Los Feliz Healthcare & Wellness Center, Lp
LOS FELIZ HEALTHCARE & WELLNESS CENTER, LP in LOS ANGELES, CA — inspection on June 28, 2024.
Found 38 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
hanging on the bed frame, without a dignity bag (privacy bag), and was visible from the hallway. LVN
provided a dignity bag for Resident 1's urinary catheter drainage bag to promote privacy and avoid embarrassment to the resident.
A review of the facility's recent policy and procedure titled, Catheter- Care of, last reviewed on 5/23/2024, indicated the resident's privacy and dignity will be protected by placing a cover over drainage bag when the resident is out of bed.
A review of the facility's recent policy and procedure titled, Resident Rights- Quality of Life, last reviewed on 5/23/2024, indicated demeaning practices and standards of care that compromise dignity is prohibited.
Facility Staff promote dignity and assist residents as needed by: A.Helping the resident to keep urinary catheter bags covered.
A review of the facility's recent policy and procedure titled, Resident Rights, last reviewed on 5/23/2024, indicated residents of skilled nursing facilities have a number of rights under state and federal law.
The Facility will promote and protect the rights.
Employees are to treat all residents with kindness, respect, and dignity and honor the exercise of resident's rights.
056380 06/28/2024
Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
During an observation and interview on 6/25/2024 at 9:45 a.m., with Certified Nursing Assistant 2 (CNA 2), observed Resident 14 asleep in bed with the call light hanging on the right side of the bed rails.
The call light touching the floor and not within the resident's reach.
Certified Nursing Assistant 2 (CNA 2) stated the call light was on the floor and not within Resident 14's reach. CNA 2 stated the call light should be within reach of the resident so the resident will be able to call for assistance if needed.
During an interview on 6/28/2024 at 4:45 p.m., with the DON, the DON stated the call light should have been within Resident 14's reach so the resident will be able to ask for assistance.
The DON stated not being to call for assistance had the potential for the resident needs not be met and compromise their health resulting from accidents or injuries.
A review of the facility's policy and procedure titled, Communication - Call System, last reviewed 5/23/2024, indicated the facility provides a mechanism for residents to promptly communicate with staff.
The policy indicated call cords will be placed within resident's reach in the resident's room and nursing staff will answer call bells promptly.
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Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
During a concurrent observation and interview on 6/25/2024, at 11:20 a.m., with Family Member 1 (FM 1), inside Resident 109's room, observed the bathroom faucet fixture with white deposits on the handles and grayish, greenish discoloration around the fixture. FM 1 stated the faucet fixture is unhygienic (unsanitary) for Resident 109.
During a concurrent observation and interview on 6/26/2024, at 12:46 p.m., with the Maintenance Director (MD), inside Resident 109's room, observed the bathroom faucet fixture and the MD stated the faucet had rust and calcium buildup.
The MD stated the bathroom fixtures should be free from rust and calcium buildup to prevent the resident from ingesting them when they brush their teeth.
During an interview on 6/28/2024, at 4:35 p.m., with the Director of Nursing (DON), the DON stated Resident 109's faucet had a mildew residue and should have been reported to the Maintenance Department so the faucet can be replaced.
The DON stated a faucet with mildew residue can be a source of infection to residents.
A review of the facility's recent policy and procedure titled, Maintenance Service, last reviewed on 5/23/2024, indicated the Maintenance Department maintains all areas of the building, grounds, and equipment.
The Director of Maintenance is responsible for developing and maintaining schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner.
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Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
the use of a manual hold to restrict freedom of movement of all or part of a resident's body, or to
Nurse will explain the risks and benefits of restraints, alternatives to restraints, how the restraint will
A review of the facility provided Owner's Manual titled, BF 1, last revised on 4/1/2018, indicated mattress must fit bed frame and assist rail snugly to help prevent patient entrapment.
Patient entrapment with assist rail may cause injury or death.
Please follow the manufacturer's instructions and monitor patient frequently.
Assist rails/bars are intended only to assist the resident during bed entry and exit.
These devices are not side rails, nor are they intended to be used in a manner that makes user entry and exit more difficult.
Accurate assessment of the resident and monitoring of correct maintenance and equipment use are required to prevent entrapment. On March 10, 2006, the U.S.
Food and Drug Administration (FDA) released guidelines for reducing the risk of hospital bed entrapment entitled; Hospital bed System Dimensional and Assessment Guidance to reduce Entrapment.
This guidance document identifies potential entrapment areas within the bed frame, rails and mattress and identifies those body parts most at risk for entrapment.
Potential risks of bed rails may include: -Strangling, suffocating, body injury or death when patients or part of their body are caught between rails or between the bed rails and mattress. -More serious injuries from falls when patients climb over rails. -Skin bruising, cuts, and scrapes. -Inducing agitated behavior when bed rails are used as a restraint. -Feeling isolated or unnecessarily restricted. -Preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet.
