Mid-Wilshire Health Care Cntr

Inspectors wroteBased on interview and record review, the facility failed to implement a comprehensive care plan for one of three sample residents (Resident 1). This deficient practice had the potential to result in delay of nursing care and medical interventions causing Resident 1's condition to worsen and possible hospitalization. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was readmitted on [DATE] (original admission date 10/21/2025). With diagnoses including but not limited to dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), overactive bladder (uncontrolled urge to urinate). [...]

Inspectors wroteBased on interview and record review, the facility failed to administer/hold medications per physicians' orders for one of three sampled residents, (Resident 1). This deficient practice had the potential to worsen Resident 1's condition, placing them at risk for electrolyte (essential minerals) imbalance, dehydration (a condition where the body loses more fluids that it takes in), hospitalization and death. During a review of Resident 1's admission Record, the admission Record indicated Resident 1 was readmitted on [DATE] (original admission date 10/21/2025). With diagnoses including but not limited to dementia (a progressive state of decline in mental abilities), dysphagia (difficulty swallowing), overactive bladder (uncontrolled urge to urinate). [...]

Inspectors wroteBased on interview and record review, the facility failed to follow up on assisting the residents with executing an advance directive (AD - a legal document indicating resident preference on end-of-life treatment decisions) for three of four sampled residents (Resident 2, 5, and 19). This failure had the potential to result in the residents' wishes regarding treatment and care needs not being met.

Inspectors wroteBased on observation interview and record review, the facility failed to provide treatment in accordance with professional standards of practice and established facility protocol for one of five sampled residents (Resident 77) for: a. The use of triple antibiotic ointment (topical antibiotic cream or ointment used to treat skin infections) without a physician order or monitoring every shift for seventy-two-hours for Resident 77. This failure had the potential to result in delayed treatment and compromised resident safety. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the nursing staffing information was posted and updated daily. This failure resulted in the total number of staff and the actual hours worked by the staff were not readily accessible to residents and visitors.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure safe and sanitary food storage practices in the kitchen when:1. A box of bananas were sitting next to an open container labeled Sanitizer disinfectant.2. A plastic container of barley in the dry storage area had no date label.3. A large clear plastic bag filled with chopped cabbage mixed with red pepper flakes with no label or date. These failures had the potential to result in cross contamination (transfer of harmful bacteria from one place to another) and an increased risk of foodborne illness (any illness resulting from eating contaminated or spoiled food) to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Perform hand hygiene for seven of seven sampled residents (Resident 5, 8, 9,19, 22, 59, and 70).2. Wear personal protective equipment (PPE - clothing and equipment that is worn or used to provide protection against hazardous substances and/or environments) in enhanced barrier precautions (EBP - infection control strategy requiring staff to use gowns and gloves during high-contact care for residents) rooms for four of four sampled residents (Resident 5, 9, 59, and 70). 3. Prevent cross-contamination during medication administration.4. Implement an effective Infection Prevention and Control Program (IPCP - a program designed to prevent healthcare-associated infections and antimicrobial resistance through education, policies, and surveillance).5. Implement the facility's water plan. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 31) was monitored for antibiotic use. This failure had the potential to result in severe organ damage and antibiotic resistance to the resident.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement policies and procedures for influenza (Flu - an infection of the nose, throat and lungs) and pneumococcal (PNA - an infection that affects one or both lungs) vaccines (medications used to prevent diseases, usually given by injection or by mouth) for five of five sampled residents (Resident 2, 14, 31, 36, and 58). This failure had to the potential to affect the residents or resident representatives' (RP) right to make an informed decision regarding the Flu and PNA vaccines.

Inspectors wroteBased on interview and record review, the facility failed provide education regarding risk and potential side effects of COVID 19 vaccine for five of five sampled residents (Resident 2, 14, 31, 36, and 58) and provide a declination form for all staff members declining COVID-19 vaccine boosters. These failures had the potential to affect the residents, residents' representatives, and staff's ability to make informed decisions regarding the COVID-19 vaccine.

Inspectors wroteBased on observation, interview and record review the facility failed to implement a Foley catheter dignity care plan for Resident 5 and ensure the Certified Nursing Assistant (CNA) 2 was seated at eye level during feeding one out of six sampled residents (Resident 16). This deficient practice has a potential for Resident's 5 and Resident's 16 dignity was not maintained.

Inspectors wroteBased on interview and record review, the facility failed to protect Resident 47's right to be free from physical abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish) by Resident 78 when he hit Resident 47 on the face. This failure had the potential to result in Resident 47 being exposed to the risk of physical injury.

