LOS ANGELES, CA - State health inspectors documented multiple deficiencies at Los Feliz Healthcare & Wellness Center during a June 2024 survey, including failures to provide consistent bathing assistance, maintain proper CPR certification for nursing staff, and assess new skin issues in residents requiring extensive daily care assistance.
Inconsistent Bathing Care Raises Quality of Life Concerns
Inspectors identified significant gaps in the facility's provision of basic hygiene care to a resident requiring substantial assistance with daily activities. The resident, admitted in 2018 with diagnoses including major depressive disorder, muscle wasting and atrophy, and difficulty walking, needed supervision with eating and substantial to maximal assistance with bathing and dressing according to assessment records from May 2024.
Documentation revealed multiple instances where bathing care was either not provided or not properly recorded. The resident's care plan specified bathing or showering on Mondays and Thursdays, but activity records showed numerous gaps. The resident refused bathing on three separate occasions in May and early June 2024, with staff instead providing bed baths on several dates. However, records contained no documentation indicating whether care was provided or refused on June 20 and June 24, 2024.
Additionally, flowsheet entries for multiple scheduled bathing days in May and June were marked only with an "X," which facility staff explained meant the bathing task was not triggered in the certified nursing assistant's assignment system. According to the Director of Staff Development, these markings could indicate the resident was neither offered nor provided bathing or bed bath alternatives on those dates.
When inspectors observed the resident on June 27, 2024, at 8:15 a.m., they noted the individual lying in bed with both lower legs exposed, displaying dry, scaly skin and redness on the right shin. Multiple staff members interviewed that day acknowledged the skin condition. Treatment Nurse 2 stated the resident had dry skin and peeling on both lower legs with redness on the right shin, noting that certified nursing assistants were supposed to apply lotion after providing daily care to help moisten skin and prevent breakdown.
Regular bathing serves multiple critical functions beyond basic hygiene. For individuals with limited mobility and skin fragility, consistent cleansing removes bacteria, dead skin cells, and irritants that can compromise skin integrity. The outermost layer of skin, the stratum corneum, acts as a protective barrier against infection and injury. When this barrier becomes excessively dry and begins to crack or peel, it creates entry points for pathogens and increases vulnerability to pressure injuries and skin tears.
The inspection report noted the resident's care plan, initiated in November 2021, specifically addressed risk for skin breakdown related to impaired mobility, incontinence, decreased sensation, and thin fragile skin. Weekly treatment documentation was supposed to include measurements of any skin breakdown areas. The facility's own policy on showering and bathing emphasized observing skin during bathing and reporting any broken skin, bruises, rashes, cuts, discoloration, or reddened areas to the charge nurse.
Certified Nursing Assistant 9 told inspectors that when residents refuse showers, staff should offer at least three times and then provide a bed bath alternative. The assistant stated that residents have lotion on their nightstands for daily application during care activities. However, the documentation gaps suggested this protocol was not consistently followed.
The Director of Staff Development acknowledged that certified nursing assistants were supposed to apply lotion to residents after providing appropriate daily care, as residents at the facility face high risk for dry, scaly skin due to their level of assistance needs. The Director noted that failing to provide appropriate daily care could potentially affect the resident's quality of life and self-esteem.
Staff CPR Certification Lacked Required Hands-On Training
Inspectors identified a critical gap in emergency preparedness when they discovered that one licensed vocational nurse's CPR certification did not include the required hands-on practice and in-person skills assessment. The staff member had obtained Basic Life Support Provider certification through the National CPR Foundation on an unspecified date, valid for two years. However, the certification was obtained through an online-only course without practical skills validation.
Cardiopulmonary resuscitation represents one of the most time-sensitive interventions in healthcare emergencies. When cardiac arrest occurs, brain cells begin dying within minutes due to oxygen deprivation. Effective chest compressions must achieve adequate depth and rate while maintaining proper hand placement and body positioning. These physical skills cannot be adequately assessed or validated through online testing alone.
The American Heart Association and other leading resuscitation organizations have established that while knowledge components can be delivered through various learning methods, psychomotor skills required for CPR must be practiced and assessed in person. Proper compression technique requires specific physical feedback—understanding how hard to push, how to position hands, and how to maintain consistent rhythm and depth. Without hands-on practice under instructor observation, healthcare providers cannot develop the muscle memory and technique necessary for effective resuscitation.
