Deficiency Records for Los Feliz Healthcare and Wellness Center, LP
Updated as of March 01, 2024
A list of the most recent deficiencies for Los Feliz Healthcare and Wellness Center, LP. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-09 | 2024-02-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-01-09 | 2024-02-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-12 | 2023-12-31 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-10-27 | 2023-11-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-10-05 | 2023-11-02 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-15 | 2023-09-14 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-08-15 | 2023-09-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-05 | 2023-06-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-19 | 2023-06-16 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-04-25 | 2023-05-25 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-04-24 | 2023-05-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-05 | 2023-04-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-04-05 | 2023-04-20 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-03-23 | 2023-04-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-21 | 2023-03-20 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-18 | 2023-02-16 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-16 | 2022-12-01 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-11-16 | 2022-12-01 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-11-16 | 2022-12-01 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-08-05 | 2022-08-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-13 | 2022-08-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-07-12 | 2022-08-02 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-04-08 | 2022-04-28 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-04-08 | 2022-04-28 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-04-08 | 2022-04-28 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-04-08 | 2022-04-28 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-04-08 | 2022-04-28 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-04-08 | 2022-04-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-04-08 | 2022-04-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-08 | 2022-04-28 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-04-08 | 2022-04-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-08 | 2022-04-28 | N |
| Provide appropriate foot care. | Health | 2022-04-08 | 2022-04-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-08 | 2022-04-28 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-04-08 | 2022-04-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-08 | 2022-04-28 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-04-08 | 2022-04-28 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-04-08 | 2022-04-28 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-04-08 | 2022-04-28 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-04-08 | 2022-04-28 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2022-04-08 | 2022-04-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-08 | 2022-04-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-08 | 2022-04-28 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-04-07 | 2022-04-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-04-07 | 2022-04-28 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-04-07 | 2022-04-28 | N |
| Ensure that laboratories employing quantities of flammable, combustible, or hazardous materials have fire resistant walls and automatic sprinkler system. | Fire Safety | 2022-04-07 | 2022-04-28 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-04-07 | 2022-04-28 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-04-07 | 2022-04-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-07 | 2022-04-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-04-07 | 2022-04-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-04-07 | 2022-04-28 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2022-04-07 | 2022-04-28 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2022-04-07 | 2022-04-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-07 | 2022-03-21 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-12-05 | 2021-12-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-13 | 2021-09-23 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-04-08 | 2019-05-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-08 | 2019-05-01 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-04-08 | 2019-05-01 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-04-08 | 2019-05-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-04-08 | 2019-05-01 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-04-08 | 2019-05-01 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-04-08 | 2019-05-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-04-08 | 2019-05-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-04-08 | 2019-05-01 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-04-08 | 2019-05-01 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2019-04-08 | 2019-05-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-08 | 2019-05-01 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-04-08 | 2019-05-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-08 | 2019-05-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-04-03 | 2019-04-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-04-03 | 2019-04-20 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2018-05-01 | 2018-06-29 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2018-05-01 | 2018-06-29 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2018-05-01 | 2018-06-29 | N |
| Develop a communication plan. | Fire Safety | 2018-05-01 | 2018-06-29 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2018-05-01 | 2018-06-29 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-05-01 | 2018-06-29 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2018-05-01 | 2018-06-29 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-05-01 | 2018-06-29 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-05-01 | 2018-06-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-05-01 | 2018-06-29 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-05-01 | 2018-06-29 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2018-05-01 | 2018-06-29 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2018-04-30 | 2018-06-14 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2018-04-30 | 2018-06-14 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-04-30 | 2018-06-14 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-04-30 | 2018-06-14 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2018-04-30 | 2018-06-14 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2018-04-30 | 2018-06-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-04-30 | 2018-06-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-04-30 | 2018-06-14 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-04-30 | 2018-06-14 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-04-30 | 2018-06-14 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-04-30 | 2018-06-14 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-04-30 | 2018-06-14 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2018-04-30 | 2018-06-14 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2018-04-30 | 2018-06-14 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-04-30 | 2018-06-14 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-04-30 | 2018-06-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-04-30 | 2018-06-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-04-30 | 2018-06-14 | N |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2018-04-30 | 2018-06-14 | N |
