Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
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 Los Angeles Comm Hospital during CMS and state inspections, most recent first.
Two residents in a persistent vegetative state had peripheral line dressings that were not changed according to the facility's policy, increasing their risk of infection. Additionally, a medication cart was not cleaned after a liquid medication spill, posing a risk of cross-contamination.
The facility did not post the results of complaint investigations by the CDPH from the past three years in accessible areas, as required by federal regulations. The DON confirmed that only the last recertification survey was available, omitting recent complaint investigation results. The ACON highlighted the importance of posting these results for transparency and compliance with resident rights.
A facility failed to accurately complete the MDS assessment for a resident by not encoding a psychotic disorder diagnosis, despite the resident receiving Quetiapine for psychosis. The MDS Nurse admitted the error, and the ACON stressed the importance of MDS accuracy for proper care. The facility's policy requires assessments to be certified for accuracy.
A facility failed to update the PASRR Level I screening for a resident with a new diagnosis of psychosis, who was prescribed Quetiapine for symptoms manifested by pulling out tubes. The DON acknowledged the oversight, as the initial screening indicated no serious mental illness, and a re-evaluation was required to determine the need for specialized services.
A resident with severe cognitive impairment and respiratory failure was using non-behavioral restraints to prevent tube removal. The care plan required releasing and repositioning the restraints every two hours, but the restraint flow sheet lacked these instructions. This discrepancy was confirmed by staff and could lead to increased discomfort for the resident.
A resident with severe medical conditions and dependent on staff for all ADLs had their hair care neglected, resulting in matted hair with dandruff. Observations and staff interviews confirmed that hair care was not provided as scheduled, despite facility policy requiring shampooing as part of the bathing program.
A facility failed to label the oxygen tubing for a resident with chronic respiratory failure, which is necessary for infection control. The tubing was not dated, making it unclear when it was last changed, posing a potential risk for respiratory infection. Interviews with the DON and ACNO confirmed that labeling is a facility policy, and the lack of adherence to this policy was noted.
A facility failed to act on a pharmacy consultant's recommendation to review and justify the use of Quetiapine for a resident with chronic respiratory failure and a tracheostomy. The resident was receiving the medication for psychosis, but there was no documentation supporting this diagnosis. The Director of Nursing did not follow through with the recommendation, risking unnecessary medication administration.
A facility failed to implement non-pharmacological interventions before administering Quetiapine to a resident without a documented diagnosis of psychosis. The resident, with chronic respiratory failure and a gastrostomy tube, was prescribed the medication for pulling out tubes, but there was no evidence of attempted behavioral interventions or a pattern of behavior justifying its use. Interviews revealed that the behavior was not indicative of psychosis, and the medication was deemed unnecessary, contrary to facility policy requiring alternative interventions before psychoactive medication use.
The facility failed to maintain a medication error rate below 5%, as observed when two residents did not receive their scheduled nebulizer medications on time. LVNs noted the delays, and the DRT confirmed the late administration, which was not documented promptly as per facility policy.
A facility failed to refrigerate an intravenous medication, Amikacin, as required by its labeling. During an observation, an RN found the medication stored in an IV cart instead of a refrigerator, despite being scheduled for administration later that day. The RN acknowledged the error, noting that improper storage could render the medication ineffective or expired. Facility policy requires proper storage conditions, including temperature control.
A facility failed to meet the required square footage for a resident room, which was intended for two residents. The room measured 155 square feet, below the required 160 square feet. The facility had submitted a waiver request for this deficiency, and the DON stated that the room was unoccupied and posed no harm to resident safety or well-being.
Infection Control and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding the timely changing of peripheral line dressings for two residents, placing them at risk for infection. Resident 19 had a peripheral line dressing on the right forearm that was not changed for seven days, despite the facility's policy requiring a change every 72 hours. Similarly, Resident 17's peripheral line dressing on the right hand was not changed for six days. Both residents were in a persistent vegetative state, dependent on ventilators, and required assistance with personal care, increasing their vulnerability to infections. Additionally, the facility did not maintain proper sanitation of a medication cart, as a sticky liquid medication spill was observed on the cart, potentially leading to cross-contamination. The facility's policy mandates that medication carts be kept free of spills to prevent contamination and ensure the effectiveness of medications. The failure to clean the medication cart after the spill was noted during an observation with an LVN, who acknowledged the risk of cross-contamination due to the soiled cart.