Inspectors wroteBased on observation, interview and record review the facility failed to implement it's written abuse polies and procedures (P&P), titled, Abuse and Neglect Prohibition Policy designed to prevent, respond to and report abuse- related incidents after physical abuse (includes, but is not limited to, hitting, slapping, punching, biting, and kicking) when staff did not immediately separate roommates Residents 47 and 78 who had physical altercation on 11/7/2026. This failure demonstrates the facility did not effectively implement its abuse prevention and response policy and procedures and did not ensure resident safety as required.

Inspectors wroteBased on interview and record review, the facility failed to report allegations of abuse to the California Department of Public Health (CDPH) within the regulated time frame of two hours. a. by failing to report an allegation of physical abuse which occurred between Resident 47 and Resident 78 who are roommates on 11/07/2025. This deficient practice resulted in CDPH's inability to investigate the allegation of abuse timely and had the potential for other allegations of abuse to go unreported.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement baseline care plan for physician orders for pain management and physical therapy (a healthcare specialty that helps individuals restore, maintain, and improve physical function, movement, and strength while reducing pain) for one of three sample residents (Resident 77). This failure had the potential to result in inadequate communication among staff regarding resident's 77 pain management needs and therapy interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise resident care plans for two of four sampled residents (Resident 31 and 62). This failure had the potential to result in Resident 31 and 62 receiving inappropriate care due to conflicting information between care plan and medication orders.

Inspectors wroteBased on observation, interview, record review, the facility failed to follow physician's order for pain management for one of three sampled resident (Resident 77). This failure had the potential to place Resident 77 at risk for adverse medication effects, including oversedation, respiratory depression and decline in overall health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe care of an arteriovenous (AV) fistula (abnormal connection of an artery and vein) for one of three sampled residents (Resident 28) receiving dialysis treatment (a procedure that cleanses the blood of waste and excess fluids when the kidneys have failed) by not using the correct arm to check blood pressure (B/P). This failure has the potential to result in injury for Resident 28 that can potentially damage the AV fistula.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure bed dimensions were inspected for appropriate size and weight for one of five sampled residents (Resident 47). This deficient practice has the potential to result in compromised resident safety associated with possible entrapment with bed rail use.

Inspectors wroteBased on observation, interview and record the facility failed to:Accurately account for Resident 62's home medications upon admission. Ensure the pharmaceutical waste container contained adequate liquid or chemical solution to render discarded tablets and capsules inaccessible and ensure the container's lid was secured according to manufacturer instructions. These deficient practices had potential to result in misappropriation or diversion of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to act upon a medication irregularity identified by the Pharmacy Consultant (PharmC/PC 2) for one of four sampled residents (Resident 62). This failure had the potential for Resident 62 receiving a repeated subtherapeutic dose (below the dosage amount needed for effective treatment) of eliquis (medication that thins blood, decreasing likelihood of blood clots in individuals who have higher risk factors for clots ) and had the potential to cause harm by increasing risk of blood clots.

Inspectors wroteBased on interview and record review, the facility failed to monitor and document the signs and symptoms of depression for one out of one sampled resident (Resident 51) on Remeron (an anti-depressant medication). This failure had the potential to result in physical and psychosocial harm to Resident 51.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a garbage dumpster lid was properly covered. This failure had the potential to attract pests and spread infection to facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of fourteen sampled residents (Resident 53) had call light within reach. This deficient practice had the potential to put Resident 53's at risk during emergency situations.

Inspectors wroteBased on interview and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 2 and Housekeeper (HK) 1 received abuse, neglect and exploitation training. This failure had the potential to place residents at risk for abuse, neglect, or exploitation due to lack identification and training.

Inspectors wroteBased on interview and record review the facility failed to include the resident's next of kin (NOK) during the care plan conference for one of four sampled residents (Resident 2). For Resident 2, the facility failed to include Resident 2's NOK during the care plan meeting on 8/1/25. This deficient practice resulted in Resident 2 and Resident 2's 's NOK's not given their right to participate in the care planning for Resident 2.

