Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Mar Vista Country Villa Healthcare & Wellness during CMS and state inspections, most recent first.
A resident was re-admitted with multiple medical conditions, including sepsis, osteoarthritis, hypothyroidism, GERD, hypertension, and electrolyte and lipid disorders, and required supervision with eating and moderate assistance with toileting and transfers. Despite a physician order for RD evaluation, no admission weight was documented, and the RD instead used the most recent GACH weight as the baseline. Subsequent weights were entered later, and the MDS triggered a significant weight change based on comparison to the hospital weight, which was documented as a clinically significant loss. In interview, the RD confirmed that the absence of an admission weight led to reliance on the hospital weight and acknowledged that an admission weight should have been obtained by staff.
A resident with ESRD and type 2 DM, who had intact decision-making capacity, was subject to a proposed discharge for improved health without receiving a properly executed 30-day written notice. The notice in the record lacked the resident or representative’s signature, and it was not sent to the ombudsman as required by facility policy. The facility representative signed the notice shortly before the planned discharge, and the physician ordered discharge with HH and DME the next day. The resident reported feeling rushed and harassed to sign discharge paperwork on the same day as discharge, while an LVN stated he received last-minute notification of the discharge. The ombudsman confirmed the notice was not faxed until much later and that prior reminders about 30-day notice and documentation had been given, while the social services director and administrator described practices that did not align with the written policy for notifying the ombudsman.
A resident with dementia and multiple comorbidities, identified as a high fall and elopement risk, was left unsupervised due to insufficient staffing and staff reassignments during the night shift. The resident wandered outside and sustained an unwitnessed fall, resulting in a laceration that required hospital treatment. Staff interviews and record reviews indicated that the assigned CNA was diverted to provide 1:1 supervision for another high-risk resident, leaving the original assignment inadequately monitored.
The facility failed to protect residents from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors.
A resident with cognitive impairments and multiple diagnoses, including hypokalemia and COPD, experienced a significant change in condition when they confabulated stories of being raped by a CNA. The LVN documented the incident but failed to notify the physician or use the SBAR tool as required by the facility's policy, potentially delaying necessary care.
A resident with cognitive impairments reported being raped by a CNA, but the LVN who documented the allegation failed to report it to the DON or FA, as required by the facility's policies. Interviews revealed that key staff were unaware of the allegations, delaying an investigation and notification to authorities. The facility's policies mandate immediate reporting of abuse allegations, which was not followed in this case.
A facility failed to investigate a resident's allegations of abuse, as required by its policies and procedures. The resident, with cognitive impairments and requiring assistance for daily activities, reported being raped and touched by a CNA. Despite documentation by an LVN, the issue was not reported to the DON or FA, nor was an investigation initiated. The RNS, DON, and SSD were unaware of the allegations, highlighting a breakdown in communication and reporting. This failure delayed a State Agency inspection and risked unidentified abuse in the facility.
A resident with cognitive impairments and multiple health conditions reported being raped and touched by a CNA, but the facility failed to document and implement a comprehensive care plan addressing the incident. The LVN acknowledged the oversight, which violated the facility's policies on care planning and change of condition notification.
A resident with a history of verbal aggression and refusal of medication repeatedly provoked another resident, leading to a physical altercation. Despite having a care plan, the facility failed to effectively monitor and document the aggressive behavior or offer prescribed medications, resulting in a deficiency in care.
A resident with multiple health conditions reported missing incontinent briefs, which were not stocked by the facility. Despite informing the social worker and DSS, the issue was not promptly addressed, and the facility failed to investigate the grievance or offer alternative solutions. The facility did not adhere to its grievance policy, resulting in unresolved complaints.
A facility failed to maintain hospice visit records for a resident receiving hospice care. The resident had multiple health conditions and required assistance with daily activities. The facility's hospice binder lacked necessary hospice nursing and doctor visit notes, contrary to the facility's policy. Interviews revealed that the facility did not follow up to obtain these notes, potentially leaving nursing staff uninformed of changes recommended by hospice staff.
A resident with cognitive impairments eloped from the facility due to inadequate supervision and lack of alarm systems on exit doors. The resident, who required supervision for daily activities, was found missing during a CNA's rounds. Despite a search by staff, the resident was only located later at a bus stop. The facility lacked proper documentation of staff rounds and did not have a wander guard on the resident, contributing to the incident.
A deficiency in medication management was identified in an LTC facility when an LVN failed to replace missing medications for residents, leading to borrowing a Lidocaine patch from another resident and missing a Florastor dose. The LVN did not follow proper procedures for reordering medications, risking residents' pain management and supplement needs.
The facility failed to manage Glucose Quality Control Solution properly, leading to potential confusion and inaccurate blood sugar readings. An LVN found mismatched lot numbers and expired solutions in Medication Cart A, with no formal policy in place. The DON admitted uncertainty about expiration dates and acknowledged the risk of false readings causing harm to residents.
The facility failed to store food in a sanitary manner, risking foodborne illnesses. A resident had apple juice on the floor, posing an infection risk. Dented and unlabeled canned food was improperly stored with ready-to-use food. The unit refrigerator for residents' food was unlocked and contained expired items due to staff miscommunication about responsibilities.
