Southern California Hosp at Culver City D/P SNF

Inspectors wroteBased on interview and record review, the facility failed to report an injury of unknown origin (the source of the injury was not witnessed by any person and the source of the injury could not be explained by the resident and the injury is suspicious because of its extent, location, the number of injuries at a time, or the number of injuries over time) to CDPH, Adult Protective Services (APS, the county agency responsible for investigating reports of abuse, neglect, or exploitation of elders and dependent adults), and the Ombudsman within 24 hours for one of three sampled residents (Resident 1) in accordance with state law and the facility's policy and procedure (P&P) titled Abuse, Elder & Dependent Adult. [...]

Inspectors wroteBased on record review, the facility failed to: 1. Provide a Payroll Based Journal information for quarter 4. This failure had resulted in the facility not providing the required information regarding the quantity of staff assigned for safe and comprehensive care for all residents, as required by federal regulations. During a review of the Fiscal Year Quarter 4 2025 PBJ Staffing Data Report for the facility, dated 2/20/2026, the Fiscal Year Quarter 4 2025 PBJ Staffing Data Report indicated the facility failed to submit data for the quarter. During an interview on 02/27/2026 at 10:34 AM, with the NM, the NM stated the information was submitted, just as it was for the previous quarters. The NM explained that the same happened for the last recertification survey, the PBJ Q4 data was not received, and there was no confirmation email after uploading the Quarter 4 staffing information. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired food items were discarded and open food packets were labeled. These deficient practices had the potential to result in pathogen (germ) exposure to residents and placed residents at risk for developing foodborne illness (food poisoning) with symptoms including upset stomach, stomach cramps, nausea, vomiting, diarrhea, and fever potentially leading to other serious medical complications and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Perform hand hygiene for one of eight residents, Resident 11, after touching Resident 11's suction canister (a medical container used to collect and store mucus, blood, or saliva) .This failure had the potential to spread infectious organisms to other areas inside Resident 11's and outside Resident 11's room.

Inspectors wroteBased on interview and record review, the facility failed to:1. Provide a signed document offering, or declining, the COVID, influenza, and pneumococcal immunizations to one of eight residents, Resident 4 and failed to provide a signed document offering, or declining, the influenza vaccine to one of eight residents, Resident 11. This failure had the potential to neglect Residents 4 and 11 rights to refuse or receive immunizations from seasonal respiratory infections. During a review of Resident 4's admission Note, dated 12/11/2025, the admission Note indicated Resident 4 has chronic respiratory failure (a long-term, ongoing condition where the lungs cannot properly exchange oxygen and carbon dioxide). [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure dignity was maintained for one of four sampled residents (Resident 3), who was left in bed exposed. This deficient practice had the potential to violate Resident 3's rights.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled resident's (Resident 1) medical order (a directive issued by a licensed physician) for a stat (immediately) electroencephalogram (EEG, a non-invasive test that records the brain's electrical activity to help diagnose conditions like epilepsy, head injuries, and other brain issues) was completed as directed by the physician. This deficient resulted in delay and can potentially cause the patient's condition to worsen or resulted in injury or harm such as prolonged seizures, permanent cognitive impairment, or the need for more invasive treatments, all of which can be prevented with timely action. [...]

Inspectors wroteBased upon interview and record review, the facility failed to: 1. Ensure the facility's Payroll-Based Journal Staffing Data Report (PBJ- a system created by Center of Medicare/Medicaid Services to collect auditable and verifiable staffing data from nursing facilities) was submitted for Quarter 4 Fiscal Year (July 2024-September 2024). This deficient practice had the potential to result in a negative impact on quality of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure two out of six sampled residents (Resident 5 and 8) scheduled showers were conducted twice a week. 2. Ensure staff sat at eye level and not standing up towering over Resident 8 while feeding. This deficient practice had the potential to result in making the residents feel intimated or unkept.

Inspectors wroteBased on observation and interview, the facility failed to: 1. Provide a Notice of Medicare Non-Coverage (NOMNC- a form that Medicare providers and health plans must give to beneficiaries when their Medicare-covered services are ending) appeal process form to 3 residents (Resident 1, Resident 10 and Resident 67). This deficient practice had the potential to result in residents and/or their responsible parties not being able to exercise their right to file an appeal.

