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Complaint Investigation

Westlake Convalescent Hospital

April 27, 2026 · Los Angeles, CA · 316 S Westlake Avenue
Citations 2
CMS Rating 4/5
Beds 114
Provider ID 056242
Healthcare Facility
Westlake Convalescent Hospital
Los Angeles, CA  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

WESTLAKE CONVALESCENT HOSPITAL in LOS ANGELES, CA — inspection on April 27, 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

FF0584
Resident Rights Deficiencies

During a review of Resident 1's admission Record, the admission Record indicated the facility admitted Resident 1 on 12/10/2022 and was re-admitted on [DATE] with diagnoses including chronic respiratory failure (a condition that results in the inability to effectively exchange carbon dioxide and oxygen), tracheostomy (an opening surgically created through the neck into the trachea [windpipe] to allow direct access to the breathing tube) and dependence on respirator (ventilator-a machine or device used medically to support or replace the breathing of a person, unable to breath on their own).

During review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/4/2026, the MDS indicated Resident 1 had impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and dependent (helper does all the effort) from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene).

During a review of Resident 1's History and Physical (H&P) dated 4/9/2026, the H&P indicated the resident did not have the capacity to understand or make decisions.

During a concurrent observation and interview with the Director of Nursing (DON) and Maintenance Staff (MS) on 4/24/2026 at 1:41 PM, inside Resident 1's room, observed Resident 1's curtain strings were tangled and ceiling had multiple brownish stains.

The MS stated that staff (in general) were supposed to check the room weekly for any issues.

The DON stated that curtain strings were not supposed to be tangled and there should not have any stains in the ceiling to be able to provide a clean and homelike environment to Resident 1.

During a review of the facility's policy and procedure (P&P), titled, Quality of Life: Homelike Environment, reviewed on 1/16/2026, the P&P indicated that residents were provided with a safe, clean, and homelike environment characterized by cleanliness and order; and privacy curtains clean and in good condition.

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

056242 04/27/2026

Westlake Convalescent Hospital 316 S Westlake Avenue Los Angeles, CA 90057

During review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 4/4/2026, the MDS indicated Resident 1 had impaired cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and dependent (helper does all the effort) from staff for activities of daily living (ADLs-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene).

During a review of Resident 1's History and Physical (H&P) dated 4/9/2026, the H&P indicated the resident did not have the capacity to understand or make decisions.

During a review of Resident 1's Care Plan Report, revised on 4/9/2026, the care plan indicated Resident 1 was at risk for fall as manifested by poor safety awareness.

The Care Plan Report indicated to assist Resident 1 with all the transfers.

During a concurrent observation and interview with Registered Nurse 1 (RN1) on 4/24/2026 at 9:06 AM, inside Resident 1's room, observed Resident 1 up in the Hoyer lift on top of the bed with no staff around. RN1 immediately called for Certified Nursing Assistant 1 (CNA1). CNA1 stated that she (CNA1) was calling another staff (unidentified) for assistance. CNA1 stated that she (CNA1) was not supposed to leave Resident 1 in the Hoyer lift unattended. RN1 stated that it was important to make sure that when a resident was up in the Hoyer lift, resident should not be left unattended due to safety concern.

During an interview with the Director of Nursing (DON) on 4/24/2026 at 11:20 AM, the DON stated that staff (in general) should not leave residents (in general) unattended when using a Hoyer lift and it was best practice to make sure there was at least two staff assisting a resident when using a Hoyer lift due to safety issues.

During a review of the facility's policy and procedure (P&P), titled, Safe Lifting and Movement of Residents, reviewed on 1/16/2026, the P&P indicated that facility used appropriate techniques and devices to lift and move residents in order to protect the safety and well-being of staff and residents and to promote quality of care.

During a review of facility's P&P titled, Safety and Supervision of Residents, reviewed on 1/16/2026, the P&P indicated that facility strived to make the environment as free from accident hazards as possible; and resident safety, supervision and assistance to prevent accidents were facility-wide priorities.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in LOS ANGELES, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from WESTLAKE CONVALESCENT HOSPITAL or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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About This Inspection Report

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.