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Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
the reason for transfer or discharge, the ombudsman would not know if the transfer or discharge was
A review of the facility's policy and procedure (P&P) titled, Notice of Transfer/Discharge, last
resident, and if known, the responsible party, and ombudsman of the transfer and the reason for transfer, and document in the resident's clinical record.
056380 06/28/2024
Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
During an interview with the Director of Nursing (DON), on 6/28/2024, at 4:36 p.m., the DON stated it is important to notify the resident or resident representative of the bed hold agreement upon transfer to the GACH so that the resident does not have to worry about having a place to return to.
The DON further stated some residents worry that they do not have a place to return to when they go to the GACH.
A review of the facility's policy and procedure (P&P) titled, Bed Hold, last reviewed 5/23/2024, indicated upon admission, the facility informs the resident and or representative in writing of the facility's bed hold policy and how to exercise the right to a bed hold and the facility notifies the resident and or representative, in writing, of the bed hold option, any time the resident is transferred to an acute care hospital or requests therapeutic leave.
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Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
minimal harm
Review of the facility's Policies and Procedures (P&P,) titled Comprehensive Person-Centered Care Planning, dated November 2018, the P&P indicated that: It is the policy of the Facility to provide person-centered, comprehensive and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being.
I.
Baseline Care Plan a.
It should address resident-specific health and safety concerns to prevent decline or injury, and would identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary.
III.
Baseline Care Plan Summary d.
If the comprehensive assessment and the comprehensive care plan identified a change in the resident's goals, or physical, mental or psychosocial functioning, which was not previously identified on the problem specific care plans used for the baseline care plan, those changes must be updated on each specific care plan used and incorporated, as applicable, into the initial and/or updated care plan summary(ies.) IV.
Comprehensive Care Plan
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Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
F 0656 a.
will be included in the resident's comprehensive care plan.
b.
Additional changes or updates to the resident's comprehensive care plan will be made based on the assessed needs of the resident. c.
The comprehensive care plan will be periodically reviewed and revised by IDT after each assessment . In addition, the comprehensive care plan will also be reviewed and revised at the following times: i.
Onset of new problems iv.
To address changes in behavior and care.
Review of the facility's P&P, titled admission Assessment, dated 08/212020, the P&P indicated: To identify the Resident's needs and accordingly develop plan of care.
II.
The admission assessment will be included in the Resident's medical record and will be used to create appropriate care plans for the Resident.
Review of the facility's P&P, titled Behavior/Psychoactive Drug Management, dated November 2018, the P&P indicated: It is the policy of the Facility to provide person-centered, comprehensive, and interdisciplinary care that reflects best practice standards for meeting health, safety, psychosocial, behavioral, and environmental needs of residents in order to obtain or maintain the highest physical, mental, and psychosocial well-being.
I.
Assessment
A.
Upon admission, quarterly, annually, and upon change of condition, the interdisciplinary Team (IDT) will collect and assess information about the resident including but not limited to past life experiences, description of behaviors, preferences .cognitive status and related abilities and medications.
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Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
F 0656 II.
A.
Non-pharmacological interventions i.
Upon identification of factors that may contribute to a resident's mood or behavior symptoms, the Licensed Nurse shall initiate .Behavior Log with Non-pharmacological interventions. ii.
The Licensed Nurse will notify and collaborate with the Attending Physician/Prescriber, family, resident, Responsible Party, and/or IDT members regarding the identified contributing factors to the resident's mood/behavior problems and the non-drug interventions taken to address the problems, as well as to evaluate the effectiveness of the non-drug interventions for further recommendations. iii.
The Licensed Nurse will document the interventions taken and recommendations in the resident's Care Plan.
F.
Any order for psychoactive medications must include: v.
Specific behavior manifested.
I.
Monitoring for Side Effects i.
Depending on the specific classification of psychoactive mediation the resident should be observed and/or monitored for side effects and adverse consequences. ii.
General/anticholinergic: constipation, blurred vision, dry mouth, urinary retention, sedation v.
Neurologic: Akathisia, dystonia, extrapyramidal effects, akinesia; or tardive dyskinesia, stroke or TIA
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Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
F 0656 III.
A.
Following admission, completion of MDS, quarterly, annually and upon significant change of condition, the IDT will review the following and make recommendations based on the resident's need: i.
The effectiveness of non-drug interventions ii.
Possible alternatives to use of psychotropic medications D.
Documentation Requirements: ii.
The Care Plan reflects the non-drug interventions prior to drug treatment, use of psychoactive medications, adverse reactions to psychoactive medications . iv.
Occurrences of behaviors for which psychoactive medications are in use will be entered with hash marks (#) on the MAR every shift.
056380 06/28/2024
Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
During a concurrent interview and record review on 6/26/2024, at 1:24 p.m., with RN 2, reviewed Resident 109's Order Summary Report and the Location of Administration of Insulin from 4/2024 to 6/2024. RN 2 stated there were multiple instances that the sites of insulin administration of insulin were not rotated. RN 2 stated insulin administration sites should be rotated to prevent lipodystrophy and bruising and hardening of the tissues.
