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 Southern California Hosp At Culver City D/p Snf during CMS and state inspections, most recent first.
A resident with chronic respiratory failure post-tracheostomy, anoxic brain injury, and chronic heart failure, and who was totally dependent for ADLs, was found by nursing staff to have unexplained redness and later a mild contusion on the forehead. Nursing notified the NP and the family and documented that VS were within normal limits and the resident showed no signs of pain or distress, but the cause of the bruise was unknown. Social services did not follow up with APS and the LTC Ombudsman until two days after the injury, and CDPH was not notified until four days after the incident, despite facility policy and state law requiring notification of the state licensing agency within 24 hours and immediate phone notification to the LTC Ombudsman when potential abuse indicators such as bruises or discoloration are identified.
A resident with acute respiratory failure did not receive a stat EEG as ordered when the EEG technician was verbally instructed by the house neurologist, who was not the ordering provider, to delay the test. The verbal hold was not documented, and the technician did not consult the ordering provider or notify nursing staff, resulting in a delay of the procedure.
The facility did not submit its PBJ Staffing Data Report for Q4 FY 2024 to CMS. The ADM stated that the CNM was responsible for the submission, which was not done on time. The facility lacked a validation report and a policy for the PBJ report. CMS policy mandates electronic submission of staffing data by a specified deadline.
Two residents did not receive scheduled showers due to a broken shower hose, resulting in only bed baths being provided. One resident was observed to be poorly groomed, and another expressed frustration over not feeling fully clean. Additionally, a CNA stood while feeding a resident, contrary to protocol, which could impact the resident's self-esteem. The facility's policies on bathing and dignity were not followed.
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) appeal process form to three residents, which is required when their Medicare-covered services are ending. This deficiency was identified during an interview with the Director of Quality and Risk Management, who acknowledged that the NOMNC forms were missing. The absence of these forms could prevent residents from exercising their right to file an appeal, potentially leading to violations of residents' rights or unwanted discharges.
The facility failed to ensure annual competencies were signed and dated by three employees, potentially leading to inadequate care. A review of employee files revealed missing signatures and dates on competencies for two LVNs. The Director of Quality and Risk Management acknowledged the risk of incomplete competencies, which could result in inadequate care.
The facility failed to maintain proper food storage and temperature monitoring practices. A walk-in refrigerator lacked a thermometer, risking food spoilage, while the reach-in freezer contained unlabeled and undated food items, potentially leading to expired food. The Sous Chef acknowledged these issues, which contravened the facility's policies requiring labeling and temperature monitoring.
A facility failed to cover a resident's indwelling catheter with a privacy bag, compromising the resident's dignity. The resident, who had multiple health issues and required assistance with daily activities, was observed without the catheter cover, contrary to facility policies. An RN acknowledged the importance of the cover for maintaining the resident's modesty.
The facility did not post survey results and complaint investigation reports in a location accessible to residents and the public, as required by CDPH regulations. The DQRM acknowledged that these documents were kept in her office instead of being available at the nursing station hallway. The CNM confirmed the importance of making these documents accessible to demonstrate compliance and quality of care. This deficiency was noted during a survey.
A facility failed to resubmit the PASARR Level I screening for a resident with anxiety, depression, and psychosis, as indicated by the MDS. The initial screening incorrectly stated no serious mental illness, closing the case without a Level II evaluation. Staff interviews revealed reliance on the transferring facility for initial screening and acknowledged the need for resubmission based on updated assessments.
A facility failed to label and date the ventilator tubing for a resident, which is crucial for preventing respiratory infections. The oversight was confirmed by a respiratory therapist who admitted to changing the tubing without dating it. A registered nurse also acknowledged the importance of dating the tubing, as it is changed daily or as scheduled. The facility's policy on mechanical ventilation did not specify the need to date and label the tubing, contributing to the deficiency.
A resident with a history of acute respiratory failure and on gastrostomy tube feeding was observed with the head of the bed elevated at only 10 degrees, contrary to the care plan requiring 45 degrees to prevent aspiration. A nurse confirmed the risk of aspiration due to the improper elevation.
