LOS ANGELES, CA - Los Feliz Healthcare & Wellness Center faced significant regulatory violations during a June 2024 inspection, with state surveyors documenting serious deficiencies in medication administration, food safety protocols, and infection control measures that potentially affected more than 120 residents.
Critical Medication Administration Errors Put Diabetic Residents at Risk
Federal inspectors identified a pattern of dangerous medication errors involving insulin administration for diabetic residents at the 124-bed facility. The violations centered on staff's failure to rotate injection sites as required by physician orders and manufacturer guidelines, potentially leading to serious complications for vulnerable residents.
The inspection revealed that nursing staff repeatedly administered insulin injections to the same body locations for three diabetic residents over multiple months. For one resident with Type 2 diabetes and kidney complications, records showed insulin was given to the same arm location on consecutive days in April and May 2024, directly violating physician orders that specifically required site rotation.
"RN 2 stated there were multiple instances that the sites of insulin administration of insulin were not rotated," according to the inspection report. The registered nurse acknowledged that this constituted a medication error and explained that proper rotation prevents lipodystrophy - abnormal fat deposits under the skin - as well as bruising and tissue hardening.
Medical protocols require insulin injection sites to be systematically rotated within body regions to prevent tissue damage. When injections are repeatedly given in the same location, the affected tissue can develop lipodystrophy, making future insulin absorption unpredictable and potentially ineffective. This can lead to poor blood sugar control, increasing the risk of diabetic complications including nerve damage, kidney problems, and cardiovascular issues.
The facility's Director of Nursing confirmed that failing to rotate injection sites constitutes a medication error, stating it results from "not following the physician's order, professional nursing practice and manufacturer guidelines." Manufacturer prescribing information for the insulin medications clearly indicates the need to rotate injection sites to reduce risk of complications.
Widespread Food Safety Violations Threaten Resident Health
Inspectors documented extensive food safety violations that created significant risks for cross-contamination and foodborne illness among medically compromised residents. The violations spanned multiple areas of food handling, storage, and preparation.
Staff were observed storing raw chicken above bacon during the thawing process, creating a direct pathway for bacterial contamination. Food safety protocols require raw poultry to be stored at the bottom of refrigeration units to prevent juices from dripping onto other foods, as this can spread salmonella and other dangerous bacteria.
Temperature control violations were particularly concerning. Inspectors found milk being served at temperatures of 42 and 50 degrees Fahrenheit - well above the required maximum of 41 degrees. The facility's dietary supervisor acknowledged that maintaining proper milk temperatures is critical to prevent diarrhea, vomiting, and stomach infections in residents.
Additional violations included improperly stored dented cans mixed with regular inventory, inadequate monitoring of food thawing temperatures, and unlabeled resident food items from outside sources. Staff demonstrated improper techniques for testing dishwashing sanitizer concentrations, using incorrect test strips and failing to follow manufacturer guidelines for ensuring dishes are properly disinfected.
The dry storage area temperature exceeded 80 degrees Fahrenheit, well above the facility's own policy requiring temperatures between 50-70 degrees. Equipment violations included refrigerator gaskets with black dirt buildup, canned goods contaminated with flour residue, and ice machine vents covered in dust.
Kitchen staff were observed stacking pots and pans while still wet, violating food safety requirements for air-drying equipment after sanitization. These practices create conditions where harmful bacteria can multiply and spread to resident food.
Infection Control Failures Create Cross-Contamination Risks
The facility failed to maintain proper infection control protocols across multiple areas, placing residents at increased risk for healthcare-associated infections. Inspectors identified violations involving respiratory equipment, medical devices, and protective equipment usage.
Oxygen tubing for residents receiving supplemental oxygen was repeatedly observed touching the floor in multiple rooms. This creates a direct pathway for bacteria and other contaminants to travel through the tubing to residents' respiratory systems, potentially causing lung infections and pneumonia in already vulnerable patients.
Urinal bottles lacked proper labeling with resident identifiers, creating risks for cross-contamination between residents sharing rooms. Facility staff acknowledged that unlabeled urinals could be accidentally switched between residents, potentially spreading infections and causing allergic reactions.
Staff failed to follow enhanced barrier precautions for a resident with stage four pressure ulcers. Despite posted signs requiring gown and glove use during high-contact care activities, nursing assistants were observed repositioning the resident while wearing only gloves, not the required gowns. These precautions are specifically designed to prevent the spread of multidrug-resistant organisms and other infections.
Additional infection control violations included urine collection bags touching the floor and linen carts covered with mesh material that allowed contamination of clean linens. The facility's infection preventionist confirmed that such practices increase cross-contamination risks and potential infection spread.
Equipment Safety Concerns and Environmental Hazards
Inspectors documented safety hazards involving resident care equipment and electrical systems. One resident's bed controller cable was found wrapped in black tape with multiple exposed wires of different colors visible near the bedside. Nursing staff and maintenance personnel acknowledged this created risks for electrical shock and potential fires.
An unsafe electrical configuration was discovered in another resident's room, where a cell phone charger was connected through both an extension cord and power strip before reaching the wall outlet. This practice, known as "daisy chaining" electrical connections, significantly increases fire risks due to heat buildup in the wiring.
Additional Issues Identified
The inspection revealed problems with menu compliance and food presentation. Posted menus in resident rooms were outdated, causing frustration for residents who were unaware of actual meal offerings. One resident specifically complained about the lack of menu updates and stated it was causing him frustration.
Food portion control violations included serving turkey portions weighing 2.35 to 2.8 ounces instead of the required 3 ounces, potentially contributing to malnutrition in residents who already face nutritional challenges. Kitchen staff acknowledged that providing insufficient protein could cause residents to lose weight.
Medication refrigerator temperatures were monitored only once daily instead of the required twice-daily checks, creating periods where vaccine and medication effectiveness could be compromised without staff knowledge. The facility's own policy required twice-daily temperature monitoring for refrigerators storing vaccines.
The violations occurred across multiple departments and affected a significant portion of the facility's resident population, indicating systemic issues requiring comprehensive corrective action to ensure resident safety and regulatory compliance.
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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