During an interview on 6/28/2024, at 4:35 p.m., with the DON, the DON stated it is important to rotate insulin administration sites to prevent phlebitis (inflammation of a vein) and lipodystrophy.
A review of the facility provided Highlights of Prescribing Information titled, Humalog (insulin lispro) injection, for subcutaneous or intravenous use, with initial U.S.
Approval in 1996, indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis.
056380 06/28/2024
Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
During an interview on 6/28/2024, at 4:35 p.m., with the Director of Nursing (DON), the DON stated it was important to provide the resident the medication list so that the resident's primary care physician (PCP) will be aware of what medications were continued or stopped.
The DON stated completing the Discharge Planning Review will prepare the resident to be discharged in the community safely and prevents readmission.
A review of the facility's recent policy and procedure titled, Discharge and Transfer of Residents, last reviewed on 5/23/2024, indicated to ensure that discharge planning is complete and appropriate, and that necessary information is communicated to the continuing care provider.
When a resident is near a planned discharge, the interdisciplinary Team (IDT) will complete a Discharge Summary/Post Discharge Plan of Care.
Nursing Staff will complete a Discharge Summary/Post Discharge Plan of Care for each resident, which will include a recapitulation of the resident's stay and a final summary of the resident's status. A copy of the Discharge Summary/Post Discharge Plan of Care will be provided to the resident, resident representative, or the receiving facility.
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Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
appropriate ADL care should be provided by the CNAs to residents including applying lotion to moisten
The DON stated not receiving the appropriate ADL care could potentially affect Resident 26's quality
A review of the facility's policy and procedure titled Resident Rights - Quality of Life, last reviewed 5/23/2024, indicated that each resident shall be cared for in a manner that promotes and enhances the quality of life, dignity, respect individuality and receives services in a person-centered manner, as well as those that support the resident in attaining or maintaining his/her highest practicable well-being.
A review of the facility's policy and procedure titled, Resident Rights, last reviewed 5/23/2024, indicated the facility makes every effort to assist residents to participate in exercising his/her rights by encouraging the residents to participate in planning their daily care routines including ADLs.
A review of the facility's policy and procedure tilted, ADL Documentation, last reviewed 5/23/2024, indicated a purpose to provide consistency in documentation of resident status and care given by nursing staff.
The policy indicated the facility will ensure documentation of the care provided to the resident for completion of ADLS manually or electronic.
A review of the facility's policy and procedure titled, Showering and bathing, last reviewed 5/23/2024, indicated a tub or shower bath is provided to residents for cleanliness, comfort, and prevent body odors.
The policy indicated to observe the skin during bath, and report any broken skin, bruises, rashes, cut, skin discoloration or reddened areas to the charge nurse.
056380 06/28/2024
Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
During a concurrent interview and record review on [DATE], at 9:19 a.m., with the Director of Staff Development (DSD), reviewed LVN 3's Employee File.
The DSD stated LVN 3 took the National CPR Foundation online course to renew LVN 3's BLS certification.
The DSD stated the renewal course did not have a hands-on training.
During a telephone interview on [DATE], at 10:31 a.m., with LVN 3, LVN 3 stated he took the CPR renewal course online and did not have an in-person and hands-on training validation for performing CPR.
During an interview on [DATE], at 4:35 p.m., with the Director of Nursing (DON), the DON stated LVN 3 should have CPR certification with in-person and with hands on training to ensure LVN 3 can competently provide CPR to residents.
The DON stated the failure of the staff to be validated for hands on training for CPR can lead to inability of the staff to perform CPR appropriately and had the potential to result in resident death.
A review of the facility's Job Description for LVN Staff Nurse, indicated a licensed professional nurse under the supervision of a Registered Nurse who provides nursing care and services to residents in a long-term care setting.
Qualifications: - Valid CPR certification.
A review of the facility's recent policy and procedure titled, Cardiopulmonary Resuscitation, last reviewed on [DATE], indicated Licensed Nursing Staff shall maintain current CPR certification for Healthcare Providers through a CPR provider whose training includes hands-on practice and in-person skills assessment; online-only certification is not acceptable.
Licensed Nursing Staff are required to be certified in basic CPR and must be recertified every two years.
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Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
Site Sheet.
- New non-pressure ulcers, skin tears, bruises and lacerations will be documented on the 24-Hour Log and an incident report will be completed by the LN to determine casual factors contributing to the development of the skin condition.
056380 06/28/2024
Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
During an interview with the DON, on 6/28/2024, at 4:36 p.m., the DON stated Resident 8 was at risk for elopement and he wanders and goes into other residents' rooms.
The DON stated Resident 8 wears a wander guard and requires supervision or queuing.
The DON further stated it is important to accurately assess a resident's safety to ensure interventions are developed and in place.
A review of the facility's policy and procedure (P&P) titled, Wandering and Elopement, last reviewed 5/23/2024, indicated the facility will identify residents at risk for elopement upon admission, and when there is a change in the condition to minimize the risk of elopement to enhance the safety of residents of the facility.
