On February 16, the Los Angeles County Office of Inspector General (OIG) issued its second report of an ongoing investigation into the crisis in nursing homes. The report and related findings from the Auditor-Controller pick up where the first interim report left off in describing the County Department of Public Health’s dysfunctional nursing home oversight system.

The new report takes an in-depth look at the evacuation of two Pasadena nursing homes that exposed their residents to life-threatening conditions during the pandemic; describes the concerns of numerous inspectors who complained that the safety of residents who live in nursing homes in L.A. County is compromised by pressures they face to prematurely close investigations and understate serious violations; makes the connection between chronically poor care and profiteering nursing home chains; and identifies systemic management failures that prevent the Department of Public Health’s Health Facility Inspection Division from prioritizing its work and from holding nursing homes accountable.

The report contains thirteen recommendations, beginning with a recommendation to develop a comprehensive county-wide skilled nursing facility crisis mitigation and response plan. It closes with a statement that “the OIG will further analyze the complex issues involving ownership structures, and make corresponding recommendations, in its final report.”