During a telephone interview with the licensed vocational nurse on June 27, 2024, the staff member confirmed taking the CPR renewal course online without in-person or hands-on training validation for performing CPR. The Director of Staff Development acknowledged during a concurrent interview and record review that the renewal course did not include hands-on training.
The facility's job description for licensed vocational nurse staff specifically requires valid CPR certification as a qualification for employment. More critically, the facility's own policy on cardiopulmonary resuscitation, last reviewed in May 2024, explicitly states that licensed nursing staff must maintain current CPR certification for healthcare providers through a provider whose training includes hands-on practice and in-person skills assessment, specifying that online-only certification is not acceptable.
The Director of Nursing stated that staff should have CPR certification with in-person and hands-on training to ensure competent provision of CPR to residents. The Director noted that failure of staff to be validated for hands-on CPR training could lead to inability to perform CPR appropriately and had the potential to result in resident death.
In nursing facilities, where the average resident age exceeds 80 years and multiple chronic conditions are common, cardiac emergencies occur with relative frequency. Staff response in the critical minutes before emergency medical services arrive can determine survival outcomes. Inadequate chest compression technique—whether too shallow, too deep, incorrect hand placement, or inconsistent rate—significantly reduces the likelihood of successful resuscitation.
Failure to Assess New Skin Discoloration
The inspection narrative referenced an additional citation related to the same resident observed with dry, scaly skin. Inspectors documented that the facility failed to ensure the resident received treatment and care in accordance with professional standards of practice by failing to assess and identify new skin issues when discoloration was observed around the ankle area.
This finding connected to the broader pattern of inadequate skin monitoring documented in the bathing care deficiency. The resident's care plan from November 2021 specifically identified risk for skin breakdown related to impaired mobility, incontinence, decreased sensation, and thin fragile skin. The plan called for weekly treatment documentation including measurements of each area of skin breakdown.
Professional nursing standards require thorough skin assessment during each shift for residents at risk for skin breakdown. Any new areas of redness, discoloration, or skin changes should prompt immediate assessment to determine whether the finding represents early pressure injury development, vascular compromise, trauma, or other conditions requiring intervention.
Discoloration around the ankle area in a resident with impaired mobility and documented muscle wasting could indicate several concerning conditions. Dependent edema, where fluid accumulates in the lower extremities due to gravity and impaired circulation, can cause skin color changes. Venous insufficiency, common in elderly individuals with limited mobility, can produce brownish discoloration. Early pressure injury development may present as persistent redness or purple discoloration that does not blanch with finger pressure.
Each of these conditions requires different interventions. Failure to assess and document new skin changes prevents appropriate treatment planning and may allow progression to more serious complications including tissue breakdown, infection, or deep tissue injury.
Additional Issues Identified
The inspection report noted that Registered Nurse 1 stated skin checks on residents should be performed every shift and documented by the charge nurse. However, the documentation gaps and unassessed ankle discoloration suggested this protocol was not consistently implemented for the resident in question.
The facility's policy on resident rights and quality of life, last reviewed in May 2024, emphasized that each resident should be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality, with services delivered in a person-centered manner to support residents in attaining or maintaining their highest practicable well-being.
The Director of Nursing's acknowledgment that not receiving appropriate daily care could potentially affect the resident's quality of life and self-esteem underscored the significance of consistent bathing assistance. Personal hygiene directly impacts residents' dignity, comfort, social engagement, and psychological well-being. Visible skin conditions and inadequate grooming can lead to social isolation and declining mental health, particularly for residents already facing challenges such as major depressive disorder.
The facility's policy on activities of daily living documentation, last reviewed in May 2024, specified providing consistency in documentation of resident status and care given by nursing staff, with the facility ensuring documentation of care provided for completion of ADLs either manually or electronically. The documentation gaps identified during the inspection indicated this policy was not effectively implemented.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Los Feliz Healthcare & Wellness Center, Lp from 2024-06-28 including all violations, facility responses, and corrective action plans.
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