056380 06/28/2024
Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
During an interview with the Director of Nursing (DON), on 6/28/2024, at 4:36 p.m., the DON stated it is important to label the resident's tube feeding with the rate and time to ensure residents receive the appropriate nutrition to prevent weight loss or gain.
A review of the facility's policy and procedure (P&P) titled, Enteral Feeding - Closed, last reviewed 5/23/2024, indicated to label the formula container and tubing with the date and time hung.
056380 06/28/2024
Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
the IV dressing timely to prevent the resident from developing infection from the insertion site.
reviewed 5/23/2024, indicated the following:
-An occlusive dressing shall be maintained over the central venous access site at all times to reduce the risk of infection to the insertion or exit site and surrounding area of a device such as midline catheters. -Central, peripherally inserted central catheter (PICC - a long, thin tube that's inserted through a vein in the arm and passed through to the larger veins near the heart), and midline catheter dressings shall be changed every seven (7) days from date of insertion. -Transparent semi-permeable (TSM) dressings are the dressing of choice for all Central, PICC, and midline catheters.
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Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
physician to prevent SOB and respiratory distress.
5/23/2024, indicated oxygen is administered under safe and sanitary conditions to meet resident
orders.
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Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
accurate. No portion of the record is to be obliterated, erased, or destroyed.
transfer of patients and records between the dialysis center and the skilled nursing facility the HDC 1
pursuant to Federal and State laws and regulations.
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Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
vary depending on the type of bed and mattress being used) upon admission when side rails are
A review of the facility provided Owner's Manual titled, BF 1, last revised on 4/1/2018, indicated
entrapment with assist rail may cause injury or death.
Please follow the manufacturer's instructions and monitor patient frequently.
Assist rails/bars are intended only to assist the resident during bed entry and exit.
These devices are not side rails, nor are they intended to be used in a manner that makes user entry and exit more difficult.
Accurate assessment of the resident and monitoring of correct maintenance and equipment use are required to prevent entrapment. On March 10, 2006, the U.S.
Food and Drug Administration (FDA) released guidelines for reducing the risk of hospital bed entrapment entitled; Hospital bed System Dimensional and Assessment Guidance to reduce Entrapment.
This guidance document identifies potential entrapment areas within the bed frame, rails and mattress and identifies those body parts most at risk for entrapment.
Potential risks of bed rails may include: -Strangling, suffocating, body injury or death when patients or part of their body are caught between rails or between the bed rails and mattress. -More serious injuries from falls when patients climb over rails. -Skin bruising, cuts, and scrapes. -Inducing agitated behavior when bed rails are used as a restraint. -Feeling isolated or unnecessarily restricted. -Preventing patients, who are able to get out of bed, from performing routine activities such as going to the bathroom or retrieving something from a closet.
056380 06/28/2024
Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
During a review of Resident 63's admission Record, dated [DATE], the admission Record indicated
diagnose of Pressure Ulcer (Injury to skin and the tissue beneath resulting from prolonged pressure on the skin causing pain.) During a review of Resident 63's MAR for [DATE], the MAR indicated Resident 63 was prescribed hydrocodone with acetaminophen 5-325 mg tablet every 4 hours as needed for moderate to severe pain, starting [DATE], with a dose administered on [DATE] for a pain level of 9 by LVN 1.
During a review of Resident 226's admission Record, dated [DATE], the admission Record indicated Resident 226 was originally admitted to the facility on [DATE] with a diagnosis including muscle weakness.
During a review of Resident 226's MAR for [DATE], the MAR indicated Resident 226 was prescribed pregabalin 100 mg tablet two times a day for neuropathy, starting [DATE], with a dose administered on [DATE] at 7:15 AM by LVN 1.
Review of the policy and procedures (P&P), titled Controlled Substances, dated [DATE], the P&P indicated that Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the facility, in accordance with federal and state laws and regulations.
A.
The Director of Nursing and the Consultant Pharmacist maintain the facility's compliance with federal and state laws and regulations in the handling of controlled medications.
F.
Accurate accountability of the inventory of all controlled drugs is maintained at all times.
When a controlled substance is administered, the licensed nurse administering the medication immediately enters the following information on the accountability record and the Medication Administration Record (MAR): a.
Date and time of administration (MAR, Accountability Record). b.
Amount administered (Accountability Record). c.
Remaining quantity (Accountability Record).
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Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
F 0755 d.
P&P indicated that Discontinued medications and medications left in the facility after a resident's discharge .are destroyed.
F.
The licensed healthcare professionals witnessing the destruction ensure the following information is entered on the medication disposition form: 1) Date of destruction. 2) Resident's name. 3) Name and strength of medication. 4) Prescription number, if applicable. 5) Amount of medication destroyed. 6) Signatures of witnesses.
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Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
The effectiveness of non-drug interventions
ii.
Need for psychotropic medication; iii.
Possible alternatives to use of psychotropic medications D.
Documentation Requirements: ii.
The Care Plan reflects the non-drug interventions prior to drug treatment, use of psychoactive medications, adverse reactions to psychoactive medications . iv.
Occurrences of behaviors for which psychoactive medications are in use will be entered with hash marks (#) on the MAR every shift.
