Inspection Reports for
Park Avenue Healthcare & Wellness Centre

The facility failed to maintain complete and accurate clinical records by not documenting required meal intake percentages for one of three sampled residents, resulting in incomplete nutritional records and potential negative effects on the resident's health and well-being.

The facility failed to maintain a clean environment for Resident 2, did not obtain timely medication admission orders for Resident 1, and failed to order the correct therapeutic diabetic diet for Resident 1. These deficiencies posed potential risks of psychosocial decline, adverse medical outcomes, and hyperglycemia respectively.

The facility was found deficient in multiple areas including failure to honor resident preferences, incomplete PASARR Level II screening, inadequate care planning and monitoring for pain and anticoagulant use, failure to follow up on infectious disease consults, failure to replace missing glasses timely, unsafe environment related to fall risks and smoking safety, inadequate catheter care, delayed response to feeding tube alarms, improper tracheostomy care, incomplete nursing assistant performance evaluations, unacted pharmacist recommendations, improper food storage temperatures, failure to document restorative nursing aide services, inadequate infection control practices, malfunctioning refrigeration equipment, and call light accessibility issues.

The facility failed to notify Resident 3's doctor of refusals to perform accu checks, failed to implement a comprehensive care plan for Resident 3, failed to ensure Resident 5 had a written physician's order for an overnight pass, and failed to provide ordered wound care for Resident 1. These failures had potential to negatively impact resident health and safety.

The complaint investigation was substantiated, revealing delays in call light response causing a resident fall, and resident-to-resident physical assaults by Resident 9 on Residents 7 and 8, resulting in injuries and hospital transfer.

The facility failed to ensure prompt response to call lights for four sampled residents, resulting in a fall incident. Additionally, the facility failed to prevent physical assaults by Resident 9 on Residents 7 and 8, causing injuries and requiring hospital transfer. The facility also failed to develop and implement an individualized care plan addressing Resident 7's injuries from the altercation.

The complaint investigation focused on Resident 2's fall on 3/8/2025 and the facility's failure to develop a care plan and include the resident in the fall management program despite a high-risk Fall Risk Assessment dated 1/11/2025. The investigation also found inaccurate documentation of the Fall Risk Assessment after the fall.

The facility failed to ensure licensed nurses developed and implemented a care plan for Resident 2 after being identified as high-risk for falls, failed to include Resident 2 in the fall management program timely, and failed to accurately document the Fall Risk Assessment after the fall. Resident 2 fell out of bed on 3/8/2025, sustaining a left elbow skin tear.

The complaint investigation found substantiated issues with call light response times, meal service not matching the menu, and food quality concerns as reported by residents and confirmed by interviews and observations.

The facility failed to promptly respond to call lights for three sampled residents, failed to serve the meal indicated on the lunch menu to one sampled resident, and failed to ensure food was palatable and attractive for two sampled residents. These failures had the potential to result in unmet care needs and risk of unplanned weight loss.

The complaint investigation found that the facility did not send the Notice of Proposed Transfer and Discharge (NPTD) to the Ombudsman prior to Resident 4's discharge on 12/23/24, with the Ombudsman receiving it only on 12/31/24. Additionally, clinical records for Residents 1 and 3 were incomplete and inaccurate regarding emergency responses, including missing documentation of staff involved and timing of interventions.

The facility failed to ensure timely notification of the Notice of Proposed Transfer and Discharge (NPTD) to the Ombudsman before Resident 4's discharge, and failed to maintain complete and accurate clinical records for Residents 1 and 3, including documentation of staff responses and interventions during rapid response events. These deficiencies had the potential to impact resident protections and care evaluation.

The complaint investigation revealed that Infection Preventionist 1 willfully falsified flu vaccine declinations by documenting verbal declinations from responsible parties without actually speaking to them. Several residents were not offered the flu vaccine, leading to an outbreak declared by the Los Angeles County Public Health Nurse. The facility also lacked a system to track vaccination status and failed to administer the vaccine to a consenting resident. Immediate jeopardy was called due to these failures.

The facility failed to accurately document flu vaccine consent/declination and failed to offer or administer the flu vaccine to several residents, resulting in an influenza outbreak with multiple residents hospitalized for complications such as sepsis and pneumonia. Additionally, the facility failed to implement an effective flu vaccine tracking system and failed to follow infection prevention protocols including hand hygiene and use of PPE for residents on enhanced barrier precautions.

