Culver West Health Center
CULVER WEST HEALTH CENTER in LOS ANGELES, CA — inspection on May 2, 2025.
Found 4 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 record review, Resident 33's History and physical (H&P -a detailed assessment a doctor does to understand a patient's health) dated 11/10/2024, the H&P indicated Resident 33 does not have the capacity (ability to do something) to understand and make decisions.
During a record review, Resident 33's Minimum Data Set (MDS - a resident assessment tool) dated 3/17/2025, indicated Resident 33 had moderate cognitive impaiment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life).
The MDS indicated Resident 33 was dependent on staff for toileting, dressing, transfers and person hygiene.
During a record review, Resident 29's physician order dated 4/17/2025, at 11:08 P.M., the physician's order indicated to collect urine for urinalysis (UA- a laboratory test that examines a urine sample to detect and analyze various substances and conditions) with culture and sensitivity (C&S - a procedure that involves growing bacteria or other microorganisms from a urine sample to identify the specific organism causing an infection and determine its sensitivity to antibiotics [medications used to prevent and treat infection]).
055350
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 055350 B.
Wing 05/02/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Culver West Health Center 4035 Grandview Blvd.
Los Angeles, CA 90066
During a facility tour on 4/28/25 at 11:35 AM, there was a sign posted outside Resident 19's room that indicated Residet 19 was EBP and to staff to don PPE prior to entering the room. CNA2 was inside the Resident 19's room and was providing ADL care to Resident19 without donning appropriate PPE (gown).
During an interview 4/28/2025 at 11:39AM, CNA2 stated CNA2 was unaware PPE had to be donned (put on PPE) continuously while providing ADL care to a resident on EBP and doffed (remove PPE) only when care was completed.
During an interview on 5/2/2025 at 1:10PM, infection prevention nurse (IPN) stated staff should don PPE when they have physical contact with a resident on EBP. IPN stated the facility had sufficient PPEs sufficient and the PPEs are located in areas close to the residents rooms for easy access. IPN stated staff who do not follow enhanced precaution procedures can spread infection to other residents through contamination of their (staff) clothing and hands from residents bodily fluids and waste.
During an interview on 5/2/2025 at 3:09 PM, the Director of Nursing (DON) stated staff should don PPE when providing care to Residents on enhanced precautions to prevent transfer of disease-causing microorganisms from staff to facility residents and to break the cycle of infection.
055350
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 055350 B.
Wing 05/02/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Culver West Health Center 4035 Grandview Blvd.
Los Angeles, CA 90066
During a record review, Resident 71's admission record (face sheet - a document containing demographic and diagnostic information) indicated, Resident 71 was admitted to the facility on [DATE] and was readmitted on [DATE] with the following diagnoses: neuromuscular dysfunction of the bladder (a condition where the nerves and muscles controlling bladder function don't work properly due to damage to the brain, spinal cord, or nerves), history of urinary tract infections (UTIs - a person has previously experienced one or more UTIs), and presence of urogenital implants (the existence of artificial devices or materials within the urogenital system, which includes the urinary and reproductive organs).
During a record review, Resident 71's History and Physical (H&P - a physician's complete patient examination) dated 1/17/2025, indicated, Resident 71 can make needs known but cannot make medical decisions.
During a record review, Resident 71's Minimum Data Set (MDS - a resident assessment tool) dated 1/20/2025 and 3/06/2025, indicated, Resident 71 was cognitively intact (a person's thinking and reasoning abilities are functioning properly and are not significantly impaired).
055350
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 055350 B.
Wing 05/02/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Culver West Health Center 4035 Grandview Blvd.
Los Angeles, CA 90066
During a record review, Resident 33's History and physical (H&P -a detailed assessment a doctor does to understand a patient's health) dated 11/10/2024, the H&P indicated Resident 33 does not have the capacity (ability to do something) to understand and make decisions.
During a record review, Resident 33's Minimum Data Set (MDS - a resident assessment tool) dated 3/17/2025, indicated Resident 33 had moderate cognitive impaiment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life).
The MDS indicated Resident 33 was dependent on staff for toileting, dressing, transfers and person hygiene.
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
055350
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 055350 B.
Wing 05/02/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Culver West Health Center 4035 Grandview Blvd.
Los Angeles, CA 90066