Inspection Reports for
Southland Living

The facility failed to prevent a duplicate blood draw on Resident 1 on 1/12/2026 despite the labs having been completed on 12/11/2025. The phlebotomist mistakenly drew blood without a new physician order due to improper management of lab requisition forms in the facility's lab binder.

The facility failed to implement its infection prevention and control program adequately, resulting in staff and visitors not consistently using required PPE, which posed a risk for spreading Covid-19 among residents and staff.

The complaint involved an allegation of resident-to-resident abuse where Resident 2 pushed Resident 1's wheelchair after being called a derogatory name. Staff failed to report the incident to the California Department of Public Health within the required two-hour timeframe and did not conduct an investigation. The Administrator did not consider the incident abuse and did not report it, risking ongoing harm.

The facility failed to report an allegation of resident-to-resident abuse within two hours and did not conduct a prompt investigation into the physical altercation between two residents. This failure potentially allowed harm to continue and prevented immediate regulatory investigation.

The complaint was substantiated. Resident 1's responsible party complained that the CT scan results were not communicated to the attending physician or responsible party, and pain management was inadequate, leading to untreated kidney stones and uncontrolled pain.

The facility failed to notify the physician and responsible party about Resident 1's CT scan results indicating multiple kidney stones, resulting in delayed treatment and care. Additionally, the facility failed to provide effective pain management for Resident 1, lacking medication coverage for moderate pain and breakthrough pain, which potentially worsened the resident's condition and quality of life.

The facility had multiple deficiencies including failure to treat residents with dignity and respect, incomplete care planning especially for residents with fractures and edema, medication administration errors, inadequate infection control practices, failure to report and investigate abuse allegations timely, improper storage of medications and food, and failure to maintain a pest-free environment.

The complaint investigation involved allegations that Resident 167 entered Resident 76's room without consent, kissed Resident 76's arm, and that an unidentified CNA isolated Resident 76 by taking her phone and turning the television loud. The facility failed to protect Resident 76, failed to report the abuse allegations timely to CDPH, and failed to investigate and submit reports properly. The complaint was substantiated with findings of minimal harm or potential for actual harm.

The facility failed to protect Resident 76 from nonconsensual abuse by Resident 167 and failed to provide appropriate assessment, monitoring, and emotional support. The facility also failed to timely report allegations of abuse to the California Department of Public Health and failed to thoroughly investigate and submit reports of abuse allegations. Additionally, infection control deficiencies were identified involving failure to follow Enhanced Barrier Precautions and other infection prevention protocols.

The facility failed to ensure proper blood glucose monitoring and diabetic care for a resident with type 2 diabetes, resulting in actual harm. Additionally, the facility failed to administer prescribed medications timely and notify the physician when medications were unavailable. The Quality Assurance and Performance Improvement committee failed to sustain corrective actions from prior deficiencies.

The facility failed to ensure oxygen tanks were safely stored in the oxygen storage room for one of three sampled residents, posing a fire hazard and risk of injury. Interviews with staff and review of facility policy confirmed that oxygen tanks should be secured in the storage room and not left in residents' rooms.

The facility failed to ensure that a Licensed Vocational Nurse (LVN 1) administered eye medication to Resident 1 on time and failed to notify and document a change of condition for Resident 2, resulting in minimal harm or potential for actual harm to some residents.

The facility failed to develop a complete care plan for one resident's dry eyes and failed to ensure timely administration of prescribed eye medication due to pharmacy delivery delays and inadequate follow-up by nursing staff.

The complaint investigation focused on Resident 1, who had a history of dementia and exhibited aggressive and noncompliant behaviors. The investigation found the facility did not follow up with psychiatric care after 2/19/2024 and failed to hold an interdisciplinary team meeting to address these behaviors. Resident 1's responsible party was not informed or included in care plan meetings, violating resident rights.

The facility failed to ensure psychiatric follow-up and interdisciplinary team meetings for Resident 1, who exhibited increased aggressive behaviors and noncompliance with care. This failure resulted in delayed care, decline in Resident 1's mental and physical health, and increased risk of injury to self and others.

The investigation was complaint-related, focusing on residents' personal hygiene and nail care. The complaint was substantiated as the facility failed to maintain proper nail hygiene for residents 1 and 2.