The facility failed to ensure staff consistently wore appropriate PPE and performed hand hygiene when caring for COVID-19 positive residents, and residents who tested positive were not wearing masks outside their rooms. These failures resulted in the transmission and spread of infection within the facility.

The facility failed to develop and implement a comprehensive person-centered care plan addressing Resident 2's individualized needs related to elopement risk. Resident 2 was moved to a locked unit (Area 4) without an appropriate care plan, and the risk for elopement was not properly documented or addressed in the care plan, potentially affecting the resident's physical and psychosocial well-being.

The facility failed to provide adequate safety measures for Resident 6, who had a history of seizures, by not ensuring bilateral padded side rails were in place on the resident's bed. This posed a potential risk for injury during a seizure episode. The facility staff later padded the side rails on the day of the inspection.

The facility failed to ensure that two sampled residents (Resident 57 and Resident 161) had complete and individualized care plans addressing Resident 57's risk for falls and Resident 161's actual fall on 7/8/2024. The care plans lacked specific interventions and were not sufficiently individualized to meet residents' needs, potentially affecting their physical well-being and optimal functioning.

The facility was found deficient in multiple areas including failure to maintain resident privacy, ensure call lights were within reach, accurately assess and update care plans, safely administer medications, maintain infection control practices, provide food preferences, and offer vaccinations. Several residents were affected by these deficiencies, which had the potential to impact their health, safety, and well-being.

The facility failed to maintain and implement its Infection Control Program, allowing two Certified Nursing Assistants with scabies to provide care to 29 residents, potentially exposing them to infection. Staff did not promptly report rashes as required by facility policy, and supervisory staff failed to prevent affected employees from working.

The complaint investigation found that Resident 5 assaulted Resident 4 on 6/2/24, hitting Resident 4 multiple times and throwing chairs, causing injury. Staff did not remove Resident 5 immediately due to fear of aggression. Resident 4 was transferred to the hospital for evaluation and treatment. Resident 5 had prior resident-to-resident altercations on 1/23/24 and 4/18/24.

The facility failed to protect Resident 4 from physical abuse by Resident 5, who physically assaulted Resident 4 causing pain, an abrasion, and requiring emergency medical evaluation. Staff did not immediately remove Resident 5 from the area, and Resident 4 felt unsafe and scared. Resident 5 had a history of multiple resident-to-resident altercations.

The facility failed to ensure residents received food and drinks according to their preferences and therapeutic diet orders, including use of disposable plates, lack of breakfast meat and eggs, and missing drinks on trays. These failures had the potential to impact residents' dignity, nutrition, and hydration.

The facility failed to ensure dignity and respect during feeding for Resident 7, failed to protect Resident 1 from physical abuse by Resident 2 resulting in minor injury, and failed to develop and implement a person-centered care plan addressing Resident 7's meal preferences. These deficiencies had the potential for minimal harm or potential for actual harm.

The complaint investigation found that the facility did not arrange transportation in a timely manner for Resident 2's pain management appointment on 1/29/2024, and did not notify the Responsible Party of the missed appointment or rescheduling. The issue was substantiated with evidence from interviews and record reviews.

The facility failed to ensure timely transportation was arranged for Resident 2's pain management appointment, resulting in a missed appointment and lack of notification to Resident 2's Responsible Party. This failure had the potential to cause increased pain and health decline for Resident 2.

The complaint investigation substantiated that Resident 2 physically assaulted Residents 1 and 6 on 2/3/2024, resulting in injuries to both residents. The facility failed to notify the Director of Nursing about Resident 2's aggressive behavior on 2/2/2024, which could have prevented the assault.

The facility failed to protect Residents 1 and 6 from physical abuse by Resident 2, who assaulted them causing injuries requiring hospital transfer for Resident 1. The facility also failed to ensure that staff notified the Director of Nursing about Resident 2's aggressive behavior prior to the assault as required by policy.

The facility failed to ensure staff consistently performed hand hygiene before and after resident contact, wore appropriate PPE when entering isolation rooms, and assisted residents with mask-wearing in hallways. Additionally, kitchen staff did not follow proper glove and hand hygiene protocols when handling dishes from the COVID unit, posing a risk for infection spread.

