Los Feliz Healthcare & Wellness Center, Lp
LOS FELIZ HEALTHCARE & WELLNESS CENTER, LP in LOS ANGELES, CA — inspection on June 28, 2024.
Found 7 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
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