Inspection Reports for
Mid-Wilshire Health Care Center
676 S Bonnie Brae St, Los Angeles, CA 90057, United States, CA, 90057
Back to Facility ProfileCitations (last 3 years)
Citations (over 3 years)
14.7 citations/year
Citations are regulatory findings recorded during state inspections.
268% worse than California average
California average: 4 citations/yearCitations per year
20
15
10
5
0
Inspection Report
Annual Inspection
Citations: 2
Date: Aug 6, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care planning and notification procedures for room changes.
Findings
The facility failed to include a resident's next of kin in the care plan conference and did not notify or provide written notice to a resident's responsible party before multiple room changes. Documentation of notifications was incomplete or lacking.
Citations (2)
F 0553: The facility failed to include Resident 2's next of kin during the care plan meeting on 8/1/25, denying their right to participate in care planning.
F 0559: The facility failed to notify Resident 1's responsible party before moving the resident to different rooms on four occasions and did not provide written notice or document the notifications properly.
Report Facts
Room changes: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Staff Development | Interviewed regarding lack of documentation for notification of Resident 2's next of kin and Resident 1's responsible party | |
| Registered Nurse (RN MDS) | Interviewed about care conference and notification of Resident 2's next of kin | |
| Social Worker | Interviewed about notification and documentation of Resident 1's room changes |
Inspection Report
Complaint Investigation
Citations: 1
Date: Jul 26, 2025
Visit Reason
The inspection was conducted due to a complaint investigation following a choking incident and subsequent death of Resident 1 related to failure to ensure proper diet consistency, supervision, and monitoring during feeding.
Complaint Details
The investigation was triggered by a complaint related to Resident 1's choking incidents on 9/18/2023 and 9/19/2023, which resulted in death. The complaint was substantiated with findings of failure to follow physician orders, lack of supervision, and inadequate policies regarding outside food.
Findings
The facility failed to ensure Resident 1 received food consistent with physician orders and proper supervision during meals, resulting in two choking incidents and the resident's death. The facility lacked a system to screen outside food for diet compliance and failed to monitor the resident as ordered. Post-incident, the facility implemented staff training, new policies for outside food, and monitoring procedures.
Citations (1)
F 0689: The facility failed to ensure Resident 1 received care in accordance with physician orders and care plans, including proper diet consistency and supervision during feeding, resulting in choking incidents and death.
Report Facts
Residents with modified diets audited: 49
Nurses trained: 42
Total nursing staff: 67
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Named in failure to supervise Resident 1 during feeding on 9/19/2023 |
| LVN 1 | Licensed Vocational Nurse | Provided information on monitoring and communication about Resident 1's choking incidents |
| RN 1 | Registered Nurse | Reported on Resident 1's unresponsiveness and confirmed aspiration monitoring orders |
| DON | Director of Nursing | Verified lack of documentation and policy regarding outside food and feeding supervision |
| ADM | Administrator | Participated in interviews and policy development post-incident |
| DSD | Director of Staff Development | Involved in staff training and policy implementation |
| MD | Medical Director | Provided expert opinion on dysphagia management and importance of policies |
| ST | Speech Therapist | Provided information on dysphagia therapy and feeding supervision requirements |
Inspection Report
Complaint Investigation
Citations: 1
Date: Jun 11, 2025
Visit Reason
The inspection was conducted due to an employee-to-resident abuse allegation involving two residents, to investigate the facility's compliance with abuse reporting policies.
Complaint Details
The complaint involved an alleged employee-to-resident abuse incident on 3/28/25. The allegation was substantiated as the facility failed to report and investigate the incident properly.
Findings
The facility failed to timely report and investigate an employee-to-resident abuse allegation involving two residents. The incident was not reported to the state licensing office, police, or ombudsman as required by policy.
Citations (1)
F 0609: The facility failed to timely report suspected abuse and did not investigate the employee-to-resident abuse allegation in a timely manner. The incident was not reported to the proper authorities as required by facility policy.
Report Facts
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding the grievance and reporting procedures. | |
| Administrator | Interviewed about awareness and reporting of the abuse incident. |
Inspection Report
Routine
Citations: 7
Date: Mar 10, 2025
Visit Reason
Routine inspection of Mid-Wilshire Health Care Center to assess compliance with healthcare regulations and standards.