Failure to Post Complaint Investigation Results
Penalty
Summary
The facility failed to post the results of complaint investigations conducted by the California Department of Public Health (CDPH) over the past three years in areas that are prominent and accessible to residents, visitors, family members, or resident representatives. During an observation and interview with the Director of Nursing (DON), it was revealed that the survey binder available at the nursing station hallway only included the last recertification survey conducted by the CDPH. The DON acknowledged that the facility had been visited by the CDPH for complaint investigations in the past two years, but the results of these investigations were not included in the survey binder. The DON admitted that all survey results should be posted and accessible to ensure transparency and compliance with resident rights. Further interviews with the Associate Chief of Nursing (ACON) confirmed that posting survey and complaint investigation results is a federal requirement. The ACON emphasized the importance of making these results available so that residents, their representatives, and facility staff can review the facility's plan of action to prevent recurrence of the identified deficiencies. A review of the facility's admission packet, specifically the section on resident rights, indicated that residents have the right to examine the results of the most recent surveys and any plans of correction. The facility's failure to post these results constitutes a violation of this right, potentially leaving residents and their families uninformed about the facility's compliance status and past performance history.
Inaccurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure an accurate Minimum Data Set (MDS) assessment for a resident, identified as Resident 8, by not correctly encoding the diagnosis of a psychotic disorder under Section I (Active Diagnoses). This error was discovered during a review of Resident 8's MDS, which indicated that the resident's cognitive skills for daily decision-making were severely impaired and that the resident was dependent on staff for various hygiene tasks. The MDS Nurse acknowledged that the MDS assessment was completed inaccurately, as there was a missing check mark for the psychotic disorder diagnosis, despite the resident receiving Quetiapine for psychosis. The deficiency was further highlighted during an interview with the Associate Chief Nursing Officer (ACON), who emphasized the importance of MDS accuracy for reflecting the care provided by the facility. The facility's policy and procedure on Assessment and Care Planning require the assessment to be certified for accuracy by the individuals completing any portion of it. The incorrect data transmitted to the Center for Medicare and Medicaid Services (CMS) had the potential to negatively affect Resident 8's plan of care.
Failure to Update PASRR Screening for Resident with New Psychosis Diagnosis
Penalty
Summary
The facility failed to complete and re-submit the Preadmission Screening and Resident Review (PASRR) Level I screening for a resident who had a new diagnosis of psychosis. This oversight involved a resident who was admitted with chronic respiratory failure and required a tracheostomy and gastrostomy tube. The resident was later prescribed Quetiapine for psychosis, which was manifested by pulling out tubes. Despite this new diagnosis and medication, the PASRR Level I screening was not updated to reflect the change in the resident's mental health status. During an interview and record review, the Director of Nursing (DON) acknowledged the failure to submit a new PASRR Level I screening after the resident's diagnosis of psychosis. The initial PASRR Level I screening indicated no serious mental illness and did not require a Level II evaluation. However, the resident's condition changed, necessitating a re-evaluation to determine if specialized services were needed. The PASRR reference manual requires facilities to notify the state mental health authority of significant changes in a resident's condition, which was not done in this case.