Inspectors wroteBased on interview and record review, the facility failed to: 1. The facility failed to ensure annual competencies were signed and dated by 3 employees. This deficient practice had the potential to result in providing incompetent and inadequate care for all residents.

Inspectors wroteBased on observation and interview the facility failed to: 1. Ensure a thermometer was inside of the kitchen's walk-in refrigerator # 1. 2. Ensure frozen foods were dated and labeled in reach-in freezer # 1. This deficient practice had the potential to result in food expiration.

Inspectors wroteDuring an observation, interview, and record review the facility failed to: 1. Ensure one out of six sampled residents (Resident 8) had an indwelling catheter (a tube inserted into the bladder to drain urine) covered with a privacy bag. This deficient practice of not covering the indwelling catheter had the potential to make Resident 8 not feel humiliated (to feel ashamed).

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure the survey results and complaint investigation reports in the previous three years were posted in a place readily accessible to the residents and public. This failure had the potential for residents, visitors, family members, or family representative not being able to examine and compare the previous survey results, and facility's deficient practice and how they were corrected.

Inspectors wroteBased on interview and record review, the facility failed to: 1. Complete and re-submit the Preadmission Screening and Resident Review ([PASARR - a tool to determine if the person had, or was suspected of having a mental illness, intellectual disability, or related condition) Level one (I) screening and refer one of two sampled residents (Resident 4) who had diagnoses of anxiety disorder (a condition that involves excessive and persistent feelings of fear, dread, and worry that can interfere with daily life), depression (a mood disorder that causes a persistent feelings of sadness and loss of interest), and psychosis (a severe mental condition in which thought, and emotions are so affected that contact is lost with reality), to the appropriate state-designated authority for PASARR Level two (II) evaluation and determination. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure one out of six sampled residents (Resident 5) ventilator tubing (the tubing carries oxygen and air to and from the patient) was labeled and dated. This deficient practice of not labeling and dating the respiratory tubing placed Resident 5 at risk for respiratory infection (infections that could affect parts of the body involved in breathing).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents on tube feeding received treatment and care in accordance with professional standards of practice by failing to: 1. Elevate the head of the bed while receiving formula through the gastrostomy tube (a surgical opening fitted with a device to allow feedings to be administered directly to the stomach common for people with swallowing problems) for one of four sampled residents (Resident 4). This deficient practice had the potential to cause aspiration (inhalation of foreign materials) that can lead to pneumonia (lung infection) for Resident 4.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure intravenous ([IV] into or connected to vein) tubing was labeled and dated for one of two sampled residents (Resident 9) who was receiving IV antibiotic (drug that treats infection) treatment. This deficient practice had the potential to placed Resident 9 at risk for infection and IV therapy complications.

Inspectors wroteBased on observation and interview, the facility failed to: 1. Ensure expired medication was not kept in the medication storage refrigerator. This deficient practice had the potential to result in administering expired medication.

Inspectors wroteBased on interview and record review the facility failed to: 1. Ensure one out six sampled residents (Resident 8) had completed laboratory ([labs] blood samples to assess a patient's health status) test. This deficient practice of not completing labs placed the resident at risk for not receiving accurate medication treatment.

Inspectors wroteBased on interview and record review the facility failed to: 1. Ensure one out of six sampled residents (Resident 13) had dental services. This deficient practice of not providing dental services had the potential to for Resident 13 to develop a mouth infection (a group of infections that occur around the oral cavity).