The facility failed to ensure two of three sampled residents had clean fingernails, resulting in a black/brown substance observed under their nails. This posed a potential infection risk and affected residents' self-esteem.

The facility had multiple deficiencies including failure to feed residents at eye level, inadequate call light accessibility, incomplete PASARR assessments, incomplete restorative nursing services, unsafe transportation practices, improper medication labeling and storage, food safety violations, inadequate infection control, and environmental safety concerns.

The investigation was triggered by a complaint related to Resident 32's accident on 3/19/2024 when the resident was not properly secured in the van and was injured. The complaint was substantiated as the facility failed to secure the resident with a shoulder strap, leading to serious injury.

The facility failed to ensure Resident 32 was properly secured with a shoulder seat belt while riding in a wheelchair in the facility van, resulting in the resident being thrown forward and sustaining multiple fractures. The facility subsequently replaced the straps and implemented shoulder restraints after the incident.

The complaint investigation found substantiated failures in PPE use by staff caring for a resident with COVID-19, placing residents, staff, and the community at higher risk for cross contamination and increased spread of infection.

The facility failed to ensure staff wore appropriate personal protective equipment (PPE) including N95 respirators, face shields, and isolation gowns while caring for a resident with COVID-19, increasing the risk of infection spread within the facility.

The investigation was triggered by a fall incident on 12/23/2023 involving Resident 1. The complaint was substantiated as the facility failed to have a physician's order for the mattress on the floor and did not update the fall care plan accordingly.

The facility failed to have a physician's order for a mattress on the floor next to Resident 1's bed and did not include this intervention in the fall care plan. This deficient practice placed Resident 1 at risk of sustaining another fall.

The complaint was substantiated. The grievance filed by the responsible party regarding care concerns was improperly handled by a staff member related to the CNA involved, causing fear of retaliation.

The facility failed to ensure the grievance was addressed without fear of discrimination or reprisal because the grievance was investigated by the Director of Staff Development, who was related to the CNA involved. This caused anxiety and worry for the resident and responsible party about potential retaliation.

The complaint investigation found substantiated deficiencies related to failure to create a care plan and failure to provide adequate supervision during care, resulting in a resident fall and injury.

The facility failed to develop and implement a complete care plan for a resident requiring two-person assistance, leading to the resident falling from bed and sustaining an inner lower lip laceration and head injury. The facility also failed to ensure adequate supervision during perineal care, resulting in the resident falling and requiring hospital evaluation.

Based on observation, interview, and record review, the complaint was substantiated as the facility failed to dress Resident 1 in his own clothes before discharge. The resident lacked decision-making capacity and was discharged wearing a hospital gown because the family had taken his personal clothing home two days prior.

The facility failed to ensure Resident 1 was dressed in his own clothes before discharge, resulting in the resident being discharged wearing a hospital gown. This practice potentially affected the resident's sense of self-worth and dignity.

The investigation was complaint-driven, focusing on allegations of inadequate personal care and infection control failures related to a scabies outbreak. The complaint was substantiated with findings of deficient care and infection prevention practices.

The facility failed to ensure proper fingernail care for one resident, resulting in potential infection risk and emotional distress. Additionally, the facility failed to recognize, report, and control a scabies outbreak affecting seven residents by not placing them on contact isolation, not reporting to the health department, and lacking a scabies prevention program.

The complaint investigation found that Resident 1's call light was repeatedly ignored for over 15 minutes despite being audible and visible to staff. Staff members, including Licensed Vocational Nurse 1, Quality Assurance nurse, Certified Nursing Assistants, and Registered Nurse Supervisor, failed to respond or delegate response to the call light. Resident 1 expressed frustration at the lack of response. Interviews with staff and administration confirmed the failure to respond timely and the importance of answering call lights within 3 to 5 minutes as per facility policy.

The facility failed to ensure that Resident 1's call light was answered promptly and that the resident's needs were inquired and identified before staff turned off the call light and left the room. This resulted in Resident 1 feeling ignored and frustrated, with potential risk of delayed care.

The facility had multiple deficiencies including failure to ensure call lights were within reach for residents, incomplete care plans, medication administration errors, expired medications, infection control lapses, missing dialysis emergency kit, and unsafe environment hazards such as loose bathroom tiles and stored bed frame.