Findings
The facility had multiple deficiencies including failure to ensure call lights were within reach, inadequate diabetic care management, improper feeding tube care, lack of annual employee performance evaluations, improper use of psychotropic medication, failure to follow pureed diet recipes and portion sizes, and unsafe food storage and preparation practices.
Citations (7)
F 0675: The facility failed to ensure a call light was within reach for one sampled resident, risking delays in meeting hydration, toileting, and daily living needs.
F 0684: The facility failed to ensure one resident with diabetes received treatment and care according to professional standards, including failure to notify the physician of high blood sugar readings.
F 0693: The facility failed to ensure enteral feeding tube bags were changed every 24 hours, risking infection and gastrointestinal complications for one resident.
F 0730: The facility failed to ensure five employees had annual performance evaluations, risking potential delays in resident care.
F 0758: The facility failed to ensure one resident's PRN psychotropic medication order had documented clinical rationale for extension beyond 14 days, increasing risk of adverse effects.
F 0803: The facility failed to follow standardized recipes and portion sizes for pureed diets, served thin and soupy pureed food inconsistent with menu, risking meal dissatisfaction and aspiration.
F 0812: The facility failed to ensure safe food storage and preparation, including thawing meat on counter, unsanitary ice machine and scoop, unlabeled milk and food items, risking bacterial growth and foodborne illness.
Report Facts
Blood sugar readings over 500: 27
Residents on pureed diet: 23
Employees without annual performance evaluations: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 4 | LVN | Interviewed regarding call light placement and psychotropic medication informed consent. |
| Director of Staff Development | DSD | Interviewed regarding call light placement, feeding tube care, ice machine cleaning, and employee evaluations. |
| Registered Nurse Supervisor 2 | RNS 2 | Interviewed regarding diabetic care and physician notification. |
| Licensed Vocational Nurse 3 | LVN 3 | Documented blood sugar readings and reported to RNS 1. |
| Director of Nursing | DON | Interviewed regarding employee evaluations and psychotropic medication assessments. |
| Pharmacy Consultant | Interviewed regarding psychotropic medication rationale. | |
| Dietary Supervisor | DS | Interviewed regarding food preparation, menu, and food safety. |
| Maintenance Supervisor | MS | Interviewed regarding ice machine cleaning. |
| Registered Dietitian | RD | Interviewed regarding menu review and pureed diet standards. |
Inspection Report
Complaint Investigation
Citations: 1
Date: Jun 24, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to prevent falls and ensure adequate supervision for a high-risk resident.
Complaint Details
The investigation was complaint-related, focusing on the fall incident involving Resident 1. The complaint was substantiated as the facility failed to prevent the fall and subsequent injury.
Findings
The facility failed to develop and implement a comprehensive fall prevention care plan for a resident with dementia and a history of falls, resulting in the resident sustaining a left femur fracture after a fall. The resident was not frequently monitored as required, and the facility did not follow its own policies for fall prevention and care planning.
Citations (1)
F 0689: The facility failed to develop a comprehensive fall prevention care plan and did not frequently monitor a high-risk resident, resulting in a fall and left femur fracture. The resident's care plan lacked interventions to prevent falls despite known risk factors.
Report Facts
Morse Fall Score: 75
Date of admission: Jun 6, 2024
Date of fall: Jun 8, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse 1 | LVN | Stated the resident was high risk for falls and should have been monitored more frequently. |
| Director of Nursing | DON | Acknowledged the lack of a fall care plan and stated the fall could have been prevented with proper interventions. |
Inspection Report
Complaint Investigation
Citations: 1
Date: Apr 23, 2024
Visit Reason
The inspection was conducted to investigate complaints related to fall prevention and accident hazards involving a high-risk resident with dementia who experienced multiple falls.
Complaint Details
The investigation was complaint-driven, focusing on Resident 1 who had dementia and a history of multiple falls. The complaint was substantiated as the facility failed to prevent repeated falls and adequately monitor or revise care plans.
Findings
The facility failed to implement effective fall prevention interventions for a high-risk resident, resulting in repeated falls and injury. Care plans were not revised appropriately after falls, and monitoring and documentation of the resident's attempts to get out of bed were inadequate.
Citations (1)
F 0689: The facility failed to implement its Fall Prevention Program to identify and evaluate interventions specific to Resident 1's fall risks, resulting in repeated falls and injury including a laceration requiring hospital transfer.
