LOS ANGELES, CA - Federal inspectors discovered staff at a Lincoln Park nursing home routinely administered oxygen therapy to residents without physician orders, a dangerous practice that officials said could cause serious illness or complications.
Unauthorized Oxygen Administration Creates Dangerous Conditions
The most egregious violation occurred when Licensed Vocational Nurse 6 (LVN 6) was observed providing oxygen therapy to a resident via nasal cannula at 5 liters per minute without any physician authorization. During the January 9, 2025 inspection, LVN 6 admitted that placing residents on oxygen without orders was "a practice facility staff was used to doing."
The violation came to light when inspectors found Resident 96 receiving oxygen therapy during their observation. When questioned, LVN 6 was unsure if there was an order for the oxygen therapy. A review of the resident's physician orders revealed no authorization for oxygen therapy had been provided. Remarkably, a physician's order for oxygen was only placed at 1:57 PM on January 9 - while inspectors were interviewing the nurse about the unauthorized administration.
The Director of Nursing acknowledged the severity of this violation, stating that administering oxygen without orders was "a dangerous move because unnecessary oxygen could be just as bad as not receiving oxygen when needed." The administrator emphasized that residents could "really become ill from administering oxygen without orders" and noted that "all medication administration requires an MD order to administer."
Medical professionals recognize oxygen as a medication that requires careful monitoring and precise dosing. Excessive oxygen can cause complications including lung damage, while inadequate oxygen can lead to organ failure. The facility's own policy clearly states that physicians must verify orders for oxygen administration and that proper documentation must be maintained.
Widespread Medication Safety Failures
The oxygen violation was part of a broader pattern of medication administration failures affecting multiple residents. Inspectors documented a medication error rate of 6.06%, exceeding the federal threshold of 5%.
Improper Medication Administration
LVN 10 was observed administering psyllium husk powder to Resident 256 dissolved in only four ounces of water instead of the prescribed eight ounces. The nurse used an unmeasured cup and admitted this constituted a medication error. Psyllium requires adequate water to prevent choking and ensure proper effectiveness. Without sufficient liquid, residents face increased risks of constipation, abdominal pain, and potentially choking.
Dangerous Patch Medication Errors
Significant errors occurred with lidocaine pain patches for Resident 256. Nursing staff failed to remove expired patches on schedule, resulting in prolonged medication exposure. Patches dated January 5 remained on the resident until January 7, when they should have been removed on January 6. LVN 16 documented patches as administered when they were never actually applied, creating dangerous documentation inaccuracies.
Excessive lidocaine absorption can cause irregular heartbeat, dizziness, nausea, and potentially require hospitalization. The facility's Director of Nursing confirmed that prolonged patch application increased risks of medication toxicity.
Aspirin Held Without Authorization
During medication administration, LVN 4 held a prescribed aspirin dose for Resident 205, claiming the resident had nosebleeds. However, physician orders specifically instructed monitoring for nosebleeds with instructions to hold a different medication (Eliquis) if bleeding occurred - not aspirin. The nurse failed to visually assess for bleeding and incorrectly documented the aspirin as administered when it was actually withheld.
This error placed the resident at increased risk for stroke and blood clots, as aspirin serves as critical preventive therapy for patients with cardiac conditions.
Medication Storage Creates Health Risks
Inspectors found multiple medication storage violations that compromised drug safety and effectiveness. Expired insulin was discovered in medication carts, including insulin that had exceeded its 28-day post-opening timeframe. Expired insulin cannot effectively control blood glucose levels, potentially leading to dangerous hyperglycemia and diabetic complications.
The facility's medication refrigerator operated at 30°F instead of the required 36-46°F range. This improper temperature affected critical medications including:
- Diabetes medications (Ozempic, Mounjaro) that become ineffective when frozen - Vaccines (Prevnar 20) for pneumonia prevention that lose potency outside proper temperature ranges - Emergency medications stored for resident care
These storage failures had the potential to render medications ineffective or unsafe, putting residents at risk for uncontrolled diabetes, increased infection susceptibility, and inadequate emergency care.
Safety Equipment Failures Endanger Vulnerable Residents
Seizure Patient Left Unprotected
Resident 238, diagnosed with epilepsy and at risk for seizures, was found with only one padded side rail when physician orders specifically required bilateral padded side rails. Licensed Vocational Nurse 8 confirmed the resident needed two padded side rails to prevent injury during seizures.
Seizures can cause violent, uncontrolled movements that risk serious injury if patients strike bed rails or fall. Proper seizure precautions require padded side rails on both sides to protect residents during episodes. The facility lacked comprehensive seizure precaution policies, leaving vulnerable residents at increased injury risk.
Unstable Toilet Equipment Causes Falls
Resident 38 reported falling in her bathroom due to loose, wobbly toilet seat side rails. During inspection, maintenance staff confirmed the side rails were "not 100% safe for residents" and "would not prevent residents from falling." The unstable equipment failed to provide necessary support for residents with mobility limitations.
Infection Control Lapses During COVID Exposure
Staff and visitors failed to wear required eye protection when caring for residents under COVID-19 observation, despite clear facility signage mandating face shields or goggles. Federal CDC guidelines require comprehensive personal protective equipment including eye protection for healthcare workers treating patients with suspected COVID-19.
Multiple staff members were observed providing direct care to COVID-exposed residents while wearing gowns, gloves, and N95 masks but lacking eye protection. This violation had the potential to spread the highly contagious virus throughout the facility's 294-resident population.
Physical Therapy Services Delayed Due to Insurance
The facility failed to provide physician-ordered physical and occupational therapy services to Resident 96 for 20 days due to insurance authorization delays. Despite physician-signed treatment plans, the facility waited for insurance approval rather than providing necessary rehabilitation services.
This delay contributed to the resident developing contractures and losing mobility function. Professional standards require facilities to provide medically necessary services regardless of insurance authorization status, with coverage issues addressed separately.
Food Safety Violations Risk Illness
Kitchen staff improperly stored expired milk and cottage cheese beyond safe consumption periods. Nutritional supplements and juices removed from freezer storage lacked required thaw dates, preventing staff from determining when products should be discarded.
Most concerning, dietary staff reused kitchen towels stored in plain water to clean food preparation surfaces. This practice created cross-contamination risks and violated food safety protocols requiring sanitizing solutions for cleaning cloths.
The inspection revealed systemic failures across medication management, safety protocols, infection control, and basic care standards at the 294-bed facility. These violations demonstrate the need for comprehensive oversight and immediate corrective action to protect vulnerable nursing home residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Kei-ai Los Angeles Healthcare Center from 2025-01-10 including all violations, facility responses, and corrective action plans.
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