The facility failed to ensure catheter drainage bags for two residents were placed inside dignity bags, violating their right to dignity. One resident with cognitive impairment had their catheter bag uncovered until the DON intervened, while another resident with dementia was observed with an exposed catheter bag in a wheelchair. This deficiency contravenes the facility's policy on maintaining residents' dignity.
A resident with dementia and other medical conditions was observed in a wheelchair with a urinary catheter drainage bag in open view, lacking a dignity cover. Staff interviews confirmed the absence of a dignity bag, which is required by the facility's policy to maintain resident dignity. The Director of Nursing acknowledged the necessity of a dignity bag for privacy and decency.
A resident with multiple health conditions, including legal blindness, was found with medications at their bedside without a physician's order or assessment for self-administration capability. Facility staff confirmed that residents should only have medications at bedside if cleared by a physician and evaluated for competence, which was not done in this case.
The facility failed to provide a quiet and homelike environment, affecting two residents' ability to sleep due to another resident's continuous screaming. Despite staff interventions, the noise persisted, and the facility lacked policies to address this issue.
A facility failed to complete a PASRR Level II assessment for a resident with multiple mental health diagnoses, as required by the PASRR Level I screening. The resident's care plans lacked individualized treatments, and staff interviews revealed no tracking system for required assessments. Facility policies outlined the need for such assessments, but the absence of a tracking log contributed to the oversight.
A resident with an indwelling catheter was found with yellow cloudy fluid and sediments in the tubing, indicating a possible infection. The facility failed to change the catheter bag as per the physician's order and did not notify the physician about the sediment, contrary to the facility's policy. This oversight placed the resident at increased risk for a urinary tract infection.
Two residents in an LTC facility did not receive the correct oxygen therapy as prescribed by their physicians. One resident, with multiple health issues, was found with a nasal cannula not placed correctly, while another resident with COPD received a higher oxygen flow rate than ordered. These errors were confirmed by nursing staff and acknowledged by the DON, highlighting a failure to follow the facility's oxygen therapy policy.
The facility did not complete annual performance evaluations for a CNA hired in 2001, as revealed during a record review with the DSD. The absence of evaluations for 2023 and 2024 was noted, with the DSD and DON emphasizing the importance of competencies for safe practices and proper resident care. The facility's policy requires competency assessments upon hiring, annually, and as needed.
The facility failed to follow infection control protocols for two residents. A resident's nasal cannula tubing was on the floor, and their oxygen humidifier was not changed weekly as required. Another resident's supra pubic catheter drainage bag was touching the floor. These lapses occurred despite facility policies mandating sanitary conditions and regular equipment changes.
The facility failed to ensure that the ADON, who is currently an LVN awaiting RN licensure in California, had the appropriate skills to train RN staff on resident care and assessment. The ADON conducted in-service training for CNAs, LVNs, and RNs, which was outside the LVN's scope of practice. Interviews with the DON and ADM confirmed that the ADON should not train RNs until obtaining an RN license, and future training will be conducted by the DON and an RN.
The facility's DSD transitioned from IPN to DSD without completing the required continuing education course, following the resignation of the previous DSD. This left the DSD without the necessary competencies to effectively manage the facility's educational programs.
The facility's governing body failed to report a change in the Administrator (ADM) as required by regulations. The ADM, who started in 10/2023, was also an ADM at another facility and could not provide documentation of the Change of Ownership (CHOW) application. The facility's policy requires reporting such changes within ten days, but this was not done, potentially affecting the safety and well-being of all 56 residents.
A resident with diabetes, chronic kidney disease, and depression experienced discomfort due to delayed lunch service at a facility. The delay was caused by logistical issues, as staff had to manually transport meal carts from the basement due to a non-functional elevator. This resulted in meals being served later than the scheduled time, affecting the resident's dignity and comfort.
A resident with severe cognitive impairment and identified as a fall risk fell and sustained injuries due to inadequate supervision and failure to follow care plan directives. The resident's bed was left in a high position with side rails up, and no floor mats were present, contrary to physician orders. The CNA left the resident unattended, leading to a fall and subsequent hospitalization for a head injury and laceration.
Failure to Obtain Admission Weight Led to Inaccurate Baseline and Triggered Weight Loss Variance
Penalty
Summary
The deficiency involves the facility’s failure to obtain an admission weight in accordance with professional standards of practice for one resident. The resident was re-admitted with multiple diagnoses including sepsis, osteoarthritis of the hip and knee, cognitive communication deficit, hypokalemia, hypothyroidism, hyperlipidemia, thrombocytopenia, vitamin D deficiency, GERD, hypertension, and a disorder of phosphorus metabolism. The resident’s MDS showed intact cognition, supervision or touch assistance needed with eating, and moderate assistance needed with toileting and transfers. A physician order dated 1/27/2026 requested an RD consultation to evaluate and treat as needed. However, the dietary profile dated 2/3/2026 showed no weights recorded, and there was no documented weight at the time of admission. Because an admission weight was not obtained, the RD used the most recent GACH weight of 110 lbs from 1/24/2026 as the baseline. A subsequent physician order dated 2/13/2026 called for weekly weights for four weeks. An IDT note dated 2/20/2026 documented that the MDS triggered a significant weight change, comparing the 110 lb hospital weight to later weights and identifying an approximate 19–19.2 lb loss, or 17.3%–17.5% change, which was described as clinically significant and placing the resident at risk for malnutrition, functional decline, dehydration, and increased morbidity. The RD’s care plan revision on 2/11/2026 listed weights of 110 lbs on 1/24/2026, 89.4 lbs on 2/4/2026, and 90.5 lbs on 2/9/2026, and documented a 20.6 lb/18.7% one-month loss. In interview, the RD stated there was no weight documented at admission, so the last hospital weight was used as the baseline, and acknowledged that ideally the RNA would obtain an admission weight and that the use of the hospital weight had triggered a weight loss variance.