Report Facts
Fall incidents: 2
Fall risk assessments: 1
Visual checks frequency: 1
Duration of Falling Star Program: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN1 | Registered Nurse Supervisor | Provided statements on Resident 1's fall incidents and care plan deficiencies |
| LVN1 | Licensed Vocational Nurse | Described Resident 1's condition and fall risk |
| DSD | Director of Staff Development | Discussed fall incidents, care plan interventions, and staff education |
| RN2 | Registered Nurse | Reviewed care plans and fall prevention interventions for Resident 1 |
Inspection Report
Complaint Investigation
Citations: 2
Date: Mar 28, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding an allegation of sexual abuse by a Certified Nurse Assistant (CNA) against a resident (Resident 1).
Complaint Details
The complaint was substantiated. Resident 1 alleged sexual abuse by CNA 1 on 3/23/2024. The facility investigation, surveillance video, interviews, and police involvement confirmed the allegations. CNA 1 was removed from the facility and did not receive abuse training during employment.
Findings
The facility failed to protect Resident 1 from sexual abuse by CNA 1, who touched the resident's private parts and coerced the resident to touch his private area. CNA 1 did not receive required abuse training, increasing the risk of abuse to residents.
Citations (2)
F 0600: The facility failed to protect Resident 1 from sexual abuse by CNA 1, who touched the resident's private parts and coerced the resident to touch his private area, causing psychological distress.
F 0726: The facility failed to ensure CNA 1 received abuse training per facility policy, increasing the risk of sexual abuse to Resident 1 and other residents.
Report Facts
Date of incident: Mar 23, 2024
Date of admission: Mar 15, 2024
Date of History and Physical: Mar 18, 2024
Date of MDS: Mar 20, 2024
Date of Nurse Staffing Assignment: Mar 23, 2024
Date of SBAR Communication Form: Mar 25, 2024
Date of Social Services Note: Mar 25, 2024
Date of Psychotherapy Note: Mar 25, 2024
Date of Follow-Up Investigation Report: Mar 29, 2024
Date of Abuse and Neglect Prohibition Policy: 202306
Date of Master Staffing Agreement: Oct 25, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nurse Assistant | Accused of sexually abusing Resident 1 and not receiving abuse training |
| Social Services Director | Social Services Director | Interviewed regarding Resident 1's report and facility response |
| Director of Staff Development | Director of Staff Development | Interviewed about CNA 1's training and registry status |
| Administrator | Administrator | Interviewed about abuse allegation and facility actions |
| Director of Nursing | Director of Nursing | Interviewed about CNA 1's registry status and abuse training |
| CG 1 | Caregiver | Received report of abuse from Resident 1 and informed facility |
Inspection Report
Routine
Citations: 7
Date: Feb 29, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including call light accessibility, advance directive documentation, timely reporting of injuries, communication aids, pressure ulcer prevention, catheter care, and respiratory care. Deficiencies were generally of minimal harm but had potential to impact resident safety and care.
Citations (7)
F 0558: The facility failed to ensure call lights were within reach for two residents, increasing risk of injury or falls.
F 0578: The facility failed to maintain a current advance directive and acknowledgment form in one resident's active medical chart.
F 0609: The facility failed to report two residents' major injuries to the state survey agency within required timelines.
F 0676: The facility failed to provide a communication device in the preferred language for one resident, hindering communication.
F 0686: The facility failed to properly set low air loss mattress settings for two residents, risking pressure ulcer development.
F 0690: The facility failed to prevent catheter-associated urinary tract infection by allowing kinked urinary drainage tubing for one resident.
F 0695: The facility failed to change nasal cannula and humidifier bottles weekly for one resident and failed to date nasal cannula changes for another, risking infection.
