, resulting in a deficiency. The resident, who had been admitted with multiple diagnoses including chronic respiratory failure, muscular dystrophy, quadriplegia, dysphagia, and a tracheostomy, was on contact isolation precautions due to candida auris. The physician's orders required condom catheter care every shift, and the care plan included checking the tubing for kinks. However, during an observation, it was found that the resident's catheter drainage bag was not properly closed, leading to urine leakage onto the floor. The incident was confirmed by a CNA who noted that the leakage was a poor infection control practice. The Director of Nursing emphasized the importance of securing urinary collection bags to prevent contamination and potential infection risks. The resident's quarterly Minimum Data Set indicated intact cognition and extensive assistance needs, highlighting the importance of diligent care. The failure to secure the catheter drainage bag properly resulted in a breach of infection control protocols, posing a risk to the resident and others in the environment.
Failure to Provide Adaptable Call Light for Resident
Penalty
Summary
The facility failed to provide an adaptable call light for a resident, identified as Resident 55, who was unable to use the standard call light due to severe weakness in both hands. This deficiency was observed during a survey where Resident 55, who had intact cognition and was able to communicate, reported that he had to make a clicking noise with his mouth to call for assistance. The resident's medical history included chronic respiratory failure, COPD, Guillain-Barre syndrome, tracheostomy, ventilator dependence, and neuromuscular dysfunction of the bladder, all of which necessitated extensive assistance with daily activities. Interviews with facility staff, including an LVN and the DON, revealed that the facility's policy required an assessment of residents' needs for appropriate call light devices upon admission and as needed. However, Resident 55 had not been provided with a tap call light, which was the alternative for residents who could not use a push call light. The lack of an appropriate call light device posed a risk of delayed care for the resident, as acknowledged by the staff.
Failure to Manage Restraint Use and Monitoring
Penalty
Summary
The facility failed to properly manage the use of physical restraints on a resident, identified as Resident 1, who was admitted with chronic respiratory failure, hypoxia, a tracheostomy, and a gastrostomy. The resident was placed on bilateral hand mitten restraints to prevent the removal of the tracheostomy and G-tubes. However, the facility did not renew the restraint orders daily as required by their policy, from May 3, 2024, to June 30, 2024. The Director of Nursing (DON) acknowledged that the facility's practice did not align with their policy, which mandates that restraint orders be renewed every 24 hours following a physician's examination. Additionally, the facility failed to conduct regular restraint assessments for Resident 1. The last documented assessment was on June 24, 2024, and no further assessments were recorded until June 30, 2024. This lack of monitoring was contrary to the facility's policy, which requires assessments every two hours to check for circulation, skin integrity, and any signs of redness or swelling. A Licensed Vocational Nurse (LVN) confirmed that such assessments were necessary to prevent injuries from restraints. As a result of these deficiencies, Resident 1 experienced redness and swelling at the knuckles, along with mild pain, which was discovered on June 30, 2024. The facility's failure to adhere to its own policies regarding restraint management and monitoring led to this adverse outcome for the resident, highlighting a significant lapse in care and oversight.
Failure to Inform Family and Obtain Consent for Pressure Injury Treatment
Penalty
Summary
The facility failed to inform the family of a resident about the development of a stage 2 pressure injury in the sacral area. The resident, who had a history of stroke, ventilator-dependent respiratory failure, dysphagia, diabetes mellitus type II, and hypertension, was admitted to the facility without any pressure injuries as indicated in the Minimum Data Set (MDS) dated 12/22/2023. However, a wound photo dated 1/9/2024 showed a stage 2 sacral wound, and the Director of Nursing (DON) confirmed that the pressure injury was acquired at the facility. The DON acknowledged that this change in condition should have been communicated to the resident's family, but there was no documentation to support that the family was notified. Additionally, the facility did not explain the risks and benefits or obtain consent from the resident's family before performing a wound debridement procedure for the stage 2 pressure injury. The wound care specialist performed an excisional debridement through subcutaneous tissue, which is considered an invasive procedure. The DON confirmed that the wound care specialist needed to obtain informed consent from the resident's family prior to the procedure, but there was no documentation of such consent in the physician's progress notes. This failure to obtain informed consent was a violation of the resident's rights as per the facility's policy and procedure on Resident's Rights and Responsibilities.