A resident receiving IV antibiotic treatment for sepsis had unlabeled and undated IV tubing, contrary to the facility's policy requiring tubing to be changed every three days and labeled. The inconsistency in practice was noted by a nurse, and the clinical nurse manager confirmed the labeling responsibility of the nursing staff.
A facility failed to remove expired medication from its storage, risking potential medication errors. During an inspection, Vancomycin prescribed for a resident with respiratory failure was found expired in the medication storage refrigerator. Staff acknowledged the oversight and the risk it posed, noting that expired medications should be returned to the pharmacy as per protocol.
A resident with thyroid cancer and other conditions did not receive a required TSH level test as ordered by a physician. The test was not conducted in November, which was confirmed by a nurse and pharmacist, potentially affecting the resident's medication management. Facility policy mandates that lab tests requested by physicians be provided, but this was not adhered to in this case.
A resident with multiple health conditions, including dysphagia, did not receive necessary dental services despite expressing a desire for dental care. Interviews with staff confirmed the absence of a dental contract and the lack of adherence to the facility's policy requiring oral assessments and arrangements for dental services.
The facility did not hold Quality Assurance Performance Improvement (QAPI) meetings quarterly as required. The last meeting was in December 2024, with the previous one in May 2024, missing the August 2024 meeting. This failure could lead to systemic issues, as confirmed by the Director of Quality and Risk Management (DQRM). The facility's policy requires quarterly meetings and monthly subcommittee meetings, which were not adhered to.
A facility failed to label and date ventilator tubing for a resident, as observed during a survey. The respiratory therapist admitted to changing the tubing without dating it, which is crucial for preventing infections. The facility's policy did not specify the need for dating the tubing, leading to a risk of respiratory infections.
The facility failed to meet nursing professional standards for two residents. One resident's elevated heart rate was not documented or addressed for over three hours, despite facility procedures requiring reassessment and documentation. Another resident did not have documented range of motion services on two scheduled days, risking contractures. These deficiencies highlight lapses in adhering to the facility's documentation policies.
A facility failed to prevent neglect and investigate alleged violations involving three residents. An LVN tied a sheet to a broken bedrail, leading to a resident's fall, ignored a wound vac alarm, leaving another resident in the dark, and failed to report critical test results for a third resident. The facility lacked investigation reports and corrective actions for these incidents.
A resident with severe cognitive and physical impairments fell from bed due to a broken bedrail that was inadequately secured with a sheet. The night shift nurse did not report the issue, and a replacement bed was not ordered, leading to the resident's unwitnessed fall. The facility's policies on equipment failure and fall prevention were not followed, resulting in a deficiency.
A facility failed to ensure an LVN in the subacute unit had a current BLS certification, as required by the job description. This deficiency was identified during a review of care for a resident with chronic respiratory failure and a preference for resuscitation/CPR. The LVN's BLS certification had been expired for over nine months, potentially delaying emergency care for the resident and others in the unit.
The facility failed to maintain room temperatures within the acceptable range of 71 to 81 degrees Fahrenheit for 17 residents in the Sub-Acute Unit. Temperatures were recorded as high as 89.7 degrees, and spot coolers were ineffective in reducing the heat. Residents and staff reported discomfort, and the facility's HVAC system was insufficient to manage the temperature, leading to an Immediate Jeopardy situation.