The complaint investigation found that the facility did not report Resident 2's allegation of abuse within two hours as required. The allegation was made on 11/3/2023, but the Licensed Vocational Nurse did not file an abuse report, citing police disbelief of the incident. Facility policy requires immediate reporting to the Administrator and notification to CDPH, Ombudsman, and Law Enforcement within two hours.

The facility failed to report one of 15 sampled resident's (Resident 2) allegation of abuse within the mandated two-hour timeframe, placing Resident 2 and all facility residents at risk. Interviews with staff revealed that the abuse report was not filed because the police did not believe abuse occurred, contrary to facility policy requiring immediate reporting.

The complaint investigation involved two separate resident-to-resident abuse incidents: one on 10/17/2023 where Resident 4 assaulted Resident 3, and another on 10/16/2023 where Resident 2 slapped Resident 1. The facility failed to protect Resident 3 from abuse and failed to report the incident involving Resident 1 and Resident 2 within the required timeframe. The incidents were substantiated based on interviews, record reviews, and facility reports.

The facility failed to protect residents from physical abuse by other residents, specifically an incident where Resident 4 physically assaulted Resident 3. Additionally, the facility failed to timely report an allegation of abuse involving Resident 1 and Resident 2 to appropriate authorities within the required two-hour timeframe.

The facility was found to have conducted remodeling projects including lobby restroom renovations, installation of patient room TV brackets, and a temporary wooden barricade installation without obtaining required HCAI building permits, resulting in a non-compliant and potentially unsafe environment.

The complaint investigation focused on medication management, resident care, and failure to provide necessary medical appointments and treatments, including oncology follow-ups and respiratory care.

The facility failed to ensure proper monitoring and documentation of psychotropic medication use, failed to provide adequate nutritional care resulting in weight loss, failed to provide appropriate respiratory care for a resident with a tracheostomy, and failed to ensure transportation for oncology appointments. These failures led to potential or actual harm including sedation, weight loss, and worsening cancer.

The visit was complaint-related due to a COVID-19 outbreak. The deficiencies were substantiated as the facility failed to follow infection control practices according to Department of Public Health guidelines and facility policies.

The facility failed to annually conduct N95 mask fit testing for two Licensed Vocational Nurses, did not maintain a monitoring log for cleaning and disinfecting high touch areas in the Red Zone, and kitchen staff failed to consistently wear masks and hairnets, posing risks for COVID-19 transmission and foodborne illnesses.

The visit was complaint-related, focusing on infection control deficiencies during a COVID-19 outbreak. The complaint was substantiated as the facility failed to meet infection prevention standards.

The facility failed to follow infection control practices by not annually conducting N95 mask fit testing for two Licensed Vocational Nurses, lacking a monitoring log for cleaning and disinfecting high touch areas in the COVID-19 Red Zone, and kitchen staff failing to wear masks and hairnets, posing risks for infection transmission and foodborne illnesses.

The facility was found deficient in multiple areas including improper use and assessment of physical restraints and bed rails for Resident 5, failure to provide restorative nursing services as ordered for multiple residents, inadequate staffing levels impacting resident care, incorrect meal tray delivery to Resident 2, poor food preparation affecting palatability and consistency, and failure to provide timely occupational and physical therapy services to Resident 2.

The facility failed to accommodate Resident 2's needs and preferences regarding clothing and call light accessibility, protect Resident 2's personal belongings from loss, ensure accurate admission assessments, and provide rehabilitative therapy to maintain and improve Resident 2's range of motion and functional mobility. These failures had the potential to cause psychosocial decline, incorrect treatments, and physical deterioration.

The complaint was substantiated. Resident 1 reported verbal abuse by LVN 1 on 7/11/23, supported by a video recording. The Administrator and Director of Nursing confirmed the incident as verbal abuse. LVN 1 resigned following the investigation.

The facility failed to ensure Resident 1 remained free from verbal abuse when LVN 1 raised her voice and spoke inappropriately to Resident 1. The facility also failed to timely report the alleged verbal abuse to the California Department of Public Health within two hours as required by policy. LVN 1 resigned following the incident.

The facility failed to follow its policy for the storage and destruction of designated record sets, specifically disposing of a Physician's Progress Note containing PHI in a regular trash can instead of a shredder bin, potentially exposing Resident 9's PHI to the public.