Failure to Develop Comprehensive Care Plan for Pressure Injury
Penalty
Summary
The facility failed to ensure its nursing staff developed a comprehensive care plan to address a pressure injury for a resident. The resident, who was admitted with multiple diagnoses including stroke, ventilator-dependent respiratory failure, dysphagia, diabetes mellitus type II, and hypertension, developed a stage 2 pressure injury on the sacral area. Despite the presence of this injury, no care plan was developed when the injury was discovered, as confirmed by the Director of Nursing (DON) during an interview. The lack of a care plan led to inadequate intervention and care, resulting in the pressure injury worsening to a stage 3 injury within a few days. The facility's policy and procedure on wound care, which mandates that a care plan should be individualized and initiated within 12 hours of admission for patients at risk for or with existing open or pressure wounds, was not followed. The DON acknowledged that the absence of a care plan could delay care and exacerbate the wound. This deficiency was identified during a review of the resident's history and physical records, Minimum Data Set, and wound photo assessments, which documented the progression of the pressure injury from stage 2 to stage 3.
Failure to Report Alleged Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse involving a resident and an LVN to the Department. The resident, who was admitted with chronic respiratory failure, anxiety disorder, blindness, and diabetes mellitus, reported to their daughter that the LVN punched them on the face during tracheostomy care. Despite the resident's daughter reporting this incident to the Interdisciplinary Team (IDT) and requesting a meeting with the Director of Nursing (DON), Administrator, and Social Worker (SW), the facility did not report the allegation to the proper authorities. The DON and Director of Therapy Services (DTS) justified their inaction by stating that the resident's daughter did not explicitly label the incident as abuse and insisted not to call the authorities. The facility's policy and procedure on abuse or neglect clearly state that all suspected cases should be reported to the proper authorities. However, the facility did not adhere to this policy. The DON acknowledged that abuse should be reported within 24 hours but did not report the incident because the resident's daughter did not explicitly state it was abuse. The DTS also confirmed that the incident should have been reported immediately, and the employee should have been suspended pending investigation. The failure to report the allegation of abuse was a clear violation of the facility's policies and procedures, potentially placing the resident and others at risk for further abuse.
Failure to Investigate Abuse Allegation
Penalty
Summary
The facility failed to ensure that an allegation of abuse was thoroughly investigated for a resident when the facility did not obtain a statement or interview from the resident or the CNA who reportedly witnessed the incident. The resident, who was admitted with chronic respiratory failure, tracheostomy, anxiety disorder, blindness, and diabetes mellitus, had complained to their daughter that a night LVN punched them on the face during tracheostomy care. The Interdisciplinary Team (IDT) attempted to explain to the resident's daughter that the resident might have misinterpreted the procedure due to anxiety. However, the facility did not follow through with a thorough investigation as required by their policy and procedure on abuse or neglect, which mandates obtaining statements from witnesses and involved parties. The Director of Nursing (DON) did not interview the resident about the incident, citing the presence of family members during the assessment as a reason. Additionally, the CNA who was present during the tracheostomy care was not interviewed as part of the internal investigation. The DON also did not report the allegation because the resident's daughter insisted it was not abuse, despite the serious nature of the complaint. This failure to conduct a thorough investigation and obtain necessary statements from all involved parties is a significant deficiency in the facility's handling of the abuse allegation.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
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Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Virgil Rehabilitation & Skilled Nursing Center | 0.4 mi | — | 28 | 0 |
| The Meadows On Sunset Post Acute | 0.6 mi | — | 49 | 1 |
| Alexandria Care Center | 0.6 mi | — | 14 | 0 |
| Garden Crest Rehabilitation Center | 1 mi | — | 15 | 0 |
| Fountain View Subacute And Nursing Center | 1.1 mi | — | 8 | 0 |
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