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Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
injection, for subcutaneous or intravenous use, with initial U.S.
Approval in 1996, indicated to rotate
056380 06/28/2024
Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
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Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
for yields needed.
056380 06/28/2024
Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
The Dietary Manager will develop menus in collaboration with the Dietitian.
Menus are to be
comparable with the rest of the meal taking into consideration color, texture, and flavor.
A review of the facility's P&P titled Standardized Recipes dated 5/23/2024, indicated To provide the dietary department with guidelines for the use of standardized recipes.
A review of the facility's P&P titled Vegetable Cookery dated 5/23/2024 indicated Policy.
Dietary department employees ensure that the food prepared in a manner that preserves quality, maximizes nutrient retention, and obtains maximum yield of the product. (VII) Recipes will be used as a guideline.
Additional seasoning may be added, to taste, for seasoning variation. (A) Therapeutic diets will be maintained with additional seasonings.
A record review of the facility's recipe titled Broccoli with Garlic dated Week 4 Tuesday, indicated Ingredients: Broccoli fresh 30 lbs. or frozen 25 lbs., margarine, melted 15 oz, garlic powder 2 1/2 tbsp to 1/4 cup + 1 tbsp and salt 1 tbsp + ¾ tsp.
A record review of the facility's recipe titled Glazed Apple Square, dated Week 4, Tuesday, indicated Directions: (7) Just before serving, mix powdered sugar with hot water until sugar is dissolved.
Drizzle syrup over top of squares.
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Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
Margarine 1 tablespoon
Glazed apple square 1 pc Milk 4 oz Large portions 2500-2800 kcal.
A review of facility's policies and procedure (P&P) titled Menus dated 5/23/2024, indicated Purpose.
To ensure that the facility provides meals to residents that meet the requirements of the Food and Nutrition Board of the National Research Council of the National Academy of Sciences.
Procedure: II.
Food served should adhere to the written menu.
A review of the P&P titled Therapeutic Diets dated 5/23/2024, indicated To ensure that the facility provides therapeutic diets to residents that meet nutritional guidelines and physician orders.
Therapeutic diets are diets that deviate from the regular diet and require physician order. (b) Food portions served are equal to the written portion sizes.
056380 06/28/2024
Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
During an observation of the dry storage area on 6/25/2024 at 9:16 a.m., there was no thermometer in the area and the dry storage log indicated a temperature was at 60°F.
During an interview with the DS on 6/25/2024 at 9:27 a.m., the DS stated it felt hot in the storage area and heat would make food not safe for consumption.
The DS stated they opened the electric fan but did not know how to use the air condition.
During an interview with DS on 6/25/2024 at 10:12 a.m., the DS stated she placed a thermometer in the storage area today and it read more than 80°F.
A review of the facility's log titled Dry Storage Temperature Log, dated June 2024, indicated Dry food storage area should be ventilated with a temperature of 50-70°F. If the temperature is not within this range, report to supervisor-on-duty immediately or contact maintenance for correction.
Document corrective actions taken in appropriate column as necessary.
A review of the facility's P&P titled Food Storage dated 5/23/2024, indicated XII Dry Storage Guidelines (C) The area should be well lit and ventilated with a temperature of 50-70°F.
056380 06/28/2024
Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
During a concurrent observation of the dumpster area outside of the facility and interview with Dietary Supervisor (DS) on 6/26/2024 at 10:34 a.m., 1 black trash bin was not completely closed and 3 blue recycle bins were overflowing with boxes.
There were giant flies on the ground and dead rat around the trash area.
The DS stated the trash bins were not completely closed and the boxes were on the floor.
The DS stated there were flies and insects around the trash area. DS stated it was important for to maintain trash bins close and ensure cleanliness of the trash area for infection and pest control.
The DS stated the insects could contaminate food and would cause residents with wounds to worsen due to infection.
During an interview with the Maintenance Director (MD) on 6/26/2024 at 12:32 p.m., the MD stated the trash black bin was not completely close because it was overflowing with trash, the blue recycle bins were also overflowing boxes and the trash area was overcrowded with boxes on the floor.
The MD stated the bins should be completely closed and the boxes should not be on the floor to prevent infection and pest control.
The MD stated the trash surroundings should be clean and clear to prevent flies and contamination.
The MD stated the dead rat in the area was not thrown away right away as they placed baking soda on it first to completely kill it and to remove the odor. MS stated the potential outcome of this was the residents could get sick, but he was not sure what kind of sickness they could get.
A record review of the facility's policies and procedures (P&P) titled Waste Management dated 5/23/2024, indicated Purpose. To reduce risk of contamination from regulated waste and maintain appropriate handling and disposable of all waste. IV.
Food waste will be placed in covered garbage and trash cans.
A review of Food Code 2017, indicated, 5-501.15 Outside receptacles. (A) Receptacles and waste handling units for REFUSE, recyclables, and returnable used with materials containing FOOD residue and used outside the FOOD ESTABLISHMENT shall be designed and constructed to have tight-fitting lids, doors, or covers.