Failure to Provide Timely 30-Day Written Discharge Notice and Ombudsman Notification
Penalty
Summary
The deficiency involves the facility’s failure to provide proper written notice of a proposed transfer and discharge to a resident, the resident’s responsible party, and the state long-term care ombudsman at least 30 days prior to the proposed discharge date. The resident, who had type 2 diabetes mellitus and end-stage renal disease and was documented as having decision-making capacity with no cognitive impairment, was initially given a Notice of Proposed Transfer and Discharge dated early in the month stating that discharge was appropriate because the resident’s health had improved sufficiently. The notice in the record lacked the resident or representative’s signature and was not faxed to the ombudsman. The facility’s policy required that a copy of the notice be placed in the medical record and faxed to the ombudsman, and that when a transfer or discharge is initiated by the facility, notice be provided to the resident, responsible party, and ombudsman 30 days prior to discharge unless specific exceptions applied. Despite this, the facility representative did not sign the notice until late in the month, and the physician’s order to discharge the resident with home health and DME was entered the following day. The resident reported not recalling receiving the proposed discharge documents within the prior four weeks and stated feeling rushed and harassed to sign a document and be discharged the same day. The ombudsman confirmed the facility did not fax the notice of proposed discharge until the day after the resident interview and had previously reminded social services about the 30-day notice and record-keeping requirements. An LVN involved in discharge planning stated he usually received at least a week’s notice for discharges but was only given the resident’s discharge plan and notification the day before the planned discharge and was told the discharge had been moved up without further details. The social services director acknowledged that when the resident declined to sign the notice earlier in the month, it was not faxed to the ombudsman, and the administrator stated the notice did not need to be faxed because it was not considered a facility-initiated or involuntary discharge, contrary to the facility’s written policies.
Failure to Provide Adequate Supervision for High-Risk Resident Resulting in Unwitnessed Fall
Penalty
Summary
The facility failed to provide sufficient nursing staff to maintain adequate supervision for a resident identified as a wanderer and at high risk for falls. The resident, an elderly female with multiple diagnoses including dementia, atrial fibrillation, and osteoarthritis, required hourly visual checks and wore a wander bracelet due to her high risk of elopement. Despite these interventions, the resident was able to leave her bed and room multiple times during the night, ultimately wandering outside onto the patio unsupervised, where she sustained an unwitnessed fall resulting in a laceration above her left eye that required hospital treatment and sutures. Review of records and staff interviews revealed that on the night of the incident, the certified nursing assistant (CNA) assigned to the resident was also tasked with being a 1:1 sitter for another high fall risk resident in a different room for several hours, leaving the original assignment unattended. The remaining CNA attempted to monitor both assignments but was also responsible for a large number of residents. Staff reported that during the night shift, there were fewer personnel available compared to the day shift, making it more difficult to provide adequate supervision for residents with high acuity and wandering behaviors. The resident's care plan included interventions such as a low bed, visual checks, and proximity to the nursing station, but no 1:1 sitter was assigned. Interviews with staff, including the charge nurse, director of staff development, and assistant director of nursing, confirmed that the resident was not identified as needing a sitter and that staffing assignments were adjusted due to a last-minute call-off. The facility's policy required adequate staffing to meet resident needs, but on the night in question, the combination of high resident acuity, staff reassignments, and reduced night shift staffing contributed to the failure to provide the necessary supervision, resulting in the resident's unsupervised exit and subsequent fall.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. This deficiency was identified based on observations and findings by surveyors, indicating that the environment posed risks for accidents and that supervision measures in place were insufficient to prevent such incidents. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Notify Physician of Change in Resident's Condition
Penalty
Summary
The facility staff failed to notify the physician of a change in condition for one of the residents, identified as Resident 1. This resident was admitted with diagnoses including hypokalemia, hypertension, and chronic obstructive pulmonary disease. The Minimum Data Set indicated that Resident 1 had moderately impaired cognitive skills and required moderate to maximal assistance for activities of daily living. On a specific date, a Licensed Vocational Nurse (LVN) documented in the progress notes that Resident 1 confabulated stories about being raped and touched by a Certified Nursing Assistant. Despite this significant change in condition, the LVN did not report the incident to the physician or document the change using the SBAR communication tool as required by the facility's policy. The facility's policy on Change of Condition Notification mandates that residents, family, legal representatives, and physicians be informed of changes in a resident's condition in a timely manner. The policy specifies that the attending physician must be notified of any sudden and marked adverse change in a resident's condition that denotes a new problem or complication. The LVN acknowledged the failure to report and document the change in condition but was unsure why it was not completed. This oversight had the potential to delay necessary care, treatment, and services for Resident 1.