Failure to Timely Report Injury of Unknown Origin to Required Agencies
Penalty
Summary
The deficiency involves the facility’s failure to timely report an injury of unknown origin for one resident to CDPH, APS, and the LTC Ombudsman within 24 hours, as required by state law and the facility’s abuse policy. The resident had been readmitted in March 2026 with chronic respiratory failure post-tracheostomy, anoxic brain injury, and chronic heart failure. An MDS assessment from January 2026 documented that the resident had severely impaired cognitive skills for daily decision-making and was dependent on staff for all activities of daily living and transfers. On 3/22/2026 at 5:49 p.m., the resident’s primary nurse notified the charge nurse that redness was noted on the resident’s forehead. The resident’s wife and daughter were at the bedside and were informed of the redness. The NP was notified to assess the resident, vital signs were within normal limits, and the resident appeared comfortable with no signs or symptoms of pain or distress. Later that evening at 8:30 p.m., nursing documentation indicated that the resident’s wife was notified that the NP had assessed the forehead discoloration as a mild contusion, with a plan to monitor and administer pain medication as needed. The cause of the bruise was unknown, meeting the definition of an injury of unknown origin. On 3/24/2026 at 10:49 a.m., a social services note documented that the SW consulted with Risk Management and the Social Services Manager regarding the need to report the bruise of unknown cause on the resident’s forehead. The SW attempted to contact the LTC Ombudsman that day, leaving a voicemail, and completed and faxed the SOC341 form to APS on the same date, which was two days after the incident. The facility’s incident report, dated 3/26/2026, showed the incident occurred on 3/22/2026 at 1:10 p.m. and that CDPH was notified on 3/26/2026, four days after the incident. During interviews, the DRQ and SW confirmed these timelines and acknowledged that reporting occurred more than 24 hours after the incident, contrary to state law and the facility’s abuse policy, which requires notification of the state licensing agency within 24 hours and immediate phone notification to the LTC Ombudsman when indicators such as bruises or discoloration are present.
Delay in Stat EEG Due to Unverified Verbal Hold Order
Penalty
Summary
A deficiency occurred when a stat (immediate) EEG order for a resident was not completed as directed by the physician. The resident, who had been admitted with acute respiratory failure, had a stat EEG ordered by a covering physician. The EEG was a contracted service to be performed by an outside technician. Although the technician arrived to perform the test, the house neurologist verbally instructed the technician to hold off on conducting the EEG, despite not being the ordering provider and without a written order to do so. The EEG was subsequently delayed until the following day. Facility policy indicated that non-emergent verbal orders should not be accepted, and emergent verbal orders must be signed by the physician prior to leaving the nursing unit. In this case, the verbal instruction to hold the EEG was not documented as a formal order, and the technician did not consult the ordering provider or inform the assigned nurse about the hold. This sequence of actions and inactions resulted in the stat EEG not being performed as ordered.
Failure to Submit PBJ Staffing Data Report
Penalty
Summary
The facility failed to submit its Payroll-Based Journal Staffing Data Report (PBJ) for Quarter 4 of the Fiscal Year 2024 to the Center of Medicare/Medicaid Services (CMS). This deficiency was identified during a record review on December 12, 2024, which revealed that the staffing data for the specified period had not been submitted. During an interview on December 15, 2024, the Administrator (ADM) acknowledged that the Clinical Nurse Manager (CNM) was responsible for submitting the staffing data but had not done so in a timely manner. The ADM also admitted that the facility could not provide a validation report to prove data submission and lacked a policy regarding the PBJ Staffing Data Report. The CMS policy requires facilities to electronically submit direct care staffing information based on payroll and other auditable data, with a deadline for the reporting period of July 1st to September 30th, 2024, being November 14th, 2024.
Failure to Provide Scheduled Showers and Maintain Dignity During Feeding
Penalty
Summary
The facility failed to ensure that two out of six sampled residents received their scheduled showers twice a week. Resident 5, who was admitted with diagnoses including respiratory failure and anoxic encephalopathy, was observed to be poorly groomed, with dirt around the ears and arms. The responsible party for Resident 5 reported that the resident had not appeared clean since admission, despite staff claims that the resident was being bathed in bed. Similarly, Resident 8, who had diagnoses including respiratory distress and thyroid cancer, reported not having received a shower in weeks due to a broken shower hose, resulting in only bed baths being provided. This lack of proper bathing was confirmed by a review of the Sub-Acute Shower Log, which showed that neither resident received showers from late November to mid-December. Additionally, the facility failed to maintain dignity during meal assistance for Resident 8. During a dining observation, a CNA was seen standing while feeding Resident 8, rather than sitting at eye level as per protocol. The CNA acknowledged that standing while feeding could negatively impact the resident's self-esteem. The Clinical Nurse Manager confirmed that the protocol required staff to sit at eye level to avoid creating a power imbalance and to prevent residents from feeling intimidated. The facility's policies and procedures, including those for bathing and resident rights, were not adhered to, as evidenced by the lack of regular showers and the improper feeding posture. The facility's policy stated that residents should receive showers or tub baths at least twice weekly and be treated with dignity and respect. The failure to provide these basic care services and maintain dignity during feeding compromised the residents' rights to a dignified existence and proper hygiene.