A review of Food Code 2017, indicated, 5-501.113 Covering Receptacles and waste handling units for refuse, recyclables, and returnable shall be kept covered: (A) Inside food establishment if the receptacles and units: (1) Contain food residue and are not in continuous use; or (2) After they are filled; and 174 (B) With tight-fitting lids or doors if kept outside the food establishment.
056380 06/28/2024
Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
During an interview with the DON, on 6/28/2024, at 4:36 p.m., the DON stated it is important to ensure linens in the linen cart are enclosed with a nonpermeable cover to protect the clean linens from dirt and liquid.
The DON further stated if exposed, there is a potential for cross-contamination.
A review of the facility's policy and procedure (P&P) titled, Infection Control - Policies & Procedures, last reviewed 5/23/2024, indicated the facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseases and infections.
A review of a document provided by the facility titled, Linen Carts - Open Shelf - 20 inches (a unit of measure for length) depth and 50 inches width, undated, indicated cart cover advantages are as follows: -Breathable standard mesh is flame resistant, mildew resistant, and high tear and tensile (capable of being drawn out or stretched) strength.
The cart cover advantage does not indicate the breathable standard mesh is antimicrobial (designed to fight the growth of bacteria, mold, fungus, and other microbes). -All solid vinyl fabrics are antimicrobial, flame resistant, high tear and tensile strength, and excellent cleanability.
056380 06/28/2024
Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
During an observation on 6/25/2024, at 10:20 a.m., inside Resident 57's room, Resident 57 was observed lying in bed with the bed controller on the left side of the resident.
The base of the bed controller cable was wrapped with black plastic tape and there were white, red, blue, and yellow wires that were exposed and not covered with the black tape.
During a concurrent observation and interview, with Licensed Vocational Nurse 5 (LVN) 5, on 6/25/2024, at 10:25 a.m., inside Resident 57's room, LVN 5 stated Resident 57's bed controller cable had exposed wires and it is not safe for the resident to have exposed wires next to them. LVN 5 further stated the exposed wires had the potential for accidents such as fire and could also possibly cause an electrical shock.
During an interview on 6/28/2024 at 10:00 a.m., the Maintenance Director (MD), the MD stated it was important to ensure all resident care equipment are in good working condition for resident safety.
The MD stated the exposed wires could potentially result in accidents such as an electrical shock resulting in injuries.
A review of the facility's policy and procedure titled, Maintenance Service, last reviewed 5/23/2024, indicated a purpose to protect the health and safety of residents, visitors, and facility staff.
The policy indicated the Maintenance Department maintains all areas of the building, grounds, and equipment.
The Director of Maintenance is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner.
056380 06/28/2024
Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
equipment.
The P&P indicated functions of the maintenance department may include, but are not
056380 06/28/2024
Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
During an interview on 6/26/2024, at 1:09 p.m., with Registered Nurse 1 (RN 1), RN 1 stated prior to installing bed rails there should be a physician order, a risk for entrapment assessment, an informed consent from the resident or representative and documentation the resident or representative were educated on the risk and benefits of bed rail use to prevent injuries to the resident.
During an interview on 6/28/2024, at 4:35 p.m., with the Director of Nursing (DON), the DON stated before installing bed rails 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.
A review of the facility's recent policy and procedure titled, Side Rails, last reviewed on 5/23/2024, the Interdisciplinary Team (IDT)- Restraint Reduction Committee will determine whether a resident should be provided with side rails on his/her bed, based on an individual assessment which includes the risk of entrapment.
Physical Restraint is defined by the Centers for Medicare and Medicaid Services (CMS) as any manual method or physical or mechanical device, material or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. (Note: the definition of restraint is based on the functional status of the resident and not on the device, therefore any device that has the effect on the resident of restricting freedom of movement or normal access to one's body could be considered a restraint).
The Licensed Nurse will maintain the Side Rail Evaluation in the resident's medical record and develop a Care Plan reflecting that assessment.
Prior to placing a side rail on the bed informed consent will be obtained when side rail meets the definition of a physical restraint even when it is also used as an enabler.
The space between the mattress and side rails and other potential entrapment zones will be assessed to reduce the risk of entrapment (the amount of safe space may vary depending on the type of bed and mattress being used) upon admission when side rails are required or after admission if side rails are required, or when a mattress is replaced.
056380
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 056380 B.
Wing 06/28/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
During an interview on 6/28/2024, at 4:35 p.m., with the DON, the DON stated it is important to rotate insulin administration sites to prevent phlebitis (inflammation of a vein) and lipodystrophy.
The DON stated not rotating insulin administration sites constitute medication error.
The DON stated medication error results from not following the physician's order, professional nursing practice and manufacturer guidelines.
A review of the facility's recent policy and procedure titled, Medication-Errors, last reviewed on 5/23/2024, indicated medication error means the administration of medication:
D.
Via the wrong route; or
E.
Which is not currently prescribed.
A review of the facility provided Highlights of Prescribing Information titled, Insulin Aspart Injection, for subcutaneous or intravenous use, with initial U.S.