Failure to Report Suspected Abuse
Penalty
Summary
The facility failed to implement its policies and procedures for reporting a reasonable suspicion of abuse in accordance with state and federal law. This deficiency was identified during a review of a resident's records and interviews with facility staff. The resident, who had been readmitted to the facility with diagnoses including hypokalemia, hypertension, and chronic obstructive pulmonary disease, had cognitive impairments and required significant assistance with activities of daily living. The resident reportedly confabulated stories of being raped and touched by a CNA, which was documented by an LVN in the resident's progress notes. Despite the documentation, the LVN did not report the allegations to the Director of Nursing (DON) or the Facility Administrator (FA), as required by the facility's policies. Interviews with the Registered Nursing Supervisor (RNS), DON, and Social Service Director (SSD) revealed that none of them were informed of the allegations. The RNS stated that if the LVN had reported the issue, an investigation could have been initiated, and the necessary authorities, including the local police, ombudsman, and Department of Public Health, could have been notified. The facility's policies and procedures, reviewed in June 2024, clearly state that all staff are mandatory reporters and must report any allegations of abuse immediately to the administrator or designated representative. The failure to adhere to these policies resulted in a delay of an onsite inspection by the State Agency, potentially leaving residents unprotected from possible abuse.
Failure to Investigate Alleged Abuse
Penalty
Summary
The facility failed to implement its policies and procedures by not ensuring an investigation was completed for a reasonable suspicion of abuse in accordance with state and federal law. This involved a resident who was admitted with diagnoses including hypokalemia, hypertension, and chronic obstructive pulmonary disease. The resident's cognitive skills for daily decision-making were moderately impaired, requiring moderate to maximal assistance from staff for activities of daily living. The deficiency arose when a Licensed Vocational Nurse (LVN) documented in the resident's progress notes that the resident confabulated stories about being raped and touched by a Certified Nursing Assistant (CNA). Despite this documentation, the LVN did not report the issue to the Director of Nursing (DON) or the Facility Administrator (FA), nor did they initiate an investigation as required by the facility's policies. The Registered Nursing Supervisor (RNS), DON, and Social Service Director (SSD) were all unaware of the resident's allegations, indicating a breakdown in communication and reporting procedures. The facility's policy on abuse and neglect mandates that all reports of resident abuse, mistreatment, neglect, exploitation, injuries of unknown source, and suspicion of crimes be promptly reported and thoroughly investigated. The failure to adhere to these policies resulted in a delay of an onsite inspection by the State Agency, potentially leading to unidentified abuse within the facility and a failure to protect residents from possible abuse.
Failure to Implement Comprehensive Care Plan After Resident's Report
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who reported being raped and touched by a Certified Nursing Assistant (CNA). The resident, who had been readmitted to the facility with diagnoses including hypokalemia, hypertension, and chronic obstructive pulmonary disease, had moderately impaired cognitive skills and required significant assistance with activities of daily living. Despite the resident's report to a Licensed Vocational Nurse (LVN), there was no documentation in the care plan addressing the incident. The LVN acknowledged the omission and confirmed that an individualized care plan should have been completed. The facility's policy on comprehensive person-centered care planning requires care plans to be reviewed and revised upon the onset of new problems or changes in condition. Additionally, the policy on change of condition notification mandates that a licensed nurse document and update the care plan to reflect the resident's current status. The failure to adhere to these policies resulted in a deficiency that could negatively impact the resident's health and safety.
Failure to Manage Resident Aggression Leads to Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse by another resident, leading to a deficiency in care. Resident 3, who had a history of verbal aggression and refused medication, repeatedly provoked Resident 4 with unwanted verbal interactions. Despite having a care plan in place to manage Resident 3's behavior, the facility did not effectively monitor or document the resident's aggressive actions, nor did they offer or document the refusal of prescribed medications like Xanax to manage anxiety and aggression. Resident 3 was admitted with diagnoses including bipolar disorder and unspecified psychosis, and was known to exhibit provocative behavior towards staff and other residents. The care plan for Resident 3 included interventions to reduce verbal aggression and promote positive interactions, but these measures were not adequately implemented. Interviews with staff revealed that Resident 3 was often verbally abusive and did not adhere to facility policies or medical orders, contributing to ongoing conflicts with Resident 4. Resident 4, who was also admitted with a history of mood disorders, was subjected to repeated verbal taunts by Resident 3, leading to a physical altercation where Resident 4 threw ice at Resident 3. The facility's failure to manage Resident 3's behavior and document interventions or notify medical staff of behavioral instability resulted in an environment where verbal abuse occurred, placing Resident 4 and others at risk for further incidents.
Failure to Investigate and Resolve Resident's Grievance
Penalty
Summary
The facility failed to investigate and resolve a grievance regarding a resident's missing incontinent briefs. The resident, who was admitted with multiple diagnoses including COPD, morbid obesity, and chronic respiratory failure, reported that their diapers were being stolen. The facility did not stock the resident's size, so the hospice company ordered them. Despite the resident's complaint to the social worker and the Director of Social Services (DSS), the issue was not promptly addressed. The DSS was informed of the missing briefs and noted the resident's grievance in a report. However, the DSS did not ensure immediate action was taken, such as installing a lock on the resident's closet as promised. The Director of Nursing (DON) acknowledged the facility's lack of investigation into the allegation and failure to offer alternative solutions, such as ordering more briefs for the resident. The facility's grievance policy requires staff to take immediate action to prevent further violations of resident rights while investigating complaints. However, the facility did not adhere to this policy, as evidenced by the lack of investigation and resolution of the resident's grievance. The resident's complaint was not adequately addressed, and the facility did not follow through with the necessary steps to resolve the issue.