Report Facts
Residents sampled: 18
Residents affected: 2
Fall risk score: 5
Pressure ulcer wound size: 0.5
Pressure ulcer wound size: 0.4
Low air loss mattress setting: 50
Low air loss mattress setting: 80
Low air loss mattress setting: 120
Resident 19 weight: 75
Oxygen flow rate: 2
Subdural hematoma size: 4.3
Fracture date: Sep 21, 2023
Fall injury date: Dec 21, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 3 | Licensed Vocational Nurse | Verified call light placement and urinary tubing condition for Resident 12 |
| RN 1 | Registered Nurse | Observed and commented on call light and oxygen equipment for Residents 27 and 48 |
| Director of Nursing | Director of Nursing | Provided statements on call light policy, injury reporting, communication board, mattress settings, catheter care, and oxygen tubing protocols |
| LVN 1 | Licensed Vocational Nurse | Reported on Resident 58 fall and injury details |
| CNA 4 | Certified Nurse Assistant | Reported finding Resident 6 on floor with head injury |
| Infection Prevention Nurse | Infection Prevention Nurse | Discussed Resident 6's bleeding risk and injury |
| LVN 2 | Director of Staff Development | Observed Resident 61's nasal cannula without date |
| Treatment Nurse 1 | Treatment Nurse | Discussed low air loss mattress settings for Resident 19 |
| Social Services Director | Social Services Director | Interviewed regarding communication device for Resident 33 |
| Administrator | Administrator | Commented on advance directive documentation for Resident 1 |
Inspection Report
Citations: 3
Date: Jan 12, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, including safe discharge preparation, prevention of urinary tract infections, and provision of respiratory care.
Findings
The facility failed to ensure a resident was properly prepared for safe discharge due to delayed delivery of durable medical equipment. Additionally, the facility did not provide appropriate care to prevent urinary tract infections for a resident with an indwelling catheter and failed to ensure nasal cannula tubing was changed per policy for another resident, posing risks of infection.
Citations (3)
F 0624: The facility failed to ensure Resident 1 was properly arranged and prepared for safe discharge, resulting in delayed discharge due to the oxygen machine being delivered to the resident's home instead of the facility.
F 0690: The facility failed to provide appropriate care to prevent urinary tract infections for Resident 2 by not assessing and documenting mucus and sediment in the indwelling catheter drainage bag, which was observed touching the floor.
F 0695: The facility failed to provide necessary respiratory care for Resident 3 by not ensuring the nasal cannula tubing was changed per facility policy, increasing risk of respiratory infection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Interviewed regarding Resident 1's delayed discharge due to oxygen machine delivery. | |
| Director of Nursing | Interviewed regarding Resident 1's discharge process and oxygen machine delivery. | |
| Administrator | Interviewed regarding safety concerns about Resident 1's discharge. | |
| Registered Nurse 1 | Observed and confirmed issues with Resident 2's catheter drainage bag. | |
| Licensed Vocational Nurse 1 | Observed and confirmed issues with Resident 3's nasal cannula tubing. |
Inspection Report
Routine
Citations: 1
Date: Sep 1, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with infection prevention and control practices, specifically regarding the use and fit testing of N95 respirator masks among staff during the COVID-19 pandemic.
Findings
The facility failed to ensure that staff, including Certified Nursing Assistants and the MDS Coordinator, were properly fit tested for the N95 respirator masks they were wearing. This failure posed a potential risk of spreading COVID-19 to residents, staff, and the community.
Citations (1)
F 0880: The facility failed to provide and implement an infection prevention and control program. Several staff members were observed wearing N95 respirator masks for which they were not fit tested, increasing the risk of COVID-19 transmission.
Report Facts
Staff fit tested for Honeywell N95 mask: 16
Date of Respirator Fit Test Record: Jun 5, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant 1 | CNA | Observed wearing N95 mask without fit testing; worked two to three days a week. |
| Certified Nursing Assistant 2 | CNA | Observed wearing N95 mask without fit testing; assigned to four COVID-19 positive residents. |
| Certified Nursing Assistant 3 | CNA | Observed wearing N95 mask without fit testing. |
| MDS Coordinator | Minimum Data Set Coordinator | Observed wearing N95 mask without fit testing. |
| Infection Preventionist Nurse | IP | Provided information on fit testing practices and mask usage. |
| Administrator | ADM | Stated staff should be fit tested upon hire and annually. |
Inspection Report
Annual Inspection
Citations: 17
Date: May 19, 2023
Visit Reason
The inspection was conducted as part of a routine annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including resident identification wrist bands, call light accessibility, notification of Medicare coverage changes, bed hold notification, provision of resident activities, pressure ulcer prevention, fall prevention, catheter care, dialysis care, nurse staffing postings, meal preparation and diet adherence, infection control, COVID-19 vaccination procedures, and pest control.
