California Post Acute in Los Angeles: Inspection Record Review, Complaints and Abuse Reports (Updated October 30, 2026)

According to the citation, CDPH identified during an annual recertification survey in July 2025 that Resident 6, a 77-year-old man with one-sided paralysis or weakness and anemia, had developed a pressure ulcer (an injury to the skin and underlying tissue caused by constant pressure). A Braden Scale assessment rated him at moderate risk for pressure ulcers in April 2025 and at high risk in June 2025. The citation states his care plan for skin breakdown did not address repositioning.

CDPH found the facility failed to make sure CNAs monitored and documented his repositioning, failed to include the registered dietitian in the team's plan to help the wound heal, and failed to follow up on lab results for albumin and hemoglobin, two blood values linked to healing. Inspectors found that a weekly pressure ulcer record dated June 18, 2025 asked the dietitian to evaluate him, but the dietitian's visit records from June 19 through July 23 showed no visit. According to the citation, he developed an unstageable pressure ulcer (one where dead tissue hides how deep the damage goes) at the tailbone, extending to both buttocks and measuring 10.1 by 14.0 centimeters.

The department issued a Class A citation for patient care with a $25,000 penalty. The federal 2567 report from the same survey cited F686, the rule on preventing and treating pressure ulcers, at severity G, which means actual harm. According to that report, the survey also cited F698 (dialysis) and F678 (cardio-pulmonary resuscitation), both at severity J, the immediate jeopardy level, and inspectors tied the dialysis finding to a different resident who missed a scheduled treatment.

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According to the citation, CDPH began an annual recertification survey on July 21, 2025. Resident 1, a 53-year-old man, had been admitted in May 2025 after a stroke, with end stage renal disease (permanent kidney failure) and dependence on hemodialysis (a machine that filters the blood when the kidneys fail). His physician order set dialysis on Wednesdays with an 11 a.m. pickup.

CDPH determined that on June 18, 2025, transportation did not pick him up, and licensed nurses and the social services director did not coordinate with the dialysis center. He was sent at 4:45 p.m. without a nursing assessment, and the center closed at 5 p.m. without treating him. Inspectors found LVN 5 did not report his shortness of breath to the medical director, nurses did not monitor him after he returned, and he was not sent to a hospital as the medical director ordered. The citation states the facility did not verify his code status from his hospital record, which showed he was full code (wanted to be revived). On June 20 at 4:30 a.m., CNA 5 and LVN 3 found him unresponsive with no pulse, and according to the citation they did not immediately start CPR. He died at the facility.

The department issued a Class AA citation for patient care with a $100,000 penalty. The federal 2567 report from the same survey cited F698 (dialysis) and F678 (CPR) at severity J, the immediate jeopardy level, and F686 (pressure ulcer care) at severity G. That report states the immediate jeopardy called on July 25 was removed on July 28 after inspectors verified the facility's corrective steps.

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According to the citation, CDPH made an unannounced visit on January 15, 2025 to investigate a facility-reported allegation of abuse. The department determined that at about 9 p.m. on January 12, 2025, Resident 1 removed the incontinence brief of her roommate, Resident 2, and touched her genital area while signaling her to stop crying. Resident 2 was a 91-year-old woman with dementia and one-sided weakness after a stroke. The citation states she cried loudly and was distressed. CNA 1 heard a noise, saw what was happening and took Resident 1 out of the room.

CDPH found the facility failed to prevent the sexual abuse as its own abuse prevention policy required. Five days earlier, on January 7, Resident 1 had punched a staff member, which the director of nursing told inspectors was a new behavior. Inspectors found the facility did not provide a 72-hour psychosocial follow-up after that incident, and the interdisciplinary team did not evaluate the new behavior to look for underlying causes, as facility policy called for. According to the citation, the director of nursing said there was no documentation that the team met after January 7.

The department issued a Class A citation for patient care, and the $25,000 penalty was trebled to $75,000. The federal 2567 report from the same investigation cited F600, the rule that residents be free from abuse and neglect, at severity G. That report states that, under a reasonable person standard, someone with Resident 2's condition could suffer pain, hopelessness and humiliation.