Failure to Maintain Hospice Visit Records
Penalty
Summary
The facility failed to maintain hospice visit records for a resident who was receiving hospice care. The resident, admitted in July 2024, had multiple diagnoses including chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, morbid obesity, heart failure, gout, major depressive disorder, gastro-esophageal reflux disease, glaucoma, and dependence on supplemental oxygen. The resident's Minimum Data Set indicated intact cognition but dependence on assistance for toileting, personal hygiene, and transfers. During an observation in December 2024, it was found that the facility's hospice binder lacked the resident's hospice nursing and doctor visit notes. Interviews with the Director of Nursing and the Director of Medical Records revealed that the facility did not have the hospice notes for the resident, and there was no follow-up to obtain them. The facility's policy required hospice notes to be included in the facility's progress notes and for nursing staff to be informed of any changes recommended by hospice staff. However, this documentation was missing, which was not in line with the facility's policy and had the potential to leave nursing staff uninformed of any changes recommended by hospice staff for the resident.
Resident Elopement Due to Inadequate Supervision and Lack of Alarms
Penalty
Summary
The facility failed to adequately monitor and supervise a resident, leading to an elopement incident. The resident, who was admitted with diagnoses including metabolic encephalopathy, unspecified altered mental status, and diabetes, was cognitively intact but required supervision for daily activities. Despite this, the resident was able to leave the facility without staff knowledge, as the facility lacked proper alarm systems on exit doors and did not have a staff member monitoring the front desk during nighttime hours. On the night of the incident, a CNA discovered the resident missing during rounds and reported it to an LVN. The staff searched the facility and surrounding area but could not locate the resident. The resident was eventually found by an LVN at a bus stop later that morning. Interviews with staff revealed that the resident did not have a wander guard at the time of the incident, and there was no documentation of regular rounding on residents, which was supposed to occur every two hours according to facility policy. The facility's policies on resident safety and elopement were not followed, as there were no alarms on exit doors, and the resident did not have a wander guard. The lack of documentation for staff rounds further contributed to the failure to prevent the resident's elopement. The facility's Director of Nursing acknowledged these deficiencies and the potential risks associated with unsupervised resident elopement.
Medication Management Deficiency in LTC Facility
Penalty
Summary
The report identifies a deficiency in pharmaceutical services at the facility, specifically involving the failure of a Licensed Vocational Nurse (LVN) to replace missing medications for residents. The LVN did not replace a missing Lidocaine patch for one resident, leading to the borrowing of a patch from another resident, which risked depleting the second resident's supply. Additionally, the LVN failed to replace a missing Florastor supplement for another resident, resulting in a missed dose. The deficiency was observed during a medication pass when the LVN discovered the absence of the Florastor bubble pack in the resident's drawer and noted the missing Lidocaine patches in another resident's bag. The LVN attempted to address the issue by writing a note to the Registered Nurse Supervisor (RNS) to reorder the Florastor and borrowed a Lidocaine patch from another resident's supply. The RNS confirmed that borrowing medication from another resident is not permitted and outlined the procedure for reordering medications when supplies are low. The residents involved had various medical conditions requiring specific medications. One resident, who required Lidocaine patches for pain management during dialysis, reported experiencing pain when the patches were unavailable. The facility's policy clearly states that medications should not be used for any patient other than the one for whom they were prescribed, highlighting the importance of maintaining adequate medication supplies and following proper procedures for reordering and administering medications.
Improper Management of Glucose Quality Control Solution
Penalty
Summary
The facility failed to properly manage and label Glucose Quality Control Solution, leading to potential confusion and inaccurate blood sugar readings. During an observation, it was found that Medication Cart A contained a Glucose Quality Control Solution with an open date and a mismatched lot number between the solution bottle and its storage box. The Licensed Vocational Nurse (LVN) acknowledged that the Director of Nursing (DON) instructed staff that the solution expires 28 days after opening, but there was no policy reviewed by the LVN regarding this. The Glucose Meter Quality Control Results Log confirmed the 28-day expiration rule, but the facility lacked a formal policy and procedure for handling the Glucose Quality Control Solution. The DON admitted uncertainty about the expiration of the Glucose Quality Control Solution and confirmed that the facility did not have a policy for the glucometer or the solution. The absence of a clear policy and the use of expired solutions could lead to false glucose readings, potentially resulting in inappropriate insulin administration and harm to residents. The DON acknowledged the risk of false readings causing severe health issues, such as hypoglycemia, which could lead to coma. However, no specific corrective actions or follow-up measures were mentioned in the report.