Deficiency in Care Plan for Resident Using Restraints
Penalty
Summary
The facility failed to ensure that a revised care plan was in place for a resident using non-behavioral restraints. The resident, identified as Resident 25, was admitted with a diagnosis of respiratory failure and had additional diagnoses of seizures and pneumonia. The resident's Minimum Data Set (MDS) indicated severe cognitive impairment and dependency on staff for daily activities. The care plan for the resident included the use of bilateral restraints to prevent the removal of medical tubes, with specific instructions to release the restraints for 15 minutes every two hours and to reposition them under supervision. However, the Non-Behavioral Restraint Order and Flow Sheet, which should have reflected the care plan's interventions, lacked specific instructions on the duration and frequency of restraint release and repositioning. This discrepancy was noted during a review of the resident's records and confirmed by both the MDS Nurse and a Licensed Vocational Nurse (LVN). The absence of detailed instructions on the flow sheet had the potential to result in the restraints being left on longer than necessary, which could increase the resident's discomfort. The facility's policy and procedure documents emphasized the importance of care planning and documentation, including the use of protective restraints and monitoring. Despite these guidelines, the care plan for Resident 25 was not adequately updated to reflect the necessary interventions, leading to a deficiency in the resident's care. The lack of alignment between the care plan and the restraint flow sheet was identified as a significant issue during the survey.
Failure to Provide Adequate Hair Care for a Resident
Penalty
Summary
The facility failed to ensure that a resident's hair was shampooed twice a week as required, leading to the resident's hair becoming matted and having an abundance of dandruff. The resident, who was admitted with chronic respiratory failure, sepsis, a tracheostomy, and encephalopathy, was in a persistent vegetative state and dependent on staff for all activities of daily living (ADLs), including personal hygiene. Observations on a specific date revealed the resident's hair condition, and interviews with staff confirmed that hair care was supposed to be provided on shower days, which occurred twice a week. The Certified Nursing Assistant (CNA) acknowledged that the resident's hair looked dirty and emphasized the importance of washing and combing the hair to prevent dryness, dandruff, and tangling. The Associate Chief Nursing Officer (ACNO) confirmed that hair care was part of the resident's ADLs and should have been performed on shower days to maintain hygiene and prevent scalp infection. The facility's policy on hair and scalp care indicated that shampooing should be part of the bathing program, and the condition of the hair and scalp should be observed, with cream rinse used if the hair is tangled.
Failure to Label Oxygen Tubing for Infection Control
Penalty
Summary
The facility failed to ensure that the corrugated oxygen tubing for a resident was labeled with a date of change, which is a critical step for infection control. This deficiency was identified during an observation and interview with a respiratory therapist who noted that the tubing was not dated, making it unclear when it was last changed. The resident in question, who was admitted with chronic respiratory failure and had a tracheostomy, was dependent on staff for all activities of daily living and was receiving oxygen therapy continuously. The lack of labeling on the oxygen tubing posed a potential risk for respiratory infection. Interviews with the Director of Nursing and the Associate Chief Nursing Officer confirmed that it is the facility's policy to label all respiratory equipment with a date of change. The Director of Nursing highlighted that a clogged oxygen tubing could result in inadequate oxygen delivery, potentially causing shortness of breath. The facility's policy and procedure document indicated that all equipment should be changed as needed or when visibly dirty and dated, but this was not adhered to in the case of the resident's oxygen tubing.
Failure to Address Pharmacy Consultant's Recommendation for Medication Review
Penalty
Summary
The facility failed to ensure that a pharmacy consultant's recommendation regarding a resident's medication regimen was acknowledged and acted upon. Specifically, the pharmacy consultant recommended a review and justification for the restarting of Quetiapine, a psychotropic drug, for a resident. This recommendation was not followed through by the Director of Nursing (DON), who was responsible for addressing such recommendations with the resident's physician. The facility's policy required that the attending physician address the consultant pharmacist's recommendation by their next scheduled visit, but this was not done. The resident involved had a history of chronic respiratory failure with a tracheostomy and a gastrostomy tube. The resident was receiving Quetiapine for psychosis manifested by pulling out tubes, but there was no documentation in the psychiatric progress notes to support the diagnosis of psychosis or the use of Quetiapine. The failure to address the pharmacy consultant's recommendation placed the resident at risk for unnecessary medication administration, as there was no documented justification for the medication's use.