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According to the citation, Resident 1 was a 63-year-old woman with a left above-the-knee amputation, visual impairment and a history of falls with injury. After she rolled out of bed in April 2024, a physician order dated April 15, 2024 called for visual safety checks every hour. A fall risk assessment on December 17, 2024 rated her at high risk.

CDPH found the facility failed to follow the order for hourly safety checks and did not review or update her fall-risk care plan after the April fall. Inspectors noted the plan's interventions had not been updated since August 2022. According to the citation, around 7:30 p.m. on December 19, 2024, her roommate told LVN 1 that Resident 1 was on the edge of the bed and was going to fall, and staff did not help reposition her. The citation states she fell off the bed, was screaming and crying, and staff called 911. At a hospital she had a 5-centimeter laceration (cut) on her forehead, and on December 20 she was admitted to the intensive care unit for an acute stroke.

CDPH also found the facility did not follow its own policies on fall risk assessment and on updating care plans every quarter. The department issued a Class A citation for patient care with a $25,000 penalty. The federal 2567 report from the same investigation cited F689, the rule on keeping residents free of accident hazards and giving adequate supervision and assistive devices, at severity G, which means actual harm.

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According to the citation, CDPH made an unannounced visit on December 2, 2024 to investigate a facility-reported fall with injury. Resident 1 had muscle weakness, a cognitive communication deficit and chronic kidney disease. A fall risk assessment dated November 11, 2024 scored him as high risk, and his assessment showed he depended on staff to get on and off the toilet. His bladder and bowel care plan called for staff to help him to the toilet every two hours.

CDPH found the facility failed to develop and update a care plan for his fall risk, including staff help and equipment for toilet transfers. Inspectors found his fall care plan had been marked resolved in September 2023, which left him with no active fall plan. A CNA log entry on November 27 said a toilet transfer was not attempted because of lack of equipment. According to the citation, at about 11:30 p.m. on November 28, 2024, he tried to go to the bathroom by himself and fell. He was sent to an acute care hospital and diagnosed with a displaced intertrochanteric fracture of the right femur (a break near the top of the thigh bone, at the hip). A progress note stated he screamed in pain during an X-ray.

The department issued a Class A citation for patient care with a $25,000 penalty. The federal 2567 report cited F689, the rule on accident hazards and supervision, at severity G, which means actual harm. Inspectors wrote in that report that the facility failed to help him to the toilet every two hours as his care plan required, and that this was a repeated deficiency.

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The 2567 report states that inspectors investigating a complaint in April 2024 found the facility failed to protect two residents, Resident 4 and Resident 2, from physical and mental abuse by another resident, Resident 5. According to the report, on April 5, 2024, Resident 5 threw urine from his urinal onto his roommate, Resident 4, and the two argued. CNA 2 told inspectors that Resident 5 became upset when she said she would change his diaper after lunch, threw his lunch tray against the door, and the two roommates began yelling and throwing things at each other.

Inspectors found that both residents were placed on one-to-one supervision until a room change. On April 7, after Resident 5 moved to a different room, he threw urine that splashed onto his new roommate, Resident 2, who threw a bottle of water back, the report states. Resident 2 was soiled with urine and needed to be cleaned. A physician order transferred Resident 5 to an acute care hospital on April 8 for verbal aggression toward a resident.

According to the report, Resident 2 described anxiety and feeling more depressed, and Resident 4 described increased depression. Resident 4 told inspectors the incident raised his anxiety and kept him from his usual activities, such as walking, reading and watching movies, for four days. The 2567 report cited F600, the rule that residents be free from abuse and neglect, at severity G, which means actual harm.

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The 2567 report states that at 11:45 a.m. on November 19, 2023, Resident 1 lit incense with a lighter inside a drawer and the drawer caught fire. Inspectors found two more fires followed early on November 20, at midnight and at 12:30 a.m. According to the report, the facility knew Resident 1's roommate, Resident 2, was on continuous oxygen on both days. Residents 2 and 3 told inspectors they feared for their lives.

According to the report, the facility failed to monitor and supervise Resident 1 after the first fire, failed to inspect and inventory his belongings and investigate that fire, and failed to check all residents, including those who smoke, for contraband such as lighters after the three fires. Inspectors wrote that the fires could have caused serious harm, smoke inhalation, explosion or death for the 57 to 60 residents in the building on those days. On December 6, 2023, the state survey agency called an immediate jeopardy.

