Cheviot Hills Post Acute
Cheviot Hills Post Acute in Los Angeles, CA — inspection on April 28, 2026.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool) dated 3/6/2026, the MDS indicated Resident 1 was severe cognitive impairment (a significant decline in mental abilities-such as memory, thinking, and judgment-that prevents a person from living independently and managing daily tasks).
The MDS indicated Resident 1 required substantial/maximal assistance from staff for most of his Activities of Daily Living (ADLs such as, toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, personal hygiene, lower/upper body dressing).
During a concurrent interview and record review of Resident 1's consents with the Assistant Director of Nursing (ADON) on 4/27/2026 at 11:06 am, the ADON stated consents for antipsychotics are completed upon admission and when there is a new order.
The ADON stated that a consent must include the name of the medication, dosage, route, and frequency of the administration.
The ADON confirmed that there was no consent for Seroquel 100mg.
The ADON stated that the importance of having a consent ensures that the resident would be getting that medication and that the resident/RP (Resident 1's mom) understood the risks and benefits of the ordered antipsychotic.
During a review of a policy and procedures (P&P) titled, Informed Consent for Psychotropic Drugs, reviewed 2/2026 indicated, This policy outlines responsibilities for obtaining, verifying, and documenting informed consent to protect resident rights, promote safety, and facilitate appropriate use of these medications for residents with behavioral or psychotic symptoms, such as those associated with dementia.
The same P&P defined informed consent as, Disclosure of material information (e.g., reasons for use, benefits, risks including black box warnings, alternatives including nonpharmacological approaches) to the residents or their representative allowing them to accept, refuse, or revoke consent.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
056451 04/28/2026
Cheviot Hills Post Acute 3533 Motor Avenue Los Angeles, CA 90034
During a review of Resident 1's physician's order dated 3/18/2026, the order indicated Quetiapine Fumarate Oral Tablet (Quetiapine Fumarate) Give 150 mg by mouth at bedtime for MDD with Psychotic [a mental state characterized by a severe loss of contact with reality] features M/B inconsolable screaming. ˆ ˆ During a review of Resident 1 ' s Minimum Data Set (MDS - a resident assessment tool) dated 3/6/2026, the MDS indicated Resident 1 was severe cognitive impairment (a significant decline in mental abilities-such as memory, thinking, and judgment-that prevents a person from living independently and managing daily tasks).
The MDS indicated Resident 1 required substantial/maximal assistance from staff for most of his Activities of Daily Living (ADLs such as, toileting hygiene, shower/bathe self, lower body dressing, putting on/taking off footwear, personal hygiene, lower/upper body dressing).
During a review of Resident 1's care plans, there was no care plan for Seroquel and no care plan for Resident 1's monitoring for his (Resident 1), psychotic behavior.
During a concurrent interview and record review of Resident 1's care plans with the Assistant Director of Nursing (ADON) on 4/27/2026 at 11:06 am, the ADON stated that care plans must be developed for residents being monitored for behavioral issues such as aggressive behaviors and yelling.
The ADON stated that care plans must be developed for medications to ensure that the care team is aware about what interventions to carry out for the resident.
The ADON confirmed that there was neither a care plan for Resident1's behavior monitoring nor Seroquel.
During a review of the policy and procedure (P&P) titled, CARE PLAN COMPREHENSIVE) reviewed 10/20/2025, the P&P indicated An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident ' s medical, physical, mental and psychosocial needs shall be developed for each resident.
During a review of a P&P titled, Behavior Management, reviewed 10/20/2025, the P&P indicated, Residents exhibiting behavioral symptoms will be individually evaluated to determine the behavior.
The interdisciplinary team identifies underlying medical, physical, functional, psychosocial, emotional, psychiatric, or environmental causes that contribute to changes in the residents' behavior.
The P&P indicated, Staff will use non-pharmacological interventions as the first line of approach to managing challenging behaviors. behaviors and interventions will be addressed in the care plan.1.
The facility will monitor identified residents who:a.
Exhibit behavioral symptoms (e.g., verbally or physical abusive, socially inappropriate/disruptive, resist care, wandering, etc.).b.
Implement non-pharmacologic interventions as initial interventions.c.
Obtain informed consent.d.
Refer to mental health services, if necessary.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.