Citations (17)
F 0550: The facility failed to have identification wrist bands for two sampled residents, risking improper resident identification and affecting resident dignity.
F 0558: The facility failed to ensure call lights were within reach for three sampled residents, risking inability to request assistance or alert staff in emergencies.
F 0582: The facility failed to provide appropriate Medicare Non-Coverage notices to two sampled residents, risking uninformed financial liability and appeal rights.
F 0625: The facility failed to provide bed hold notification at hospital transfer for one sampled resident, denying information on bed reservation rights.
F 0679: The facility failed to provide activities reflecting resident choice for one sampled resident, risking isolation and decreased well-being.
F 0686: The facility failed to maintain correct low air loss mattress settings for one sampled resident, increasing risk of pressure ulcer development.
F 0689: The facility failed to place fall mats at bedside for one sampled resident at risk for falls, increasing injury risk.
F 0690: The facility failed to ensure indwelling Foley catheter tubing was patent and not kinked for one sampled resident, risking urinary tract infection.
F 0698: The facility failed to provide dialysis emergency kit and alert signage at bedside for one sampled resident with arteriovenous fistula, risking emergency management and access site injury.
F 0732: The facility failed to post current nurse staffing information daily in a prominent place accessible to residents and visitors.
F 0803: The facility failed to follow menu requirements for fortified diets for two sampled residents, risking unplanned weight loss.
F 0812: The facility failed to ensure safe and sanitary food storage and preparation practices, including staff wearing nail polish, improper handwashing, dirty storage areas, and improper food storage, risking foodborne illness.
F 0865: The facility failed to maintain effective Quality Assurance and Performance Improvement (QAPI) program documentation and oversight, risking repeat deficiencies.
F 0867: The facility failed to implement a data collection or monitoring system to assess effectiveness of QAPI efforts, risking quality of care.
F 0880: The facility failed to implement infection control measures including oxygen tubing changes, hand hygiene before medication administration, and proper PPE use, risking infection spread.
F 0887: The facility failed to educate and offer COVID-19 vaccination to one resident and failed to obtain informed consent before administering booster to another, violating resident rights.
F 0925: The facility failed to maintain sanitary conditions in the kitchen with flies observed on surfaces and utensils, risking foodborne illness for all residents receiving food.
Report Facts
Residents affected: 2
Residents affected: 3
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Provided statements regarding importance of wrist bands, call light placement, catheter care, dialysis kit, infection control, and COVID-19 vaccination procedures. |
| Registered Nurse Supervisor | Registered Nurse Supervisor | Verified missing wrist bands and catheter tubing issues. |
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Verified call light placement issues for residents. |
| Licensed Vocational Nurse 1 | Licensed Vocational Nurse | Observed dialysis care deficiencies and medication administration hand hygiene failure. |
| Dietary Supervisor | Dietary Supervisor | Confirmed missing fortified diet items and kitchen sanitation issues. |
| Infection Preventionist | Infection Preventionist | Provided statements on infection control failures and COVID-19 vaccination education. |
| Business Office Manager | Business Office Manager | Responsible for Medicare coverage notification forms; confirmed failure to provide forms. |
| Administrator | Facility Administrator | Acknowledged deficiencies in QAPI documentation and COVID-19 vaccination consent. |
Inspection Report
Annual Inspection
Citations: 1
Date: May 3, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with competency requirements for nursing staff, specifically to ensure that certified nursing assistants have the necessary skills to safely care for residents, including safe transfer procedures.
Findings
The facility failed to ensure that two certified nursing assistants had the required annual competency evaluations and skills checks for safely transferring residents. This deficiency posed a potential risk of harm to residents due to inadequate staff competency in resident care.
Citations (1)
F 0726: The facility failed to ensure certified nursing assistants had annual competency evaluations for safe resident transfers. Two CNAs did not receive required return demonstrations or skills checks, risking resident safety.
Report Facts
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Named in competency skills check deficiency for resident transfer |
| CNA 2 | Certified Nursing Assistant | Named in competency skills check deficiency for resident transfer |
| Director of Staff Development | Director of Staff Development | Interviewed regarding competency checklist and staff evaluations |
| Director of Nursing | Director of Nursing | Interviewed regarding staff competency requirements and deficiencies |
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