Failure to Provide NOMNC Forms to Residents
Penalty
Summary
The facility failed to provide a Notice of Medicare Non-Coverage (NOMNC) appeal process form to three residents, which is required when their Medicare-covered services are ending. This deficiency was identified during an interview with the Director of Quality and Risk Management (DQRM), who acknowledged that the NOMNC forms were missing for the residents in question. The DQRM explained that the absence of these forms could prevent residents and their responsible parties from exercising their right to file an appeal, potentially leading to violations of residents' rights or unwanted discharges. The facility's policy and procedures, titled Medicare Beneficiary Discharge Dispute Process, require informing Medicare patients of their rights to dispute a discharge through the Important Message from Medicare (IMM) form. However, the failure to provide the NOMNC forms as part of this process was noted as a deficiency, impacting the residents' ability to make informed decisions regarding their Medicare coverage and potential liabilities.
Incomplete Employee Competencies
Penalty
Summary
The facility failed to ensure that annual competencies were signed and dated by three employees, which could potentially lead to incompetent and inadequate care for all residents. During a record review of five randomly selected employee files, it was found that a Licensed Vocational Nurse (LVN 1) had missing employee and preceptor signatures on their Restraints, Skills Fair, and Critical Clinical Alarm competencies. Additionally, another Licensed Vocational Nurse (LVN 2) had missing dates and no facilitator's name or signature on their General Hiring Orientation form and Care of the Post-Op Bariatric Surgery Patient In-service quiz. Furthermore, LVN 2's Nursing Intravenous (IV) Medication Mixing Skills Checklist was incomplete, with no date and the facilitator's name struck out. During a concurrent interview and record review with the Director of Quality and Risk Management (DQRM), it was stated that all staff competencies and skill fairs should be completed upon hire and annually with the facility's education department and unit. The DQRM acknowledged that all competencies should have been signed by the employees, facilitators, and dated once completed. The DQRM also noted that the risk of incomplete employee competencies could result in inadequate care and uncertainty about whether the competency was truly authenticated with what was taught and learned. The facility's policy and procedures indicated that the Sub Acute Unit should have sufficient nursing to provide services to maintain the highest practical well-being of each patient, as determined by patient assessments and individual care plans.
Deficiencies in Food Storage and Temperature Monitoring
Penalty
Summary
The facility failed to ensure proper temperature monitoring and labeling of food items in the kitchen, which could potentially lead to food spoilage and expiration. During an observation and interview with the Sous Chef, it was noted that the walk-in refrigerator, which stored vegetables and fruits, lacked a thermometer. The Sous Chef acknowledged that a thermometer was necessary to monitor the temperature and prevent food spoilage, and speculated that it might have been removed by someone. Additionally, during an inspection of the reach-in freezer, it was observed that there were opened and unlabeled Ziplock bags containing Uncrustables peanut butter and jelly sandwiches, as well as unlabeled and undated pureed rice and breakfast kosher meals. The Sous Chef admitted that the absence of labels and dates on frozen foods could result in uncertainty about their expiration status. The facility's policy and procedures require that unused portions and open packages be covered, labeled, and dated, and that each refrigerator storage unit have an independent thermometer.
Failure to Maintain Resident Dignity by Not Covering Catheter
Penalty
Summary
The facility failed to ensure that a resident's indwelling catheter was covered with a privacy bag, which is a practice intended to protect the resident's modesty and dignity. This deficiency was observed during an inspection involving Resident 8, who was admitted to the facility with diagnoses including respiratory distress, thyroid cancer, and neurogenic bladder. The resident's Minimum Data Set (MDS) indicated that they were cognitively able to understand and required assistance with range of motion, toileting hygiene, showering, and dressing. Despite these needs, the facility did not adhere to its policy of covering the indwelling catheter, potentially leading to feelings of humiliation for the resident. During an interview, a registered nurse (RN) confirmed that the indwelling catheter should have been covered with a privacy bag to maintain the resident's dignity, likening the cover to a piece of clothing that would improve the resident's appearance. The facility's policies on resident rights and guidelines emphasize the importance of treating residents with kindness, dignity, and respect, and providing necessary care to maintain their highest practicable wellbeing. However, the failure to cover the catheter was a deviation from these policies, as it did not align with the facility's commitment to ensuring residents' comfort and dignity.