Deficiencies in Food Storage and Handling
Penalty
Summary
The facility failed to ensure food was stored in a sanitary manner, which could lead to foodborne illnesses. During a facility tour, a resident was observed with a bottle of apple juice on the floor by her bed, which was brought by a friend a few days prior. The resident, who has multiple medical conditions including diabetes and dysphagia, was assessed to have intact cognition and the capacity to make medical decisions. The Licensed Vocational Nurse noted that placing the juice on the floor posed an infection control issue, and the Director of Nursing stated that food brought by visitors should be stored in a communal refrigerator to prevent potential food poisoning. In the kitchen's walk-in food storage area, dented and unlabeled canned food was found stored alongside ready-to-use canned food. The Dietary Supervisor confirmed that dented or expired canned food should be separated and returned to the manufacturer or discarded to prevent accidental use. The facility's policy requires food items to be correctly labeled and dated, with dented or bulging cans placed in a separate storage area. The unit refrigerator used to store food brought by residents' families was found unlocked, with food dated beyond the allowed storage period. The Infection Preventionist and Director of Nursing stated that food should be discarded after 72 hours, but due to a miscommunication about staff responsibilities, expired food was not removed. The Administrator acknowledged the miscommunication, which led to the failure in maintaining the residents' refrigerator, resulting in expired food being accessible to residents.
Failure to Maintain Dignity with Catheter Bag Coverage
Penalty
Summary
The facility failed to ensure that catheter drainage bags for two residents were placed inside dignity bags, violating their right to dignity. Resident 50, who was readmitted with acute kidney failure, cognitive impairment, and other health issues, was observed with their catheter drainage bag not initially placed in a dignity bag. During an observation, the Director of Nursing was seen placing the catheter bag in a dignity bag, acknowledging the importance of maintaining the resident's dignity. Resident 46, diagnosed with dementia, mild cognitive impairment, and other health conditions, was observed in a wheelchair with their urinary catheter drainage bag visibly exposed and not covered by a dignity bag. The facility's policy emphasizes the importance of maintaining residents' dignity and quality of life, which includes keeping urinary catheter bags covered. The failure to adhere to this policy resulted in a deficiency concerning the residents' dignity.
Failure to Provide Dignity Bag for Catheter Compromises Resident's Dignity
Penalty
Summary
The facility failed to maintain the dignity of a resident by not providing a dignity bag cover for a urinary catheter drainage bag. The resident, who was admitted with diagnoses including dementia, mild cognitive impairment, muscle wasting, benign prostate hypertrophy, and obstructive and reflux uropathy, was observed in a wheelchair with the catheter drainage bag in open view, without a privacy cover. This observation was made during a tour, where the resident was seen using his legs to wheel himself around the facility, with the drainage bag hoisted and tucked in the back pocket of the wheelchair. Interviews with staff revealed that the Restorative Nurse Assistant (RNA) acknowledged the absence of a dignity bag and was unaware of who assisted the resident to the wheelchair. The Director of Nursing confirmed that a dignity bag should be provided for decency and privacy. The facility's policy on resident rights and quality of life prohibits demeaning practices and emphasizes the importance of covering urinary catheter bags to promote dignity. The failure to provide a dignity bag compromised the resident's right to be treated with dignity.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that medications were not left with a resident who was not capable of self-administering oral medications. Resident 29, who had multiple diagnoses including diabetes mellitus, dysphagia, congestive heart failure, atrial fibrillation, breast cancer, hearing loss, and acute angle-closure glaucoma, was observed with several medications on top of their bedside drawer. These medications included a nasal decongestant, pain relief ointment, antibiotic ointment, and a laxative. Despite Resident 29's statement that they were cleared by an ER doctor to have these medications at bedside, there was no evidence of a physician's order or an assessment by the interdisciplinary team to confirm the resident's capability to self-administer these medications safely. Interviews with facility staff, including an LVN and the DON, revealed that residents are only allowed to have medications at bedside if they have a physician's order and have been evaluated for competence in self-administration. The LVN expressed concerns about Resident 29's legal blindness and the potential for inaccurate self-administration, which could lead to health complications. The facility's policy requires an assessment of the resident's cognitive, physical, and visual ability to self-administer medications, which was not documented in this case.
Failure to Maintain a Quiet and Homelike Environment
Penalty
Summary
The facility failed to ensure a quiet, comfortable, and homelike environment for two residents, resulting in their inability to sleep or rest peacefully. Resident 210, who was admitted with hypertension and muscle weakness, reported being unable to sleep due to noise at night and during the day, caused by another resident's continuous screaming. This resident expressed concern for the screaming resident's well-being and feared that she might not receive help if needed. Similarly, Resident 48, who also had hypertension, muscle weakness, and hyperlipidemia, reported being unable to sleep at night due to the same issue. Both residents indicated that the screaming persisted until the day shift staff intervened. Observations confirmed that a resident was continuously screaming and yelling, with staff entering the room to calm the resident temporarily. However, the screaming resumed once staff left the room. Interviews with staff, including a CNA and a Registered Nurse Supervisor, revealed that the screaming resident frequently called for help, stopping only when checked on by staff. The facility lacked a policy and procedures to maintain a quiet, comfortable, and homelike environment, contributing to the deficiency.
Failure to Complete PASRR Level II Assessment for Resident
Penalty
Summary
The facility failed to ensure that a PASRR Level II assessment was completed for Resident 27, as required by the PASRR Level I screening. This oversight placed Resident 27 at risk of not receiving the necessary care and specialized services tailored to their mental health needs. The resident's care plans did not indicate any individualized rehabilitative treatments and services as required by the PASRR Level II for their mental health condition. Resident 27 was admitted and readmitted to the facility with multiple diagnoses, including metabolic encephalopathy, multiple sclerosis, major depressive disorder, bipolar disorder, paranoid personality disorder, and schizophrenia. Despite these conditions, the facility did not complete the necessary PASRR Level II assessment, which was indicated by the PASRR Level I screenings conducted on two separate occasions. The resident's medical records, including progress notes and psychosocial notes, highlighted ongoing mental health challenges and the need for specialized therapeutic interventions. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing, revealed a lack of a tracking system to monitor which residents required PASRR Level II assessments. The facility's policies and procedures outlined the need for such assessments and the role of the Interdisciplinary Team in reviewing and implementing recommendations. However, the absence of a tracking log and reliance on identifying residents with psychosis or on psychotropic medications as triggers for Level II assessments contributed to the oversight in Resident 27's case.
