TORRANCE, CA - A federal inspection of Heritage Rehabilitation Center revealed serious violations involving inadequate nutrition management leading to severe weight loss and failures in pain management during wound care procedures. The June 2024 survey documented multiple instances where facility staff failed to follow care protocols, resulting in actual harm to residents requiring specialized medical care.
Severe Weight Loss Due to Nutritional Management Failures
The facility failed to prevent a 9.57% weight loss over just 34 days for a resident receiving tube feeding nutrition, despite multiple opportunities to intervene and correct the declining trajectory. The resident, who had amyotrophic lateral sclerosis and required gastrostomy tube feeding, lost nine pounds between April 29 and June 1, 2024, dropping from 94 pounds to 85 pounds.
Medical records showed the resident's body mass index of 17.9 placed them in the underweight category, where even small weight losses can have serious health consequences. The facility's registered dietitian had initially recommended increasing the resident's enteral feeding from 250 milliliters four times daily to five times daily, providing 1,500 kilocalories. However, documentation revealed this critical recommendation was never implemented.
The weight decline showed a clear pattern requiring immediate intervention: - May 12: Seven pounds lost (7.45% decrease) - May 19: 6.6 pounds lost (7.02% decrease) - May 26: 8.6 pounds lost (9.15% decrease) - June 1: Nine pounds lost (9.57% decrease)
Despite the resident's care plan specifically stating that any weight loss of five pounds should trigger immediate notification to the physician and dietitian, staff failed to report the progressive weight loss or hold required weekly weight variance meetings. The Director of Nursing confirmed that without documentation of these meetings, "it means it was not done."
The dietitian acknowledged during the inspection that the resident did not receive the estimated 1,495 to 1,709 kilocalories needed daily. Review of medication administration records revealed the resident received only 250 milliliters at lunch instead of the ordered 500 milliliters for at least 14 days during May 2024, further reducing caloric intake below minimum requirements.
Pain Management Failures During Wound Care
The inspection documented disturbing instances of uncontrolled pain during pressure ulcer treatment for a resident with a Stage 4 sacral wound. The resident, who had dementia and could not verbally communicate pain levels, repeatedly screamed and moaned during wound care procedures on June 10 and June 13, 2024.
During the June 10 observation, the attending physician entered the room and offered to prescribe Norco for pain management after witnessing the resident's distress. The treating nurse declined this recommendation, stating the Lidocaine spray would be sufficient. The nurse then proceeded with the wound treatment despite the resident's continued screaming and moaning throughout the procedure.
The facility's Director of Staff Development stated that "when Resident 73 screamed loudly during the pressure ulcer treatment, RN 6 should have stopped the treatment, assessed Resident 73 pain level, including the non-verbal cues like facial grimacing, notified the physician, and provide Resident 73 pain medication."
Although the resident had received Tylenol 325 mg before the procedure, the medication's effectiveness was never evaluated before beginning treatment. The treating nurse later admitted the resident "continued to suffer from pain because her pain was not addressed and managed during the pressure ulcer treatment."
Medical Implications of These Violations
Severe weight loss in already underweight residents creates cascading health problems. When body mass index falls below 18.5, the body lacks adequate reserves to maintain essential functions. This places residents at heightened risk for pressure ulcer development, delayed wound healing, increased infection susceptibility, and decreased immune function. For residents with neurodegenerative conditions like amyotrophic lateral sclerosis, maintaining adequate nutrition becomes even more critical as the disease progressively affects swallowing and metabolic needs.
Inadequate pain management during wound care procedures causes more than immediate distress. Uncontrolled pain triggers physiological stress responses that impair healing, increase blood pressure, and can lead to behavioral changes in residents with dementia. Stage 4 pressure ulcers extend through all skin layers into muscle and bone tissue, making them extremely painful even with gentle handling. Standard protocols require comprehensive pain assessment before, during, and after wound treatments, with immediate intervention when pain indicators appear.
Systemic Staffing Deficiencies
The inspection also revealed chronic understaffing in the facility's restorative nursing program, affecting 95 residents with physician orders for specialized services. Throughout May and June 2024, the facility consistently operated below the minimum four restorative nursing aides required daily, with staffing dropping to just two aides on multiple weekend days.
Staff members reported being unable to provide ordered services due to inadequate staffing levels. One restorative nursing aide stated she attempted to serve 15-20 residents daily but acknowledged "many residents in the facility would not be seen for RNA treatment due to lack of staffing." Another aide described having "double or triple the workload" when covering for absent colleagues.
Additional Issues Identified
The inspection revealed multiple systemic failures in the facility's care delivery systems. Staff failed to conduct required nutritional assessments upon admission and did not complete weekly monitoring for at-risk residents. Communication breakdowns between nursing staff and the dietitian meant critical weight loss information never reached the appropriate professionals for intervention. The facility's own policies requiring immediate dietitian notification for 5% weight loss were repeatedly ignored. Documentation gaps throughout resident records suggested widespread non-compliance with established protocols for monitoring and reporting changes in resident conditions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Heritage Rehabilitation Center from 2024-06-13 including all violations, facility responses, and corrective action plans.
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