Failure to Implement Non-Pharmacological Interventions Before Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure consistent indication and identification of behavior, as well as the implementation of non-pharmacological interventions, before administering Quetiapine, a psychotropic drug, to a resident. The resident, who was admitted with chronic respiratory failure and a gastrostomy tube, was prescribed Quetiapine for psychosis manifested by pulling out tubes. However, the Director of Nursing (DON) confirmed that there was no documentation of the resident's behavior or attempted behavioral interventions prior to the initiation of Quetiapine. Furthermore, the resident's psychiatric progress notes did not indicate a diagnosis of psychosis, and the facility lacked evidence of a pattern of behavior that would justify the use of the medication. Interviews with the Director of Staff Development (DSD) and the Associate Chief Nursing Officer (ACON) revealed that pulling out tubes was not considered a specific behavior of a resident with psychotic features. The DSD acknowledged that the use of Quetiapine was unnecessary and could lead to adverse effects, including chemical imbalance and cardiac complications. The ACON stated that the facility should have employed less restrictive measures, such as hand mittens or one-on-one monitoring, before resorting to psychotropic medication. The facility's policy required that alternative interventions be attempted and documented before administering psychoactive medications, which was not adhered to in this case.
Medication Administration Errors Due to Delayed Dosing
Penalty
Summary
The facility failed to ensure that the medication error rate was less than 5%, resulting in medication errors. During an observation of 27 medication administration opportunities, two routine medications were not administered at their scheduled times. Licensed Vocational Nurse 1 (LVN 1) observed that a nebulizer medication, levalbuterol, was not administered to a resident at the scheduled time of 7:00 a.m. as per the Medication Administration Record (MAR). LVN 1 acknowledged that not administering routine medications at the scheduled time could lead to medication errors. Similarly, Licensed Vocational Nurse 2 (LVN 2) observed that another nebulizer medication, albuterol/ipratropium, was not administered to a different resident at the scheduled time of 7:00 a.m. The Director of Respiratory Therapy (DRT) confirmed that both medications were administered after their scheduled times, as indicated by a red box on the MAR. The DRT acknowledged that this delay could result in medication errors, overmedicating residents, and a lack of communication between staff. The facility's policy on medication administration requires that medications be charted immediately after administration, which was not adhered to in these instances.
Improper Storage of Intravenous Medication
Penalty
Summary
The facility failed to ensure that an intravenous medication, Amikacin, was refrigerated as required by its labeling. During an observation and interview, a registered nurse identified that the medication, which was scheduled to be administered at 9:00 p.m., was improperly stored in the intravenous medication cart instead of being refrigerated. The nurse acknowledged that the medication should have been refrigerated and noted that improper storage could lead to the medication being ineffective or expired. The facility's policy on medication storage mandates that drugs be stored under proper conditions, including temperature control.
Room Size Deficiency Identified in Facility
Penalty
Summary
The facility failed to meet the minimum square footage requirement for a resident room, specifically room [ROOM NUMBER], which was intended to accommodate two residents. The required size for such a room is 160 square feet, but the room was measured to be only 155 square feet. This discrepancy was identified during an observation conducted by the Director of Nursing (DON) and the Maintenance Supervisor (MS). The facility had previously submitted a room waiver request to address this issue, indicating that the room was slightly below the required size. During the survey, the DON confirmed that the room was unoccupied and did not have ventilator or tracheostomy access. The facility had been submitting annual waiver requests for this room due to its size deficiency. Despite the room's size not meeting the regulatory requirements, the DON stated that there was no harm to resident safety or well-being. Observations made over the course of the survey indicated that the room sizes did not adversely affect the health or safety of residents.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 5,563 citations issued within 25 miles in the last 12 months — including the 29 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Costa Del Sol Healthcare | 0.6 mi | — | 5 | 0 |
| East Los Angeles Doctors Hosp | 0.7 mi | — | 7 | 0 |
| Infinity Care Of East Los Angeles | 2 mi | — | 10 | 0 |
| Hollenbeck Palms | 2.2 mi | — | 21 | 0 |
| Maywood Skilled Nursing & Wellness Centre | 2.3 mi | — | 25 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Los Angeles Comm Hospital.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.