LOS ANGELES, CA - Federal inspectors cited Los Feliz Healthcare & Wellness Center for multiple safety violations during a June 2024 inspection, including failures to properly monitor residents receiving critical medical treatments and maintain basic safety protocols.
Medication Monitoring Breakdown
The most serious violation involved a 6-year resident who was prescribed daily aspirin following a stroke. The facility's own care plan required daily skin inspections and monitoring for signs of bleeding including bruising and discoloration - standard protocol for patients on anticoagulant therapy.
Despite these requirements, staff failed to detect linear discoloration around both ankles that developed over time. When federal inspectors discovered the skin changes during their visit on June 27, 2024, multiple nursing staff members were unaware of the condition.
The resident's certified nursing assistant stated she "was not aware of the resident having skin issues" and would have reported it immediately if noticed. The treatment nurse acknowledged the last documented weekly skin check occurred nearly a month prior on May 28, 2024.
Anticoagulant medications like aspirin require careful monitoring because they increase bleeding risk. Skin discoloration can indicate internal bleeding or circulation problems that require immediate medical attention. When blood-thinning medications affect circulation, patients may develop bruising or discoloration that signals potentially serious complications.
Safety Assessment Failures
Inspectors identified significant gaps in the facility's safety protocols across multiple areas:
Smoking Safety Violations: A resident with balance problems and encephalopathy was found with cigarettes stored in his room despite facility policies requiring all smoking materials be controlled by staff. The interdisciplinary team failed to properly assess whether the resident was an independent or at-risk smoker, creating fire hazards.
Fall Prevention Lapses: Staff left a high fall-risk resident's bed in the elevated position while unattended. The resident had documented confusion and required assistance with mobility, making falls from height particularly dangerous. Falls from elevated beds can result in serious injuries including fractures and head trauma.
Elopement Risk Assessment: The facility's May 2024 elopement evaluation incorrectly classified a legally blind resident as "not at risk" despite documented wandering behavior and a January attempt to leave the facility. This misassessment could have prevented proper safety interventions.
Medical Treatment Inconsistencies
The inspection revealed troubling patterns in medical care delivery:
Feeding Tube Management: Three residents with feeding tubes experienced labeling and monitoring failures. One resident's water flush bag was labeled with an incorrect infusion rate (60 ml/hr instead of the ordered 45 ml/hr), potentially causing dehydration or fluid overload. Another resident's irrigation syringe lacked proper identification and date labeling, creating infection control risks.
Oxygen Therapy Interruption: A resident with pleural effusion and heart disease was found with their oxygen concentrator turned off, despite physician orders for continuous 2-liter oxygen therapy. Interruption of prescribed oxygen can cause dangerous drops in blood oxygen levels, leading to respiratory distress.
IV Catheter Care: An IV catheter dressing lacked the required insertion date, preventing staff from knowing when the dressing change was due. Delayed dressing changes increase infection risk at catheter sites.
Dialysis Care Documentation Gaps
The facility failed to maintain proper oversight of a resident receiving hemodialysis three times weekly. Staff did not consistently perform required post-dialysis assessments and improperly discarded documentation from the dialysis center instead of maintaining it in the medical record.
Hemodialysis patients require careful monitoring because the treatment can cause fluid imbalances, blood pressure changes, and bleeding at access sites. Post-treatment assessments help detect these potentially serious complications.
Physical Safety Hazards
Two residents with bed rails lacked proper safety assessments for entrapment risk. The facility failed to obtain physician orders, provide required education about risks and benefits, or secure informed consent before installing the rails.
Bed rails can cause entrapment injuries when residents become caught between the rail and mattress. Proper assessment protocols help identify residents at risk for these potentially fatal complications.
Medical Standards and Expectations
Healthcare facilities are required to maintain comprehensive monitoring systems for residents receiving medical treatments. For anticoagulant therapy, this includes:
- Daily visual skin assessments by direct care staff - Weekly formal skin evaluations by licensed nurses - Immediate reporting of any changes in skin condition - Proper documentation of all monitoring activities
When these systems fail, residents face increased risks of undetected bleeding, delayed medical intervention, and worsening health conditions.
For residents requiring specialized equipment like feeding tubes or oxygen therapy, facilities must ensure proper labeling, monitoring, and maintenance according to manufacturer guidelines and physician orders. Failures in these areas can result in malnutrition, dehydration, respiratory distress, or infections.
Regulatory Response
The violations were classified as causing "minimal harm or potential for actual harm" affecting "few" to "some" residents. However, the cumulative pattern suggests systemic issues with the facility's quality assurance and staff training programs.
Federal regulations require nursing homes to provide services that meet professional standards and ensure resident safety. The identified violations indicate gaps in fundamental care processes including assessment, monitoring, documentation, and interdisciplinary communication.
Facility Operations
Los Feliz Healthcare & Wellness Center, located on Rowena Avenue in Los Angeles, provides skilled nursing and rehabilitation services. The facility must submit a plan of correction addressing each violation and demonstrate how it will prevent future occurrences.
The inspection findings highlight the critical importance of consistent monitoring protocols and staff training in medical facilities. Proper implementation of safety procedures protects vulnerable residents and ensures compliance with federal care standards.
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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