Mid-Wilshire Health Care CNTR

In the surveyor’s words

From the most serious findings on record at Mid-Wilshire Health Care CNTR, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 26, 2025

  Based on interview and record review, the facility failed to ensure one of eight sampled residents' (Resident 1) food consistency and texture brought in by Resident 1's son on 9/18/23 was allowed and in compliance with her mech soft, finely chopped diet being the food was fed to the resident, and that Resident 1 was assisted, supervised, and monitored for choking when eating. The facility failed to ensure: 1.There was a system in place to check/screen food brought into the facility from outside for consistency and texture to match that which the physician had ordered.2.The physician's order was followed to monitor choking signs and symptoms while feeding the resident.3. Certified Nursing Assistant (CNA 1) did not feed Resident 1 while resident is drowsy on 9/19/2023. […]

• Actual harm, isolatedF689Jun 24, 2024

  Based on observation, interview and record review, the facility failed to ensure one sampled resident (Resident 1), who had diagnosis of dementia (loss of cognitive functioning - thinking, remembering, and reasoning - to such an extent that the loss interferes with a person's daily life and activities), had history of fall, and was assessed as high risk for falls, received the care and services necessary to prevent accidents and falls by failing to: -Develop a comprehensive care plan for Resident 1's fall prevention, per the facility's policy and procedure (P&P) titled, Person Centered Plan of Care. -Frequently monitor Resident 1 and anticipate resident's needs to ensure the resident's safety to prevent fall accidents. […]

• Actual harm, isolatedF689Apr 23, 2024

  Based on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1), who had dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities), a history of multiple falls, and was a high risk for falls, received the care and services necessary to prevent accidents and falls by failing to: 1. Implement facility's policy and procedure (P&P) titled Fall Prevention Program, to identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling. 2. Evaluate interventions for effectiveness and implement new interventions to prevent repeated fall incidents after Resident 1 fell on [DATE], 3/20/2024, and 4/17/2024. 3. […]

• Actual harm, isolatedF600Mar 28, 2024

  Based on observation, interview, and record review, the facility failed to provide protection from sexual (non-consensual sexual contact of any type with a resident, including sexual harassment, sexual coercion, or sexual assault) by facility staff, for one of three sampled residents (Resident 1). Resident 1 alleged sexual abuse by Certified Nurse Assistant (CNA) 1, when CNA 1 touched the resident ' s private parts and held Resident 1's hand on his (the CNA's) private part. This deficient practice resulted in Resident 1 having psychological distress (a state of emotional suffering), was crying and reported feeling afraid, ashamed, anxious and guilty. […]

• No harm, potential for more than minimal, patternF578Mar 12, 2026

  Based on interview and record review, the facility failed to follow up on assisting the residents with executing an advance directive (AD - a legal document indicating resident preference on end-of-life treatment decisions) for three of four sampled residents (Resident 2, 5, and 19). This failure had the potential to result in the residents' wishes regarding treatment and care needs not being met. Findings: During a review of Resident 2's admission Record, the admission Record indicated Resident 2 was admitted on [DATE] with diagnoses including but not limited to atherosclerotic heart disease (the hardening and narrowing of arteries due to plaque buildup), hemiplegia (total paralysis of the arm, leg, and trunk on the same side of the body), and high blood pressure. […]