Failure to Post Survey Results and Complaint Reports
Penalty
Summary
The facility failed to ensure that survey results and complaint investigation reports from the previous three years were posted in a location readily accessible to residents and the public. During an observation and interview, the Director of Quality and Risk Management (DQRM) admitted that these documents were kept in a separate binder in her office and were not available at the nursing station hallway as required. This practice was contrary to the facility's policy and the California Department of Public Health (CDPH) regulations, which mandate that such information be accessible to residents, visitors, and family members. The Clinical Nurse Manager (CNM) confirmed that the survey results and complaint investigation reports should be easily accessible to ensure transparency about the facility's compliance and quality of care. The facility's Resident Orientation Packet and the California Standard Admission Agreement for Skilled Nursing Facilities both emphasize the residents' right to examine survey results and plans of correction. However, the facility did not adhere to these guidelines, resulting in a deficiency noted by the surveyors.
Failure to Resubmit PASARR Level I Screening for Resident with Psychiatric Disorders
Penalty
Summary
The facility failed to complete and re-submit the Preadmission Screening and Resident Review (PASARR) Level I screening for a resident with diagnoses of anxiety disorder, depression, and psychosis. This oversight was identified during a review of the resident's Minimum Data Set (MDS), which indicated active psychiatric disorders. The initial PASARR Level I screening, completed by the facility, incorrectly stated that the resident had no serious mental illness diagnosis and was not receiving psychotropic medications, leading to the case being closed without a Level II mental health evaluation. Interviews with facility staff revealed that the Clinical Nurse Manager relied on the transferring facility to complete the Level I screening before transfer, and the Registered Nurse responsible for PASARR acknowledged the need to resubmit a new Level I screening based on the updated MDS assessment. The PASRR reference manual requires facilities to notify the state authority of significant changes in a resident's mental condition, which was not done in this case, potentially impacting the resident's access to appropriate psychiatric care.
Failure to Date Ventilator Tubing
Penalty
Summary
The facility failed to ensure that the ventilator tubing for one resident was labeled and dated, which is a critical step in preventing respiratory infections. During an observation, it was noted that the ventilator tubing connected to the resident's tracheostomy was not dated. This oversight was confirmed during an interview with a respiratory therapist who admitted to changing the tubing but neglecting to date it. The therapist acknowledged the importance of dating the tubing to monitor how long it has been in use, which is essential to prevent bacterial growth and subsequent respiratory infections. Further interviews with a registered nurse corroborated the requirement for the respiratory tubing to be dated, as it is changed daily or as scheduled by the respiratory therapist. The facility's policy and procedure on mechanical ventilation, dated December 2023, highlighted the risk of infection as a common hazard associated with mechanical ventilation. However, the policy did not explicitly state the need to date and label the ventilator tubing, which contributed to the deficiency observed.
Improper Bed Elevation for Resident on Tube Feeding
Penalty
Summary
The facility failed to ensure that a resident receiving tube feeding was provided care in accordance with professional standards of practice. Specifically, the head of the bed for a resident on gastrostomy tube feeding was not elevated to the required 30 to 45 degrees, as observed during a survey. Instead, the head of the bed was elevated at approximately 10 degrees while the resident was receiving continuous tube feeding. This practice was contrary to the resident's care plan, which specified that the head of the bed should be elevated at 45 degrees to prevent aspiration. The resident involved had a history of acute respiratory failure and was receiving tube feeding due to dysphagia and respiratory failure. The facility's policy on gastric tube feeding, dated September 2022, indicated that patients fed by gastric tubes should receive appropriate treatment to prevent aspiration and other complications. During an interview, a registered nurse confirmed that the head of the bed should be elevated at least 30 to 45 degrees for residents receiving continuous tube feeding to prevent aspiration, acknowledging that the resident was at risk due to the improper bed elevation.