Inspectors wroteBased on interview and record review, the facility failed to: 1. Ensure Quality Assurance Performance Improvement (QAPI- Quality Assurance and Performance Improvement-a data driven proactive approach to improvement used to ensure services are meeting quality standards) meetings were held quarterly (every 3 months). This deficient practice had the potential to result in systemic issues within the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Ensure one out of six sampled residents (Resident 5) ventilator tubing (the tubing carries oxygen and air to and from the patient) was labeled and dated. This deficient practice of not labeling and dating the respiratory tubing placed Resident 5 at risk for respiratory infection (infections that could affect parts of the body involved in breathing).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing professional standards were provided for two of three sampled residents (Resident 1 and Resident 3), when: 1. No documentation of an assessment (to evaluate a resident ' s health) was found in Resident 1 ' s electronic health record (EHR - a digital version of a resident ' s medical history) when Resident 1 had heart rate of 106 beats per minute (bpm - the normal range is between 60 to 100 bpm, an elevated heart rate is greater than 100 bpm and may indicate many problems such as pain, infection, or anxiety). This failure resulted in Resident 1 ' s elevated heart rate not being addressed for more than three hours from 8:19 p.m. to 11:38 p.m. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent further potential neglect and have evidence that all alleged violations were thoroughly investigated as indicated in the facility's Abuse Investigation policy for three of three sampled residents (Resident 1, 2 and 3) when: 1. Licensed vocational nurse (LVN - an entry-level health care provider who is responsible for rendering basic nursing care) 1 tied a sheet to the Resident 1 ' s bed frame and broken bedrail. This deficient practice resulted in Resident 1 falling out of bed and had the potential to result in unidentified neglect, mistreatment, and failure to protect Resident 1 from further neglect. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility's policies and procedures were followed for of one of three sampled residents (Resident 1), when Resident 1's bedrail was tied with a sheet after it was found to be broken and the facility staff failed to monitor Resident 1 while the bedrail remained broken. This failure resulted in Resident 1 falling out of bed and had the potential for risk of entrapment or strangulation due to the sheet tied from the bed rail to the lower bed frame.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was cared for by a health care clinician that has a current Basic Life Support (BLS, care that first-responders, healthcare providers and public safety professionals provide to anyone who is experiencing cardiac arrest [the heart stop functioning], respiratory distress or an obstructed airway) in accordance with the facility job description for Licensed Vocational Nurses. (LVN). LVN 1 who was assigned to work on the facility subacute unit (a unit that provide intensive care, but to a lesser degree than acute care), did not have a up to date BLS certification. This deficient practice had the potential of delayed provisions of emergency care for Resident 1 and the 39 residents in the subacute unit who wishes to have full treatment in a life-threatening situation.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain acceptable room temperature ranging from 71 to 81 degrees Fahrenheit (F, A unit of temperature measurement) for 17 of 17 residents (Resident 1 to Resident 17) in the Sub-Acute (a medical facility that provides medical care to chronically ill patients who are medically stable) Unit. This deficient practice placed the 17 residents on the Sub-Acute Unit at risk for dehydration (excessive loss of body water) and/or heat stroke (internal body heat with complications involving the central nervous system that occur after exposure to high temperatures). [...]

Inspectors wroteBased on interview and record review the facility failed to provide prompt efforts to resolve grievances of residents voiced to the facility through the Resident Council Meetings for two of eighteen sampled residents (resident 9 and Resident 15) who used to attend to a monthly group meeting. This deficient practice resulted in unresolved residents' grievances related to delay in assistance for residents' care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an activity program for five of five sampled residents (Residents 3, 9, 14, 15, and 16) who wanted to participate in activities. The failure to implement a plan to conduct activities in the absence of an activity coordinator placed the residents' mental, psychosocial, and emotional well-being at risk of feeling isolated and depressed. This deficient practice of not having an activity program meant the residents lacked substandard practice and care for their practical well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the urine in the indwelling catheter tubing collecting bag for three out of eighteen sampled residents (Residents 9, 11, and 14). 1. Resident 11 had an indwelling catheter (inside the body that drains urine from the bladder into an outside bag) with noticeable sediment (accumulation of white blood cells) that was cloudy and without a privacy bag. 2. Resident 14 had a condom catheter (a soft latex applied over the penis that pushes urine through tubing) with noticeable sediment in the urine tubing with no privacy bag. 3. Resident 9 had an indwelling catheter with noticeable sediment in the urine tubing. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of 9 sampled residents' (Resident 7 and Resident 15) gastrostomy tube ([GT] tube placed directly into stomach to give direct access for supplemental feeding, hydration, or medicine) feeding formula was labeled with the date and time according to the facility's policy and procedure (P&P). This deficient practice had the potential to result in Resident 7 and Resident 15 receiving tube feeding formula over the expiration or maximum formula hang time (how long a tube feeding formula should hang safely prior to discarding or changing) and could adversely affect the resident's health and wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure stored food were labeled with open date and expiration date. 2. Ensure expired food were not stored in the kitchen and accessible for use in preparing foods in accordance with professional standards for food service safety. This practice had the potential to result in foodborne illnesses which can affect the health and safety of all residents in the facility.