Failure to Change Catheter Bag and Monitor for Infection
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling catheter, leading to a deficiency in care. The resident, who had a history of hypertensive chronic kidney disease, obstructive and reflux uropathy, and other conditions, was observed with yellow cloudy fluid and sediments in the catheter tubing. The facility's policy required the catheter bag to be changed per the physician's order, which was not adhered to, as the catheter bag had not been changed since the date written on it, 10/21/2024, despite the physician's order to change it per schedule and as needed. Observations and interviews with the Director of Nursing (DON) and other staff revealed that the catheter bag was overdue for a change, and the presence of sediment indicated a possible infection. The DON and other staff acknowledged that the sediment could be a sign of infection and that a physician should be notified immediately. However, the facility's records did not indicate that the catheter had been changed as required, and the staff failed to notify the physician about the sediment in the catheter tubing. The facility's policy and procedures for catheter care, revised on 6/10/2021, required nursing staff to assess the indwelling catheter for signs of infection, including cloudiness and sediment, and to notify the physician for clinical interventions. The failure to follow these procedures placed the resident at increased risk for a urinary tract infection, as the catheter bag was not changed according to the physician's order and facility policy, and the presence of sediment was not promptly addressed.
Oxygen Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that two residents received the correct amount of prescribed oxygen as ordered by their physicians. Resident 7, who was admitted with multiple diagnoses including encephalopathy, diabetes mellitus, and dementia, was observed with an oxygen concentrator set at 3 liters per minute, but the nasal cannula was not placed on the resident's nostrils as required. Instead, it was found on the resident's chest, covered by linens. This oversight was confirmed by a Licensed Vocational Nurse (LVN), who acknowledged the error and corrected it by placing the nasal cannula on the resident's nostrils. The Director of Nursing (DON) later confirmed that this failure could have led to desaturation and other serious health issues. Resident 2, who was admitted with chronic obstructive respiratory disease (COPD) and other respiratory conditions, was observed receiving oxygen at 3 liters per minute, contrary to the physician's order of 2 liters per minute. A Registered Nurse (RN) confirmed the discrepancy and acknowledged that administering oxygen at a higher rate than prescribed constitutes a medication error. The DON emphasized that oxygen is considered a medication, and incorrect administration could lead to complications such as hypercapnia. The facility's policy on oxygen therapy, dated 2017, mandates that oxygen be administered per physician orders to meet resident needs safely. Both incidents highlight a failure to adhere to these policies, resulting in potential risks to the residents' health. The facility's job description for Licensed Vocational Nurses also requires them to prepare and administer medication as ordered by the physician, which was not followed in these cases.
Failure to Conduct Annual Performance Evaluations for CNA
Penalty
Summary
The facility failed to complete annual performance evaluations for one out of five sampled staff members, specifically a Certified Nursing Assistant (CNA 2) who was hired on 10/29/2001. During a record review with the Director of Staff Development (DSD), it was found that there was no performance evaluation for CNA 2 for the years 2023 or 2024 in the employee file. The DSD acknowledged the importance of competencies to ensure staff are performing safe practices and are competent, noting the potential harm to residents if evaluations are not conducted. The Director of Nursing (DON) confirmed that performance evaluations are conducted annually and as needed to ensure staff have the proper skills to care for residents. The facility's policy on Staff Competency Assessment, revised on 3/17/2022, states that competency assessments should be performed upon hiring, during the employee's 90-day employment, annually, or any time new equipment or procedures are introduced and as needed.
Infection Control Lapses in Oxygen and Catheter Management
Penalty
Summary
The facility failed to adhere to infection control measures for two residents, leading to potential infection risks. Resident 2's nasal cannula tubing was observed touching the floor, and the oxygen humidifier had not been changed since 10/13/2024, despite facility policy requiring weekly changes. Resident 2 was admitted with chronic obstructive respiratory disease, chronic respiratory failure with hypoxia, and heart failure, and was dependent on staff for various activities. During an observation, the Registered Nurse confirmed the humidifier's outdated status and acknowledged the risk of infection from tubing contact with the floor. Resident 50's supra pubic catheter drainage bag was found touching the floor, which could lead to infection. Resident 50 had been readmitted with acute kidney failure and a history of transient ischemic attack, and was also dependent on staff for daily activities. The Director of Nursing raised the bed to prevent the catheter bag from touching the floor, acknowledging the infection risk. The facility's policies on infection control and oxygen therapy emphasize maintaining a sanitary environment and changing equipment per guidelines, which were not followed in these instances.