Approval in 2000, indicated to rotate injection sites within the same region for one injection to the next to reduce risk of lipodystrophy and localized cutaneous amyloidosis.
A review of the facility provided Highlights of Prescribing Information titled, Levemir (insulin detemir injection), for subcutaneous use, with initial U.S.
Approval in 2005, indicated to rotate injection sites within an injection area (abdomen, thigh, or deltoid) to reduce the risk of lipodystrophy.
056380
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 056380 B.
Wing 06/28/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
During an observation on 6/27/2024 at 8:15 a.m. inside Resident 26's room, observed resident lying in bed asleep and partially covered with a sheet with both lower legs exposed.
Observed both lower legs with discoloration in a straight line above the ankles.
During a concurrent observation on 6/27/2024 at 8:24 a.m. inside Resident 26's room, Certified Nursing Assistant 9 (CNA 9) verified the discoloration around the resident's ankles. CNA 9 stated she was not aware of the resident having skin issues or skin discoloration and if she had seen the discoloration, she would have reported it to the charge nurse immediately. CNA 9 stated she did not know when did the discoloration developed on the resident.
During a concurrent interview and record review on 6/27/2024 at 8:43 a.m., with Treatment Nurse 2 (TN 2), reviewed Resident 26's Weekly Skin/Wound Assessment. TN 2 stated the last documented weekly skin check for Resident 26 was on 5/28/2024. TN 2 skin checks are done every Thursday. TN 2 stated she was made aware today (6/27/2024) Resident 26 had discoloration on both lower legs. TN 2 stated the discoloration did not happen overnight and stated she thinks the discoloration was cause by the resident wearing socks. TN 2 stated it was important to perform skin checks on the residents to identify any skin changes or wounds and to provide proper interventions timely.
056380
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 056380 B.
Wing 06/28/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
During an observation on 6/27/2024 at 8:15 a.m. inside Resident 26's room, observed resident lying in bed asleep and partially covered with a sheet with both lower legs exposed.
Observed resident's both lower legs with dry, scaly skin and redness on the right shin.
During an interview on 6/27/2024 at 8:43 a.m., with Treatment Nurse 2 (TN 2), TN 2 stated Resident 26 had dry skin and peeling of skin on both lower legs and redness on the right shin. TN 2 stated the CNAs are supposed to apply lotion after providing ADL care to residents to help moisten the skin and prevent skin breakdown from very dry skin.
During an interview on 6/27/2024 at 9:01 a.m., with Licensed Vocational Nurse 11 (LVN 11), LVN 11 stated Resident 26's skin was flaky and dry, and with redness on the right shin. LVN 11 stated she did not know when Resident 26's skin dryness started. LVN 11 stated CNAs are supposed to apply lotion after shower to help moisten the skin and prevent skin breakdown.
During an interview on 6/27/2024 at 9:30 a.m., with Registered Nurse 1 (RN 1), RN 1 stated skin check on residents are done every shift and documented by the charge nurse. RN 1 described Resident 26's skin as slightly dry with redness on the right shin. RN 1 stated CNAs are supposed to apply lotion after providing care to the residents to moisten the skin and prevent skin breakdown.
During a concurrent observation on 6/27/2024 at 12:08 p.m. inside Resident 26's room, Certified Nursing Assistant 9 (CNA 9) stated Resident 26's both lower legs had dry scaly skin with redness on the right shin. CNA 9 stated if a resident refuse shower, she offers at least three times and if the resident still refuse, she will offer bed/towel bath instead. CNA 9 stated residents have lotion on their nightstands and is applied everyday with during ADL care.
During a concurrent interview and record review on 6/27/2024 at 12:21 p.m., with the Director of Staff Development (DSD), reviewed Resident 26's ADL Flowsheet and shower schedule.
The DSD stated Resident 26 's shower schedule is on Mondays and Thursdays.
The DSD there was no documented evidence if Resident 26 was provided or refused bath/shower or bed/towel bath on 6/20/2024 and 6/24/2024; from 5/10/2024 - 5/19/2024 and 6/7/202 - 6/16/2024, the flowsheet was marked with and X on shower days 5/13/2024, 5/15/2024, 6/10/2024, and 6/13/2024.
The DSD stated the X mark means bathing/shower was not triggered in the CNA task to be provided to Resident 26 and could mean that the resident was not provided or offered bathing/shower or bed/towel bath.
The DSD stated CNAs are supposed to apply lotion to residents after providing appropriate ADL care as they are a high risk for dry, scaly skin due to the level of assistance required to help moisten the skin and prevent skin breakdown.
The DSD stated if residents refused, ADL care should be offered multiple times and documented in the flowsheet.
The DSD stated not providing the appropriate ADL care Resident 26 needs could potentially affect his quality of life and self-esteem.
056380
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 056380 B.