Inspectors wroteBased on interview and record review the facility failed to notify the residents and/or their responsible party (RP) of room change for one of four sampled residents (Resident 1). For Resident 1, the facility failed to:1. Notify Resident 1's RP before moving Resident 1 to another room on 2/7/25, 2/10/25, 3/4/25 and 3/26/25.2. Provide a written notice including the reason for room change before moving Resident 1 to another room. 3. Document in Resident 1's medical record the room change and the notification of Resident 1's RP. These deficient practices resulted in Resident 1 and Resident 1's RP not given their right to know before the room changes occur. During a review of the admission Record indicated the facility admitted Resident 1 on 9/20/24 and readmitted on [DATE] with diagnoses including dementia (a progressive state of decline in mental abilities) and anxiety disorder. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of eight sampled residents' (Resident 1) food consistency and texture brought in by Resident 1's son on 9/18/23 was allowed and in compliance with her mech soft, finely chopped diet being the food was fed to the resident, and that Resident 1 was assisted, supervised, and monitored for choking when eating. The facility failed to ensure: 1. There was a system in place to check/screen food brought into the facility from outside for consistency and texture to match that which the physician had ordered.2. The physician's order was followed to monitor choking signs and symptoms while feeding the resident.3. Certified Nursing Assistant (CNA 1) did not feed Resident 1 while resident is drowsy on 9/19/2023. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow its' abuse policy and procedures for two of nine sampled residents (Residents 2 and 3). This failure resulted in an employee-to-resident allegation of abuse incident not being reported to state licensing/certification office, police, and ombudsman, and the incident not investigated in a timely manner.

Inspectors wroteBased on interview and record review, the facility failed to ensure five employees had annual performance evaluations. This failure had the potential to affect the quality of care for the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the standardized recipes and portion sizes for lunch menu was followed on 3/10/2025 when: -Facility failed to ensure staff followed food production recipes for the pureed diet (food that is blended to a pudding consistency, no chewing required) during tray line observation. Twenty-three residents on puree diet did not receive the pureed soybean paste stew and fern salad, they received pureed meat, pureed rice and beans. -Twenty-three residents on the pureed diet received a pureed diet texture that was thin and soupy instead of pureed food that was homogenous, cohesive and had a pudding like consistency. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage and preparation practices in the kitchen when: -Meat to be used for lunch preparation was thawing on the kitchen counter. -Ice machine was not maintained in a sanitary manner, the inside compartment of ice machine was dirty and the ice scoop was last cleaned 3/5/2025. -Two gallons of milk and nine individual cups of beverages stored in the reach in refrigerator with no open or use by date. One bag of sliced cheese not in original packaging stored in plastic bag and 14 Individual cups of kimchi stored with no label or date in the walk-in refrigerator. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a call light was within reach for one sampled resident (Resident 25). This deficient practice had the potential to result in a delay in meeting the resident's needs for hydration, toileting, and activities of daily living.

Inspectors wroteBased on interview and record review, the facility failed ensure one of 16 sampled residents (Resident 63) received treatment and care in accordance with professional standards of practice. Resident 63, who had a history of diabetic ketoacidosis (DKA - a serious, potentially life-threatening complication of diabetes that occurs when the body does not have enough insulin [a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication], causing it to burn fat for energy instead of sugar, leading to a buildup of harmful acids called ketones in the blood) had abnormally high blood sugar readings, and did not have defined parameters for blood sugar readings to notify the doctor. This deficient practice caused an increased risk in Resident 63 having another episode of DKA.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one of two sampled residents (Resident 57) received treatment and services to prevent complications of an enteral feeding tube (g tube, delivery of liquid nutrients through a tube directly into the gastrointestinal tract). Resident 57's enteral feeding tube bag was not changed every 24 hours per the facility's Enteral Feeding Via Pump Administration policy. This deficient practice had the potential to place Resident 57 at risk for infection and gastrointestinal (GI) complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure one sampled resident (Resident 23) with prescribed Ativan (anxiolytic, psychotropic medication) as needed (PRN) order had a documented clinical rationale to extend the medication beyond 14 days. This deficient practice caused an increased risk in Resident 23 experiencing adverse consequences.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one sampled resident (Resident 1), who had diagnosis of dementia (loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that the loss interferes with a person's daily life and activities), had history of fall, and was assessed as high risk for falls, received the care and services necessary to prevent accidents and falls by failing to: -Develop a comprehensive care plan for Resident 1's fall prevention, per the facility's policy and procedure (P&P) titled, Person Centered Plan of Care. -Frequently monitor Resident 1 and anticipate resident's needs to ensure the resident's safety to prevent fall accidents. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), who had dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), a history of multiple falls, and was a high risk for falls, received the care and services necessary to prevent accidents and falls by failing to: 1. Implement facility's policy and procedure (P&P) titled Fall Prevention Program, to identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling. 2. Evaluate interventions for effectiveness and implement new interventions to prevent repeated fall incidents after Resident 1 fell on [DATE], 3/20/2024, and 4/17/2024. 3. Monitor the resident for the behavior of trying to get out of bed without assistance as per physician's order dated 11/10/2023. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide protection from sexual (non-consensual sexual contact of any type with a resident, including sexual harassment, sexual coercion, or sexual assault) by facility staff, for one of three sampled residents (Resident 1). Resident 1 alleged sexual abuse by Certified Nurse Assistant (CNA) 1, when CNA 1 touched the resident ' s private parts and held Resident 1's hand on his (the CNA's) private part. This deficient practice resulted in Resident 1 having psychological distress (a state of emotional suffering), was crying and reported feeling afraid, ashamed, anxious and guilty.