Inadequate Training by LVN for RN Staff
Penalty
Summary
The facility failed to ensure that the Assistant Director of Nursing (ADON) and a licensed vocational nurse (LVN) possessed the necessary skills to train registered nursing staff on resident care and assessment. The ADON, who has been in the position since March 2024, does not hold a California registered nursing (RN) license and is currently licensed as an LVN while awaiting her RN credentials in California. Despite this, the ADON was responsible for conducting in-service education and training for Certified Nursing Assistants (CNAs), LVNs, and RNs, including topics such as abuse and falls. The facility's in-service records confirmed that the ADON provided training to the nursing staff, either independently or with the Director of Staff Development (DSD). Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that the ADON was training RNs, which was acknowledged as being outside the scope of practice for an LVN. The DON stated that moving forward, only the DON and an RN would conduct in-service training for RNs, as LVNs are not authorized to train RNs. The ADM also recognized that the ADON should not be training RNs until she obtains her RN license in California. The facility's job descriptions and policies further highlighted the discrepancy, as the LVN's role is to provide nursing care under the supervision of an RN, and the ADON's responsibilities include assisting the DON and supervising nursing personnel.
DSD Lacks Required Competencies Due to Incomplete Training
Penalty
Summary
The facility failed to ensure that the Director of Staff and Development (DSD) possessed the necessary competencies and skill sets required to effectively plan, implement, direct, and evaluate the educational programs for all employees. This deficiency arose because the DSD transitioned from the role of Infection Preventionist Nurse (IPN) to DSD without completing the mandatory continuing education course required for the position. The transition occurred in March 2023 following the resignation of the previous DSD, leaving the current DSD to manage the responsibilities without the requisite training. The DSD acknowledged during an interview that she had not completed the necessary continuing education due to the abrupt transition and was in the process of handling the paperwork herself to obtain the required certificates.
Failure to Report Change in Administrator
Penalty
Summary
The facility's governing body failed to ensure that the Administrator (ADM), responsible for managing and overseeing the implementation of policies and procedures, reported a change in the Administrator as required by State and Federal regulations. This deficiency was identified through interviews and record reviews, revealing that the Electronic Licensing Management System (ELMS) listed a different name for the ADM of Skilled Nursing Facility 1 (SNF 1) as of 7/29/2024. The ADM, who started in 10/2023, was also serving as an ADM at another facility. During an interview, the ADM admitted to applying for the Change of Ownership (CHOW) with the State Department in 10/2023 but was unable to provide documentation of the application to the surveyor, claiming it was not a regulation to keep a copy. The facility's policy and procedure, titled Governing Body and revised on 5/23/2019, states that the Governing Body appoints a qualified Administrator licensed by the State of California, responsible for the facility's management and accountable to the Governing Body. The policy also requires the facility to submit a new application package to the California Department of Public Health whenever a change in ownership occurs, and all other changes must be reported to the Licensing and Certification District Office in writing within ten days of the change. The failure to report the change in Administrator had the potential to affect the safety and overall well-being of all 56 residents in the facility.
Delayed Meal Service Affects Resident Dignity
Penalty
Summary
The facility failed to provide timely meal service to a resident, which compromised the resident's dignity and comfort. The resident, who has type two diabetes mellitus, chronic kidney disease, and major depressive disorder, was observed waiting for a lunch tray past the scheduled meal time. The resident expressed irritation and discomfort due to hunger, as the lunch trays were consistently delivered late, often close to 1 p.m., despite the meal schedule indicating that lunch should be served at 12 p.m. The delay in meal service was attributed to logistical challenges faced by the staff. The facility's elevator was out of service, requiring certified nursing assistants to manually transport meal carts from the basement kitchen to the first floor via a steep ramp. This process was time-consuming and interfered with their ability to assist residents promptly. The facility's policy mandates that meals be served at regularly scheduled hours, and the failure to adhere to this schedule resulted in the resident's dissatisfaction and discomfort.
Failure to Prevent Resident Fall Due to Inadequate Supervision
Penalty
Summary
The facility failed to ensure adequate monitoring and supervision of a resident, leading to a fall and subsequent injuries. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was identified as a fall risk. Despite having a care plan and physician orders that required the bed to be in a low position and floor mats to be in place, these measures were not followed. The resident's bed was left in a high position with side rails up, and no floor mats were present, contrary to the care plan and physician orders. On the day of the incident, a Certified Nursing Assistant (CNA) left the resident unattended after providing care, with the bed in a high position and side rails up. The CNA stepped away to call for assistance in repositioning the resident, during which time the resident fell from the bed, sustaining a head injury and a laceration to the left eyebrow. The resident was subsequently transferred to a hospital for evaluation and treatment, where a CT scan revealed frontal scalp soft tissue swelling, and the resident received sutures for the laceration. Interviews with staff and other residents confirmed that the bed was not in the prescribed low position, and floor mats were absent at the time of the fall. The facility's policies on fall management and resident safety were not adhered to, as the necessary precautions to prevent falls were not implemented. The incident highlights a failure to follow established care plans and physician orders, resulting in harm to the resident.
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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 Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Culver West Health Center | 0.2 mi | — | 4 | 0 |
| Meadowbrook Behavioral Health Center | 0.6 mi | — | 14 | 0 |
| Vista Del Sol Care Center | 0.6 mi | — | 3 | 0 |
| Marina Pointe Healthcare & Subacute | 1.7 mi | — | 7 | 0 |
| Overland Terrace Healthcare & Wellness Centre, Lp | 1.8 mi | — | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.