Failure to Label and Date IV Tubing
Penalty
Summary
The facility failed to ensure that intravenous (IV) tubing was labeled and dated for a resident receiving IV antibiotic treatment. This deficiency was observed in the case of a resident who was admitted with diagnoses including tracheostomy and anemia and was in a comatose state. The resident had an active order for Zosyn, an antibiotic, to be administered intravenously every eight hours for the treatment of sepsis. During an observation, it was noted that the IV tubing connected to the medication was unlabeled and undated, and the registered nurse present was unable to determine when the tubing was last changed. The facility's policy and procedure for intravenous therapy indicated that IV tubing should be changed every three days and labeled with the date of change. However, the registered nurse stated that the tubing should be changed twice a week, on Thursdays and Sundays, which was inconsistent with the facility's policy. The clinical nurse manager confirmed that it was the responsibility of the licensed nursing staff to label the IV tubing with the date it was changed, as part of the standard practice to track when it needs to be replaced. The failure to label and date the IV tubing had the potential to place the resident at risk for infection and IV therapy complications.
Expired Medication Found in Storage
Penalty
Summary
The facility failed to ensure that expired medication was not kept in the medication storage refrigerator, which could potentially lead to administering expired medication. During an observation of the facility's medication storage room refrigerator, a medication prescribed for a resident with a diagnosis of respiratory failure was found to be expired. The medication, Vancomycin, was labeled with an expiration date and time that had already passed. During an interview, a registered nurse acknowledged that the expired medication should have been returned to the pharmacy and recognized the risk of storing expired medication, which could result in a medication error. The clinical nurse manager also confirmed that the protocol for expired medication was to contact the pharmacy for replacement. The facility's policy indicated that expired medications should be removed and stored separately from those available for administration.
Failure to Complete Ordered Laboratory Test for Resident
Penalty
Summary
The facility failed to ensure that a laboratory test was completed for one of the sampled residents, identified as Resident 8. The resident was admitted with diagnoses including respiratory distress, thyroid cancer, and neurogenic bladder, and was dependent on staff for various activities of daily living. A physician order dated 11/4/2024 required a thyroid stimulating hormone (TSH) level test to be conducted, but this test was not completed for the month of November. This oversight was confirmed during an interview with a registered nurse, who acknowledged that the absence of the TSH test could place the resident at risk for not receiving the correct dose of thyroid medication. Further interviews with the facility's pharmacist corroborated the failure to conduct the TSH test as ordered. The pharmacist emphasized the importance of monitoring TSH levels to ensure the resident's thyroid levels remain within a normal range, as deviations could exacerbate the resident's thyroid condition. The facility's policy indicated that lab tests requested by physicians should be provided to residents, but this protocol was not followed in this instance, leading to the deficiency.
Failure to Provide Dental Services to Resident
Penalty
Summary
The facility failed to provide dental services to one of the six sampled residents, identified as Resident 13. Resident 13 was admitted with a diagnosis of dysphagia and had additional medical conditions including peripheral vascular disease, chronic renal failure, and congestive heart failure. Despite being independent in oral hygiene, Resident 13 expressed discontent about not receiving dental services and desired to have his teeth cleaned. Interviews with the resident and staff, including a social service worker and a registered nurse, confirmed that no dental services were provided, and there was no dental contract in place for the unit. The facility's policy and procedure on dental services, dated July 2022, required an oral assessment upon admission and arrangements for necessary dental services. However, the policy was not followed, as evidenced by the lack of dental care for Resident 13. The social service worker and registered nurse acknowledged the importance of dental care to prevent oral health issues, yet no actions were taken to ensure Resident 13 received the necessary services. The deficiency was identified through interviews and record reviews, highlighting a failure to adhere to the facility's established procedures for dental care.
