Inglewood Health Care Center

In the surveyor’s words

From the most serious findings on record at Inglewood Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF880Feb 14, 2022

  Based on observation, interview, and record review, the facility failed to implement interventions to prevent and control the spread of the coronavirus ([COVID 19]) an illness caused by a virus that can easily spread from person to person), by not ensuring the following: 1.Two out of two Certified Nursing Assistants (CNA) 1 and CNA 2 wore appropriate ( N95, eye protection [goggles or face shield], gown and gloves ) personal protective equipment ([PPE] equipment worn to minimize exposure to hazards that cause injuries and illnesses, fitted N95 mask [mask worn over the face to cover the nose and mouth that provides respiratory protections against aerosols (a suspension of fine solid particles or liquid droplets in air) and prevent infections], eye protection, gloves, and a gown) prior to… […]

• Immediate jeopardy, patternF812Aug 18, 2025

  Based on observation, interview, and record review, the facility failed to ensure safe dietary services were provided to 88 of 93 residents who were served food from the kitchen, when:1. On 8/13/2025, from 5:30 am to 2:25 pm, liquid eggs (processed form of whole eggs, also known as cartoned eggs) were thawed (defrost) at room temperature (ambient temperature [actual temperature] measured by a thermometer around 73 degrees Fahrenheit ([ F]- a unit of temperature) without monitoring the time and temperatures. Liquid eggs were at 55 F which was within the danger zone [41-135 F] temperature range where bacteria grow quickly). 2. On 8/13/2025 from 12:10 p.m. to 1:30 p.m., ground beef was thawed at room temperature without time and temperature monitoring. […]

• Immediate jeopardy, isolatedF689Oct 25, 2022

  Based on interview and record review, the facility failed to provide supervision to one of one sampled resident (Resident 1) while smoking in the smoking patio on 10/8/22, to prevent the resident from leaving the facility unsupervised. Resident 1 had impaired cognition with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), high blood pressure and [CONDITION(S)] (mental illness that can affect your thoughts, mood, and behavior) disorder. Resident 1 was assessed as a high risk for elopement. A Housekeeping Staff (HSK) 1 deactivated the door leading to the smoking patio, opened the door to allow Resident 1 to go out and smoke without supervision. […]

• Actual harm, isolatedF689Jan 14, 2026

  Based on observation, interview and record review, the facility failed to ensure for one of three sampled residents (Resident 1), who was assessed as being at risk (likelihood) for elopement (leaving the facility unsupervised) and wandering (walking/ travelling from place to place, without any clear aim or purpose) out of the facility and being high risk for falls with a history of multiple falls, was monitored and whereabouts (location in the facility) checked. This failure resulted in Resident 1 wandering out from the facility on 1/9/2026 without the facility's knowledge and supervision leading to the resident's fall and sustaining left hand fourth (4th) and fifth (5th) fingers fracture (brake in bone), left frontal scalp hematoma (a collection or pool of blood that forms outside of… […]

• Actual harm, isolatedF686Jan 5, 2022

  Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) received all the necessary care and services to prevent pressure sore(s) from developing and deterioration. The facility failed to: 1. Ensure the licensed nurses assess Resident 1's skin tear, identified and documented skin tear location, notify the resident's physician and obtained treatment order for it. 2. Ensure Resident 1 did not develop a Stage II pressure ulcer ([PU] injuries to skin and underlying issue resulting from prolonged pressure on the skin) to a right buttock. On 2/24/2021 Resident 1 developed a PU to a right buttock that licensed nurses did not assess, did not notified the physician of it, and did not obtained treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] 3. […]