Wing 06/28/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
During an interview on 6/26/2024, at 1:09 p.m., with Registered Nurse 1 (RN 1), RN 1 stated prior to installing bed rails and placing the bed against the wall there should be a physician order, a risk for entrapment assessment, an informed consent from the resident or representative and documentation the resident or representative were educated on the risk and benefits of bed rail use and placement of bed against the wall to prevent injuries to the resident.
During an interview on 6/28/2024, at 4:35 p.m., with the Director of Nursing (DON), the DON stated before applying restraints to residents such as bed rails and placement of bed against the wall 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.
A review of the facility's recent policy and procedure titled, Restraints, last reviewed on 5/23/2024, indicated to ensure that all restraints are used properly and only, when necessary, on residents at the facility.
The facility honors the resident's right to be free from any restraints that are imposed for reasons other than that of treatment of the resident's medical symptoms.
Restraints require a physician order and are used as a last resort measure to be used only when deemed necessary by the interdisciplinary Team (IDT) and in accordance with the resident's assessment and Plan of Care.
Before any type of restraint is used, the License Nurse will verify that informed consent was obtained from the resident and has been documented in the resident's medical record.
Physical restraint means the use of a manual hold to restrict freedom of movement of all or part of a resident's body, or to restrict normal access to the person's body, and that is used as a behavioral restraint.
All use of restraints must conform to the manufacturer's instructions.
Before applying the restraint, a Licensed Nurse will explain the risks and benefits of restraints, alternatives to restraints, how the restraint will treat the resident's medical condition.
056380
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 056380 B.
Wing 06/28/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
During a concurrent observation, interview, and record review on 6/25/2024, at 2:31 p.m., with Registered Nurse 2 (RN 2) and the Assistant Director of Nursing (ADON), inside Resident 118's room, observed Resident 118's both upper bed rails up, and the bed was placed against the wall. Resident 118's care plans were reviewed with RN 2. RN 2 stated there was no care plan addressing restraints, bed rails and placement of bed against the wall. RN 2 stated the care plan serves as a communication tool to all care givers to standardize care.
During an interview on 6/26/2024, at 1:09 p.m., with Registered Nurse 1 (RN 1), RN 1 a care plan should be developed on bed rail use and placement of bed against the wall to reflect the goals of the care plan and to ensure the interventions are implemented.
During an interview on 6/28/2024, at 4:35 p.m., with the Director of Nursing (DON), the DON stated 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.
A review of the facility's recent policy and procedure titled, Comprehensive Person-Centered Care Planning, last reviewed on 5/23/2024, indicated within 7 days from the completion of the comprehensive MDS assessment, the comprehensive care plan will be developed.
All goals, objectives, interventions, etc. from the current baseline care plan will be included in the resident's comprehensive care plan.
1.b A review of Resident 378's Admission Record indicated the facility admitted the resident on 6/18/2024, with diagnoses including hepatic encephalopathy (a decline in brain function that occurs as a result of severe liver disease), seizures, and muscle weakness.
A review of Resident 378's H&P, dated 6/21/2024, indicated the resident had the capacity to understand and make decisions.
A review of Resident 378's Fall Risk Evaluation, dated 6/18/2024, indicated the resident was high risk for potential falls.
056380
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 056380 B.
Wing 06/28/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
During an interview on 6/28/2024, at 4:35 p.m., with the DON, the DON stated it is important to rotate insulin administration sites to prevent phlebitis (inflammation of a vein) and lipodystrophy.
A review of the facility provided Highlights of Prescribing Information titled, Insulin Aspart Injection, for subcutaneous or intravenous use, with initial U.S.
Approval in 2000, indicated to rotate injection sites within the same region for one injection to the next to reduce risk of lipodystrophy and localized cutaneous amyloidosis.
A review of the facility provided Highlights of Prescribing Information titled, Levemir (insulin detemir injection), for subcutaneous use, with initial U.S.
Approval in 2005, indicated to rotate injection sites within an injection area (abdomen, thigh, or deltoid) to reduce the risk of lipodystrophy.
b. A review of Resident 118's Admission Record indicated the facility admitted the resident on 5/14/2024, with diagnoses including type 2 diabetes mellitus and obesity (abnormal or excessive fat accumulation that presents a risk to health).
A review of Resident 118's H&P, dated 5/18/2024, indicated the resident had the capacity to understand and make decisions.
The MDS indicated the resident had the ability to make self-understood and understand others.
The MDS indicate the resident was on a high-risk drug class hypoglycemic medication.
A review of Resident 118's Order Summary Report indicated the following orders:
-5/15/2024 Insulin Lispro Injection Solution 100 unit/ml (Insulin Lispro).
Inject as per sliding scale: if 0-149= 0 units. If less than or equal to 70 mg/dl- hypoglycemia protocol; 150-199= 3 units; 200-249= 4 units; 250-299= 7 units; 300-349= 10 units; 350-399= 12 units. 399 or more- call doctor, subcutaneously before meals and at bedtime for type 2 DM.
Rotate injection sites.
056380
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 056380 B.
Wing 06/28/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Los Feliz Healthcare & Wellness Center, LP 3002 Rowena Avenue Los Angeles, CA 90039
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.