Failure to Hold Quarterly QAPI Meetings
Penalty
Summary
The facility failed to ensure that Quality Assurance Performance Improvement (QAPI) meetings were held quarterly as required. During an interview and record review with the Director of Quality and Risk Management (DQRM), it was revealed that the last QAPI meeting was conducted in December 2024, with the previous meeting held in May 2024. The DQRM acknowledged that a meeting should have been held in August 2024, but it did not occur. This lapse in holding quarterly meetings was identified as having the potential to result in systemic issues within the facility. The facility's policy, titled Quality Council/Leadership Committee, dated July 2022, mandates that the committee meet at least quarterly. Additionally, a subcommittee, including the Program Director, Medical Director, and Director of Nursing, along with any appropriate staff, is required to meet monthly. The failure to adhere to this schedule was confirmed by the DQRM, who noted the risk of systemic issues arising from not meeting the quarterly requirement.
Failure to Date Ventilator Tubing
Penalty
Summary
The facility failed to ensure that the ventilator tubing for one of the sampled residents was labeled and dated. During an observation, it was noted that the ventilator tubing connected to the resident's tracheostomy was not dated. This oversight was confirmed during an interview with a respiratory therapist who admitted to changing the tubing but not labeling it with the date. The therapist acknowledged the importance of dating the tubing to monitor how long it has been in use, which is crucial for preventing bacterial growth and respiratory infections. Further interviews with a registered nurse corroborated the requirement for the tubing to be dated, as it is typically changed daily or as scheduled by the respiratory therapist. The facility's policy on mechanical ventilation, while addressing infection control practices, did not specifically mandate the dating and labeling of ventilator tubing. This omission in the policy and the failure to date the tubing placed the resident at risk for respiratory infections.
Deficiencies in Documentation and Care Standards
Penalty
Summary
The facility failed to ensure nursing professional standards were met for two residents. For the first resident, there was no documentation of an assessment in the electronic health record (EHR) when the resident's heart rate was elevated at 106 beats per minute, which is above the normal range. This elevated heart rate was not addressed for over three hours, from 8:19 p.m. to 11:38 p.m. The resident, who was bed-bound with a tracheostomy and a G-tube, had a care plan that required monitoring for physical or nonverbal indicators of discomfort or distress. Interviews with registered nurses revealed that the facility's procedure for abnormal vital signs was to reassess and document the vital signs, administer any necessary PRN orders, and notify the attending physician if needed. However, the documentation was missing during the specified time frame. For the second resident, the facility failed to document the provision of range of motion (ROM) services on two specific dates. The resident, who was in a persistent vegetative state with chronic respiratory failure and flaccid quadriplegia, had a care plan that included maintaining muscle strength and preventing contractures through ROM exercises. The EHR indicated that passive ROM was scheduled to be provided weekly on specific days, but the records for two of these days were blank, indicating a lack of documentation for the services rendered. An interview with the Assistant Chief Nursing Officer confirmed the absence of documentation for the ROM services on the specified dates. The facility's policy and procedure on documentation, revised in September 2022, stated that continuous reassessment and documentation of patient care activities are expected. However, the lack of documentation for both residents' care activities indicates a failure to adhere to these standards, resulting in deficiencies in the care provided to the residents.
Neglect and Investigation Failures in LTC Facility
Penalty
Summary
The facility failed to prevent potential neglect and thoroughly investigate alleged violations involving three residents. In the first case, a Licensed Vocational Nurse (LVN) tied a sheet to a resident's bed frame and broken bedrail, which resulted in the resident falling out of bed. The resident, who was nonverbal and quadriplegic, required assistance with all activities of daily living. Despite the incident, the LVN continued to be assigned to the resident's care without any corrective action being taken. In the second case, the same LVN refused to assess another resident's wound vacuum when it was alarming, instead shutting the door and turning off the light, leaving the resident in the dark without assistance. The resident, who had a chronic lower extremity ulcer and a recent hip debridement, expressed feeling unsafe in the care of the LVN. The facility's former manager confirmed that the LVN did not follow standard nursing care procedures to assess the wound or seek assistance from more knowledgeable staff. In the third case, the LVN failed to report a resident's KUB test results to the physician, which indicated a possible ileus or obstruction. The resident had a history of chronic encephalopathy and dysphagia. The failure to report the results delayed the physician's awareness and potential treatment. The facility was unable to provide investigation reports or corrective actions for these incidents, despite having a policy in place for mandatory reporting and investigation of abuse and neglect.
