The June inspection at Los Feliz Healthcare & Wellness Center revealed a pattern of care planning failures that left vulnerable residents without proper oversight. Inspectors found three residents whose complex medical needs weren't addressed through individualized care plans, despite facility policies requiring such documentation within seven days of admission.
Resident 118 arrived May 14 with a surgically amputated right foot toe, muscle weakness, and unsteadiness. The facility's own fall risk evaluation classified the resident as high risk for potential falls. Yet when inspectors visited the room June 25, they found both upper bed rails raised and the bed positioned against the wall.
"There was no care plan addressing restraints, bed rails and placement of bed against the wall," Registered Nurse 2 told inspectors during the room visit. The nurse acknowledged that care plans "serve as a communication tool to all care givers to standardize care."
A second resident, identified as Resident 378, faced identical circumstances. Admitted June 18 with hepatic encephalopathy, seizures, and muscle weakness, this resident was also classified as high fall risk. Inspectors found the same setup: both bed rails up, bed against the wall, no care plan.
The facility's Director of Nursing admitted the oversight during a June 28 interview. "A person-centered care plan should be developed and implemented for resident using restraints to ensure resident safety and to provide quality care to residents," the director stated.
The care planning failures extended beyond physical restraints. Resident 79, admitted in October 2023 with a stage four pressure ulcer and congestive heart failure, developed a serious foot infection requiring powerful IV antibiotics. On June 24, the wound care specialist noted increased swelling and pain in the resident's right foot, recommending IV antibiotics through the primary care physician.
The physician ordered vancomycin hydrochloride, a medication used for serious bacterial infections, to be administered intravenously once daily for two weeks starting June 27. But when inspectors reviewed the resident's records, they discovered no care plan existed for the antibiotic treatment.
"There was no care plan developed for the use of vancomycin hydrochloride," MDS Coordinator 1 told inspectors during a June 26 interview. The coordinator explained that creating such plans "is important to ensure staff are aware of the resident's plan of care and to prevent delay in meeting the resident's needs."
The Director of Nursing acknowledged this failure as well, stating that "the care plan should have been developed the same time the order for the antibiotic was received."
Perhaps most troubling was the case of Resident 67, a dementia patient who had been receiving antipsychotic medication for months without proper monitoring. The resident's medication records showed prescriptions for Risperdal 0.5 milligrams twice daily for delusions from March 27 through May 6, 2024.
But the medication administration record contained no documentation tracking whether the delusions actually occurred, no monitoring for adverse effects of the powerful psychiatric drug, and no evidence that staff tried alternative therapies before resorting to medication.
Licensed Vocational Nurse 2 explained the dangers of this approach during a June 26 interview. Without monitoring specific occurrences of delusions, "it will be unknown if Risperdal was effective in reducing the target behavior." Without adequate side effect monitoring, "it may harm Resident 67 by causing dizziness and sedation." And without trying alternative therapies, "Risperdal maybe used unnecessarily further causing harm by negatively affecting the physical and psychosocial well-being."
The Director of Nursing conducted a thorough search of Resident 67's clinical record but could not locate care plans for the delusions, monitoring protocols for Risperdal side effects, or documentation of non-drug interventions. The director acknowledged that monitoring for specific behavioral occurrences "was important to measure effectiveness of Risperdal and when to make medication changes, such as lowering the dose or discontinuing."
The director also recognized the serious health risks involved. Monitoring for side effects "was important to ensure Resident 67 did not have unnecessary side effects such as tardive dyskinesia, akathisia, tremors, dizziness, sedation causing negative impact on their health and well-being."
The facility's own policies, last reviewed May 23, 2024, clearly required comprehensive care plans within seven days of completing resident assessments. The policies specified that plans should address "resident-specific health and safety concerns to prevent decline or injury" and be updated whenever new problems arise or conditions change.
For psychiatric medications specifically, facility policy mandated that any order "must include specific behavior manifested" and required staff to monitor residents for side effects including "constipation, blurred vision, dry mouth, urinary retention, sedation" and neurological effects like "akathisia, dystonia, extrapyramidal effects" or "tardive dyskinesia."
The policy also required that "occurrences of behaviors for which psychoactive medications are in use will be entered with hash marks on the MAR every shift."
None of this monitoring occurred for Resident 67.
Inspectors also identified problems with insulin administration, finding that the facility failed to rotate injection sites for three diabetic residents. This practice can lead to lipodystrophy and other skin complications, but the inspection report provided limited details about this violation.
The facility operates under the ownership of Los Feliz Healthcare & Wellness Center, LP, at 3002 Rowena Avenue in Los Angeles. The inspection, completed June 28, 2024, classified all violations as causing "minimal harm or potential for actual harm" affecting "some" residents.
But the cumulative effect of these care planning failures suggests a more systemic problem. Three different types of high-risk situations, three different residents, and in each case the same fundamental breakdown: staff providing medical interventions without the individualized care plans that federal regulations require to ensure safe, effective treatment.
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.
Additional Resources
- View all inspection reports for Los Feliz Healthcare & Wellness Center, Lp
- Browse all CA nursing home inspections