The 2567 report cited F689, the rule on keeping residents free of accident hazards and giving adequate supervision, at severity L, the immediate jeopardy level for a widespread problem. The report states the facility gave an acceptable removal plan on December 7 and the immediate jeopardy was lifted that evening after surveyors confirmed it. The plan included new inventories of residents' belongings, staff training on the smoking policy, new smoking assessments for the ten residents who smoke, fire drill training and tracking of packages delivered to residents.

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The 2567 report states that on October 17, 2023, Resident 1 repeatedly asked nursing staff to clean her roommate, Resident 2, who smelled of urine and stool. Resident 2 had impaired cognition and depended on staff for daily care. According to the report, CNA 1 said several times she would come back to clean Resident 2 and did not, and Resident 2 was left lying in urine and feces from about 8:20 a.m. to 1:20 p.m., four hours and 50 minutes.

Inspectors found that around 1:20 p.m., CNA 1 yelled at Resident 1, told her to shut up and used vulgar words in CNA 1's native language, and kept arguing after LVN 1 told her to leave the room. The report states Resident 1 could not eat breakfast because of the smell and afterward had a pounding heart, anxiety, trouble sleeping and fear. CNA 1 resigned by phone the same day. According to the report, the facility's own investigation substantiated the allegation and it held a staff in-service on abuse and de-escalation.

The 2567 report cited F600, the rule that residents be free from abuse and neglect, at severity G, which means actual harm. Inspectors found the facility failed to protect Resident 1 from verbal and mental abuse and failed to protect Resident 2 from neglect. Using a reasonable person standard, the report states Resident 2 experienced psychosocial harm, including embarrassment, humiliation and a loss of dignity.

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The 2567 report states that at 5:38 a.m. on September 3, 2023, LVN 1 and CNA 1 found Resident 1 trying to light incense with a lighter torch in the room he shared with Resident 2, who used oxygen. LVN 1 took away the torch and incense and told Resident 1 that the oxygen made it a hazard. According to the report, Resident 1 then went to Resident 2's bed and yelled at him, and later threatened to beat him up.

Inspectors found the facility failed to protect Resident 2 from verbal and mental abuse by Resident 1, as its abuse prevention policy required. The report states Resident 2 did not feel safe, had more anxiety and trouble sleeping, and feared for his life. According to the report, the doses of two of his anti-anxiety medications were increased afterward. Resident 2 told inspectors he had a friend sit with him so Resident 1 would not hurt him, and that he never felt safe while they shared a room.

According to the report, the facility was cited under F600, the rule that residents be free from abuse and neglect, at severity G, which means actual harm. The same report also cited F609, on reporting alleged violations, at severity D, which means no actual harm with potential for more than minimal harm. The full narrative for F609 is in the linked report.

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The 2567 report states that Resident 1, who had heart failure and fluid around the lungs, was allergic to onions and melons, and his diet card listed both. According to inspectors, he had allergic reactions after eating food with onions on March 8, 2023 and July 22, 2023, when he ate potato salad, and another reaction on July 3 with no documented cause. His care plan from March 2023 said the allergen would not be given at any time.

Inspectors found that on July 27, 2023, his dinner tray included macaroni salad, and the facility's standardized recipe called for chopped onion. Cook 1 told inspectors he followed the recipe. Resident 1's top lip swelled and he was given Benadryl, an allergy medication. The report states the reaction could have led to anaphylactic shock (a severe allergic reaction that can close the airway), cardiac arrest or death. The assistant dietary supervisor told inspectors that food preferences and food allergies were getting mixed up, and said she did not know what was done after he reported the July 22 reaction.

The 2567 report cited F806, the rule on meeting residents' food allergies, intolerances and preferences, at severity J, the immediate jeopardy level. According to the report, inspectors notified the facility of an immediate jeopardy on July 27 and removed it on July 28 after verifying the facility's removal plan. That plan included checking the dinner meals of all residents, having the dietitian reassess every resident's restrictions and preferences, and training dietary staff on food allergies and meal preparation.

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