Failure to Address Broken Bedrail Leads to Resident Fall
Penalty
Summary
The facility failed to adhere to its policies and procedures regarding medical equipment failure and supervision, resulting in a deficiency. A resident with a complex medical history, including chronic respiratory failure, quadriplegia, and severe cognitive impairment, was involved in an incident where a broken bedrail was inadequately secured with a sheet by a night shift nurse. This makeshift solution was not reported to the house supervisor, and a replacement bed was not ordered, leaving the resident at risk. The resident, who required assistance with all activities of daily living and was nonverbal, fell from the bed due to the broken bedrail. The incident was unwitnessed, and the resident was found on the floor by a respiratory therapist. The day shift nurse, upon discovering the situation, requested a new bed, but the fall had already occurred. The facility's Director of Risk Management confirmed that the root cause analysis identified the failure to report the broken bedrail and the inadequate temporary fix as the primary issues. The facility's policies on medical equipment failure and fall prevention were not followed. The policy required immediate removal and securing of malfunctioning equipment and appropriate clinical intervention, which did not occur. Additionally, the fall prevention program outlined strategies to minimize fall risks, such as ensuring bedrails are functional and beds are in the lowest position, which were not adequately implemented in this case.
Expired BLS Certification for LVN in Subacute Unit
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN) assigned to the subacute unit had a current Basic Life Support (BLS) certification, as required by the facility's job description. This deficiency was identified during a review of the care provided to a resident with a history of chronic respiratory failure, recent tracheostomy, cardiac arrest, and anoxic encephalopathy. The resident's Practitioner Orders for Life Sustaining Treatment (POLST) indicated a preference for resuscitation/CPR in life-threatening situations. Despite this, LVN 1, who was responsible for the resident's care on multiple occasions, had an expired BLS certification for over nine months. The issue was discovered during an interview and record review with the Operational Manager of Human Resources, who acknowledged that a report had been sent to the unit manager regarding the expired certification. However, the Manager of the Subacute unit admitted that the expiration was overlooked due to a flaw in the process where employees upload their certificates, but Human Resources does not always see them. This oversight had the potential to delay emergency care for the resident and other residents in the subacute unit who required full treatment in life-threatening situations.
Failure to Maintain Safe Room Temperatures in Sub-Acute Unit
Penalty
Summary
The facility failed to maintain acceptable room temperatures ranging from 71 to 81 degrees Fahrenheit for 17 residents in the Sub-Acute Unit. This deficiency was observed during a survey conducted on September 9, 2024, where temperatures in the residents' rooms and common areas were recorded as being above the acceptable range, with some rooms reaching as high as 89.7 degrees Fahrenheit. The issue was first noticed on September 8, 2024, by an engineer who reported the temperatures were out of range and requested an increase in the chiller's capacity. Interviews with staff and residents revealed that the facility's HVAC system was running at full capacity, yet it was insufficient to maintain the required temperature range. Spot coolers were brought in to assist with cooling, but residents reported that these measures were ineffective in bringing the temperature down. Residents expressed discomfort due to the heat, and staff members, including a Licensed Vocational Nurse, also noted the high temperatures and took personal measures to cope with the heat, such as using portable fans. The facility's policies and procedures indicated that the sub-acute unit should provide a safe and comfortable environment, with specific temperature ranges outlined. However, the facility was unable to adhere to these guidelines, resulting in an Immediate Jeopardy situation being called by the Department. The facility's failure to maintain a safe and comfortable environment for its residents was a significant deficiency, as it placed residents at risk for heat-related health issues.
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What surveyors actually found near you
We read the 4,763 citations issued within 25 miles in the last 12 months — including the 30 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 Culver City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Overland Terrace Healthcare & Wellness Centre, Lp | 0.6 mi | — | 2 | 0 |
| Cheviot Hills Post Acute | 0.6 mi | — | 24 | 0 |
| Marina Pointe Healthcare & Subacute | 1.7 mi | — | 7 | 0 |
| Meadowbrook Behavioral Health Center | 1.7 mi | — | 14 | 0 |
| Vista Del Sol Care Center | 1.9 mi | — | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.