Inspectors wroteBased on interview and record review, the facility failed to ensure competent staff and provide abuse training, per facility policy, to Certified Nursing Assistant (CNA) 1, who was accused of sexually abusing Resident 1. CNA 1 did not receive Abuse Training while employed at the facility for several months. This deficient practice caused an increased risk of sexual abuse to Resident 1 and other facility residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a call light (a device used by a patient to signal his or her need for assistance from a professional staff) was within reach for two of 18 sampled residents (Resident 12 and Resident 48) investigated for the call lights care area. This deficient practice had the potential to result in the residents not being able to call for facility staff assistance and increase their risk for injury or fall.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly set the low air loss mattress (LALM) settings for two of two sampled residents (Resident 12 and Resident 19). This deficient practice had the potential to cause harm to Resident 12 and Resident 19 by not providing services to promote the prevention pressure ulcer development.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care services for two of eighteen sampled resident (Resident 27 and Resident 61) by failing to: a. Change Resident 27's nasal cannula (device used to deliver supplemental oxygen placed directly on a resident's nostrils) and humidification bottle every 7 days. b. Ensure Resident 61 had a date on the nasal cannula to ensure prompt weekly changing of the nasal cannula. These deficient practices had the potential to cause complications associated with oxygen therapy, including infection or respiratory distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure a current copy of the resident's advance directive and/or advance directive acknowledgement form (a written statement of a person's wishes regarding medical treatment, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) was complete and in the resident's medical chart for one of one sampled resident (Resident 1) medical records. This deficient practice had the potential for the facility to not honor the resident's medical decisions regarding end-of-life treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to report unusual occurrences to the state survey agency (SSA) within 2 hours for two of two sampled residents (Resident 6 and Resident 58). The facility failed to report: -Resident 58 sustained a right 10th rib fracture (broken bone) after a fall on 9/21/2023. -Resident 6 sustained a temporal subdural hematoma and right frontal hematoma on 12/21/2023. These deficient practices resulted in a delay of State Survey Agency from investigating the circumstances of the injuries and potentially placed Resident 6 and 58 at further risk for injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident was provided a communication device or board with the language that the resident was able to understand for one of one sampled resident (Resident 33). This deficient practice prevented the resident from communicating with the staff and had a potential to delay receiving care/treatment the resident needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the appropriate care and services to prevent urinary tract infections for one of one sampled resident (Resident 12) by failing to ensure that urinary bag tubing was not kinked. This deficient practice had the potential to result in catheter-associated urinary tract infection for Resident 12.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident was properly arranged and prepared for safety discharge to home for one of one sampled resident (Resident 1). This deficient practice resulted in Resident 1 ' s delayed discharge due to the arrangement of the delivery of their durable medical equipment (DME).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections (UTI-an infection in any part of your urinary system your kidneys, ureters, bladder and urethra) for one of one sampled resident (Resident 2) by failing to assess Resident 2 who had an indwelling urinary catheter (foley catheter - a hollow tube left implanted in a body canal or organ, especially the bladder, to promote drainage) and document mucus and sediments (visible particles in the urine that can be made up of a variety of substances, including sloughing of tissue [debris]). The most common cause of sediment in the urine is a UTI. As a result, Resident 2 was placed at risk for a delay in necessary care and services to treat a possible UTI.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary respiratory care services for one out of one sampled resident (Resident 3) by failing to ensure Resident 3 ' s nasal cannula (NC -a connector attached to oxygen) tubing was changed per facility ' s policy. This deficient practice had the potential for the residents to develop respiratory infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices as evidenced by: -Certified Nursing Assistant 2 ( CNA 2) was observed not wearing the appropriate N95 respirator mask (a respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles) that was fit tested (a test protocol conducted to verify that a respirator is both comfortable and provides the wearer with the expected protection) for her. -CNA 1, CNA 3, and the Minimum Data Set (MDS- a standardized assessment and care screening tool) Coordinator were not N95 respirator mask fit tested. These deficient practices had the potential to expose residents, staff, and the community to Coronavirus (COVID-19, a virus that spreads from person to person causing respiratory illness).