The facility failed to implement its Pest Control Policy by not ensuring the facility was free of flies, staff were unaware of pest control recommendations, and the Administrator did not receive written reports from pest control visits. Multiple observations noted the presence of fruit flies and large flies throughout the facility, including hallways and the Admissions Office.

The facility was found deficient in three areas: failure to have a physician's order for oxygen administration for one resident, improper transport of soiled diapers and linens risking cross-contamination, and malfunctioning call lights in five resident rooms potentially delaying care.

The facility was found deficient in multiple areas including improper storage of resident belongings, failure to follow manufacturer guidelines for special air-filled mattresses, inadequate maintenance and inspection of beds and bed rails leading to potential entrapment risks, and failure to safeguard resident medical records containing protected health information. All deficiencies were assessed as causing minimal harm or potential for actual harm to residents.

The facility failed to ensure food items in the kitchen were stored in a safe and sanitary manner, including uncovered containers, food stored directly on the floor, expired food items, and food debris on storage carts. The Director of Nutrition Services acknowledged these issues and confirmed that food containers should have lids and be stored off the floor.

The complaint investigation found that the facility did not readmit Resident 1 after hospitalization due to lack of isolation beds, despite the resident being cleared for discharge and an empty room being available. The facility staff and administration acknowledged the refusal was due to the resident's C-aureus isolation status and the perpetual nature of the infection, which was against facility policy.

The facility failed to readmit Resident 1 after hospitalization because of the resident's need for C-aureus isolation. Despite having an empty room available and staff trained to care for isolation cases, the facility did not accommodate the resident due to the perpetual nature of the isolation requirement, violating their own readmission policy.

Resident 1 complained that staff were heard arguing loudly and using foul language in the hallway and inside the residents' room on 3/13/2023 at approximately 4 am. The complaint was substantiated by interviews with staff and residents.

The facility failed to protect the rights of three residents when staff (LVN 1, CNA 1, and CNA 2) had a loud argument and LVN 1 used foul language inside the residents' room, causing psychosocial harm. Interviews and record reviews confirmed the incident and unprofessional behavior.

The complaint investigation found that Resident 1 did not receive atorvastatin calcium 20 mg because the pharmacy never delivered the medication to the facility, despite licensed nurses documenting administration on the MAR. The pharmacy confirmed no prescription was filled or delivered. The Director of Nursing confirmed nurses should not have signed off on medication administration if the medication was not given.

The facility failed to ensure that atorvastatin calcium 20 mg was available and administered to Resident 1 according to the physician's order. Licensed nurses documented administration on the MAR despite the medication not being present or delivered by the pharmacy, resulting in Resident 1 not receiving the prescribed medication.

The complaint investigation focused on Resident 1's rights being violated due to administration of lorazepam without informed consent, inadequate fall prevention and management including failure to assist Resident 1 after being found on the floor mat, and failure to provide nonpharmacological alternatives before psychotropic medication use. The psychiatrist's note indicated that Resident 1's responsible party initially declined consent but later consented, then withdrew consent for lorazepam use.

The facility failed to ensure informed consent was obtained prior to administering lorazepam to Resident 1, failed to provide nonpharmacological alternatives before administering psychotropic medication, and failed to properly assess and assist Resident 1 after being found on the floor mat multiple times. The facility also failed to ensure Resident 1's call light was within reach and to follow its fall prevention and management protocols.

The complaint investigation found that Resident 1 was intentionally scratched by CNA 1 during care on 12/26/2022. The physician was not notified until five hours after the end of the shift. The facility failed to document the wound description and treatment accurately. The Director of Nursing confirmed the lack of timely notification and incomplete documentation.

The facility failed to notify the physician promptly after Resident 1 was scratched by a Certified Nurse Assistant, resulting in delayed treatment notification. Additionally, the injury was not accurately assessed or documented in the resident's medical records, including the wound description and treatment provided.

The facility was found deficient in multiple areas including resident care, medication management, infection control, staffing, and safety measures. Specific issues included failure to provide adequate bed linen, failure to inform residents of their health status in understandable language, improper medication administration, inadequate assistance with activities of daily living, failure to monitor and report abuse allegations timely, incomplete care plans, failure to assess residents for safe oxygen use, failure to monitor antibiotic use, and lapses in infection prevention practices.