LOS ANGELES, CA - Federal inspectors documented serious safety violations at Western Convalescent Hospital, including improperly configured extension cords that created fire hazards and insufficient nursing staff to provide essential rehabilitation services to residents.
The March 21, 2025 inspection revealed multiple deficiencies that put vulnerable residents at risk, with particular concern for electrical safety practices and the facility's ability to maintain adequate staffing levels for specialized care programs.
Dangerous Extension Cord Configuration Creates Safety Hazards
Inspectors discovered a particularly concerning safety violation in the room of a resident with severe medical conditions including Stage 4 pressure ulcers and chronic respiratory failure. Personal chargers were plugged into an extension cord that ran along the ground next to the resident's bed, then connected to another extension cord with its socket end lying on the floor under the bed.
This daisy-chain configuration violates basic electrical safety standards and creates multiple hazards for residents who depend on staff assistance for mobility and daily activities. The affected resident required help with all activities of daily living, including toileting, dressing, and personal hygiene, making them particularly vulnerable to trip and fall incidents.
A Licensed Vocational Nurse present during the inspection immediately recognized the danger, stating the extension cords "should not be like that" and confirming this created both fall and fire risks that could harm residents. The facility's own Maintenance Aide echoed these concerns, noting it was "the wrong type of extension cord to use" and should not be plugged into another extension cord or lying on the ground.
Medical Risks of Improper Electrical Setup
Extension cord misuse in healthcare settings poses significant risks beyond typical household hazards. Daisy-chaining extension cords can cause electrical overheating, increasing fire risk in environments where residents may have limited mobility to evacuate safely. The ground-level positioning creates trip hazards particularly dangerous for elderly residents who often experience balance issues, vision problems, or use mobility aids.
For residents with respiratory conditions requiring supplemental oxygen or other life-support equipment, electrical fires pose immediate life-threatening risks. The resident in whose room these violations occurred had chronic respiratory failure, making rapid evacuation in case of fire particularly challenging.
Nursing homes must maintain higher electrical safety standards because residents typically cannot respond quickly to emergencies and often require assistance for evacuation. Proper electrical safety protocols require extension cords to be secured, not placed where they can cause trips or overheat, and never connected to additional extension cords.
Inadequate Staffing Affects Essential Therapy Programs
The inspection revealed systemic staffing issues preventing residents from receiving prescribed Restorative Nursing Aide treatments. These specialized programs help residents maintain joint mobility and prevent contractures - a crucial service for residents recovering from strokes, brain injuries, or other conditions affecting movement.
Multiple residents experienced gaps in their prescribed RNA treatments, with documented missed sessions on various dates throughout February and March 2025. The violations affected residents with serious conditions including hemiplegia following brain hemorrhages, cerebrovascular disease, and muscle contractures.
One resident with right-side paralysis from a brain hemorrhage was prescribed specific splinting schedules and range-of-motion exercises. However, documentation showed RNA treatments were not completed on several scheduled days, potentially allowing contractures to worsen and limiting the resident's functional recovery.
Impact on Stroke Recovery and Mobility
RNA programs are particularly critical for stroke survivors and residents with neurological conditions. When residents don't receive prescribed range-of-motion exercises and splinting treatments, muscles can weaken and joints can develop contractures that permanently limit movement. This can transform temporary limitations into permanent disabilities.
The facility's Director of Staff Development acknowledged that missing RNA treatments could worsen residents' contractures and muscle weakness, directly contradicting the program's goal of helping residents "improve and thrive and participate in daily activities." Proper rehabilitation requires consistent, daily interventions to maintain gains and prevent functional decline.
For residents with conditions like hemiplegia, where one side of the body is paralyzed, consistent splinting and range-of-motion exercises help maintain what function remains and can sometimes facilitate recovery. Missing these treatments can result in permanent loss of mobility that significantly impacts quality of life.
Oversight Failures in Joint Mobility Assessments
Beyond daily treatment gaps, the facility failed to complete required annual joint mobility screenings for multiple residents. These assessments help therapists track changes in residents' range of motion and adjust treatment plans accordingly. Some residents went multiple years without proper assessments despite having conditions that put them at risk for progressive contractures.
The Director of Rehabilitation explained that these screenings are essential for catching declines in mobility before they become irreversible. Without annual assessments, staff cannot determine if treatments are effective or if residents need different interventions to maintain function.
Unauthorized Splinting Procedures
Inspectors also documented RNA staff applying ankle splints to one resident without proper physician orders. While well-intentioned, this practice creates liability and safety risks because therapists, not nursing aides, are trained to determine appropriate splinting duration and fit.
Improperly fitted or worn splints can cause skin breakdown, pain, and circulation problems. The facility's own therapy staff emphasized that only therapists have training to determine safe wearing times and assess risks of extended splint use, particularly for residents with decreased sensation who might not notice developing pressure sores.
Systemic Issues Requiring Comprehensive Response
These violations indicate broader systemic problems with safety protocols and staffing management at Western Convalescent Hospital. The electrical safety violation suggests inadequate maintenance oversight and staff training on basic safety requirements. The RNA program failures point to chronic understaffing or poor staff allocation that prevents residents from receiving prescribed medical treatments.
Both issues demonstrate gaps in supervision and quality assurance that federal nursing home regulations require facilities to maintain. Effective facilities implement regular safety rounds to identify hazards before they endanger residents and maintain adequate staffing levels to ensure all prescribed treatments are delivered consistently.
The facility's policies correctly outlined safety requirements and treatment expectations, but implementation clearly failed to meet standards. This gap between written policies and actual practice often indicates insufficient staff training, inadequate supervision, or systemic resource limitations that compromise resident care quality.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Western Conv. Hospital from 2025-03-21 including all violations, facility responses, and corrective action plans.
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