Los Feliz Healthcare: Restraints Used Without Orders - CA
Federal inspectors discovered the unauthorized restraint use during a June inspection of the facility on Rowena Avenue. Both residents were identified as high fall risks, but the facility bypassed required safety protocols before restricting their movement.
Resident 118 had been admitted in May following surgical amputation of a toe on the right foot, with diagnoses including muscle weakness and unsteadiness. The resident's bed rail assessment contained contradictory recommendations, stating both that side rails "are indicated" and "are not indicated at this time."
When inspectors observed the room on June 25, Registered Nurse 2 acknowledged there was no physician order for the bed rail use or wall placement. The nurse confirmed no safety assessment had been conducted and no informed consent obtained.
"There was no safety assessment conducted for placement of bed against the wall, no informed consent and documentation the resident and their representative were educated on the risk and benefits of bed rail use," the nurse told inspectors.
Resident 378, admitted in mid-June with hepatic encephalopathy, seizures, and muscle weakness, faced identical violations. Inspectors found both upper bed rails raised and the bed positioned against the wall, again without required approvals.
The facility's own restraint policy, reviewed as recently as May 23, explicitly requires physician orders before applying any restraints. The policy states restraints should be used "only when deemed necessary by the interdisciplinary Team and in accordance with the resident's assessment and Plan of Care."
Licensed nurses must verify informed consent before restraint use and explain "the risks and benefits of restraints, alternatives to restraints, how the restraint will treat the resident's medical condition," according to facility policy.
Director of Nursing acknowledged the violations during a June 28 interview, stating that before applying restraints like bed rails and bed placement against walls, "there should be a risk for entrapment assessment, a physician order and an informed consent from the resident or their representative to ensure resident safety."
The facility's bed frame owner's manual warns that "patient entrapment with assist rail may cause injury or death" and instructs staff to "follow the manufacturer's instructions and monitor patient frequently."
The manual details specific risks including "strangling, suffocating, body injury or death when patients or part of their body are caught between rails or between the bed rails and mattress." Additional dangers include more serious injuries from falls when patients climb over rails, skin injuries, and agitated behavior when bed rails function as restraints.
Both residents had capacity to understand and make decisions according to their medical records, yet neither was consulted about the restraint use.
Inspectors also uncovered systematic assessment failures affecting resident care. The facility incorrectly coded discharge information for Resident 123, marking a planned discharge as "unplanned" in required federal paperwork.
The resident's March discharge order clearly stated "May discharge on 3/29/2024, to Independent Living" with home health services. The discharge notice confirmed the move was "appropriate because the resident's health has improved sufficiently."
Despite the documentation, the Minimum Data Set Coordinator coded the discharge as unplanned. When questioned by inspectors, the coordinator admitted "Resident 123's discharge was planned and should have been coded as planned."
"It was important to code the resident's assessment accurately for recording and tracking purposes, and to ensure the resident will be provided with the necessary care and services," the coordinator told inspectors.
A second assessment error involved Resident 72, who had orders for Plavix, an antiplatelet medication used to prevent blood clots. The facility's assessment incorrectly classified this as an anticoagulant, a different type of blood-thinning medication.
The Minimum Data Set Coordinator acknowledged the error, stating "the assessment should have been coded Resident 72 received antiplatelet and not an anticoagulant." She noted accurate coding was necessary "for tracking purposes and continuity of care and to prevent delay in providing the necessary care and services needed by the resident."
Care planning failures extended to a third resident receiving vancomycin, an antibiotic for serious bacterial infections. Resident 67, who received the antipsychotic medication Risperdal for delusions, lacked measurable goals for monitoring the condition or the medication's effectiveness.
The resident's care plan contained no non-pharmacological interventions for delusions and no monitoring for Risperdal's side effects from March 27 through May 6. The medication carries risks including involuntary muscle movements, tremors, dizziness, and sedation.
The Director of Nursing signs all assessment documents for accuracy but failed to catch the coding errors affecting multiple residents' care tracking and service delivery.
Facility policy requires assessments that "accurately depict and identify resident-specific issues and objectives" and serve as "the basis for the accurate assessment of each resident's functional capacity and health status."
The violations occurred despite the facility's stated commitment to honor residents' rights "to be free from any restraints that are imposed for reasons other than that of treatment of the resident's medical symptoms."
Federal guidelines from the Food and Drug Administration specifically warn about bed rail entrapment risks, noting potential for strangulation, suffocation, and death. The guidance identifies body parts most at risk and recommends frequent monitoring when rails are used appropriately.
The inspection found residents subjected to restraints that could prevent them "from performing routine activities such as going to the bathroom or retrieving something from a closet" while potentially "inducing agitated behavior" and causing residents to feel "isolated or unnecessarily restricted."
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
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
LOS FELIZ HEALTHCARE & WELLNESS CENTER, LP in LOS ANGELES, CA was cited for violations during a health inspection on June 28, 2024.
Federal inspectors discovered the unauthorized restraint use during a June inspection of the facility on Rowena Avenue.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.