ROSEMEAD, CA - Federal health inspectors identified multiple violations at Green Acres Healthcare Center during a February 2025 inspection, including failures in mental health services, communication support for hearing-impaired residents, and infection control protocols.
Mental Health Care Failures Put Residents at Risk
The inspection revealed significant deficiencies in behavioral health services for residents with mental illness. A resident with schizophrenia who exhibited aggressive behavior toward staff and other residents did not receive timely psychiatric evaluation despite facility policies requiring such consultation.
The resident's medical records documented two separate incidents in January 2025 where she attempted to attack staff and other residents, and was found taking personal belongings from other residents' rooms. While the facility created a care plan on January 28, 2025, that specifically included psychiatric consultation as an intervention, administrators failed to follow through with the referral.
During interviews, Licensed Vocational Nurses confirmed they had initiated Change of Condition assessments documenting the aggressive episodes. The Director of Nursing acknowledged that the facility "overlooked that intervention and failed to refer Resident 9 to the psychiatrist."
Mental health conditions like schizophrenia require ongoing psychiatric oversight to ensure proper medication management and behavioral interventions. Untreated behavioral symptoms can escalate, potentially leading to injury of the resident or others, and may result in the need for emergency psychiatric hospitalization. Residents with serious mental illness have the right to receive appropriate specialized care to maintain their highest level of functioning and prevent symptom deterioration.
Communication Barriers Leave Resident Isolated
Inspectors documented severe communication failures affecting a resident with hearing loss who spoke limited English. The resident relied primarily on written communication but reported that staff members would sometimes leave her room when they couldn't understand her needs, failing to return with appropriate assistance.
The resident stated she "had never been offered communication board, audio or video materials in the language that she speaks" and was observed "expressing frustration, weeping" due to poor communication. Her care plan identified her communication needs but staff failed to implement effective solutions.
Medical records from January through February 2025 showed no documented evidence that translators or communication aids were provided despite the resident's identified needs. Staff reported using various inadequate methods including body language and phone translation services that were ineffective due to the resident's hearing impairment.
Effective communication is fundamental to safe healthcare delivery. When residents cannot communicate their symptoms, pain levels, or care preferences, medical conditions may go unrecognized or untreated. This creates risks for medication errors, falls, pressure ulcers, and other preventable complications. Federal regulations require nursing homes to assess communication needs and provide appropriate assistive devices and interpretation services.
The facility's own policy requires comprehensive assessment of communication barriers and implementation of person-centered interventions, standards that were clearly not met in this case.
Infection Control Protocols Compromised
The inspection revealed dangerous gaps in infection prevention practices that could facilitate the spread of healthcare-associated infections. A resident with a suprapubic catheter who was placed on Enhanced Barrier Precautions received high-contact care from nursing staff who failed to wear required protective gowns and did not perform hand hygiene after the procedure.
The resident's care plan specifically required enhanced precautions including gloves, gowns, and hand hygiene for all direct contact due to his catheter-associated infection risk. However, inspectors observed a Licensed Vocational Nurse and Certified Nursing Assistant providing catheter care without proper protective equipment before proceeding directly to the nurses' station.
The LVN acknowledged awareness of the requirements, stating she "just forgot" and admitting that "not using PPE prior to taking care of Resident 3 and not performing hand hygiene after providing care to Resident 3 had the potential to spread virus and bacteria in the facility."
Enhanced Barrier Precautions are implemented specifically to prevent transmission of multi-drug resistant organisms (MDROs) that can cause life-threatening infections in vulnerable nursing home residents. Healthcare-associated infections are a leading cause of morbidity and mortality in long-term care settings, with urinary tract infections being among the most common.
Improper Catheter Management Creates UTI Risk
The same resident experienced additional infection risks due to improper catheter positioning and maintenance. Inspectors observed the suprapubic catheter drainage bag hanging above the resident's bladder level and noted catheter tubing wrapped around the resident's leg, both practices that can cause urine backflow and increase urinary tract infection risk.
Multiple nursing staff acknowledged these positioning errors violate facility protocols. The Infection Preventionist confirmed that proper catheter management requires the drainage bag to remain below bladder level at all times and tubing should never be wrapped around extremities to ensure free urine flow.
Urinary tract infections in catheterized residents can lead to serious complications including kidney infections, sepsis, and prolonged hospitalizations. Proper catheter care is essential for preventing these preventable complications that significantly impact resident quality of life and health outcomes.
Additional Issues Identified
The inspection documented several other concerning violations:
Medication Safety Concerns: Nurses were observed mixing four different crushed medications together in a single container without regard for potential drug interactions or resident awareness of individual medications being administered. This practice achieved a 13.79% medication error rate, well above the 5% threshold for acceptable performance.
Improper Drug Storage: External medications like hydrogen peroxide were stored alongside oral medications, creating risk for dangerous medication mix-ups that could result in accidental ingestion of topical preparations.
Food Safety Lapses: Temperature monitoring logs for refrigeration equipment showed gaps in documentation from February 4-6, 2025, potentially compromising food safety and resident health.
Room Configuration Issues: Several resident rooms exceeded occupancy limits or fell below minimum square footage requirements, though the facility had requested waivers for these conditions and residents reported no concerns about their living arrangements.
The violations at Green Acres Healthcare Center highlight systemic issues in care coordination, staff training, and quality oversight that nursing homes must address to ensure resident safety and wellbeing. These deficiencies demonstrate the critical importance of proper implementation of care plans, infection control protocols, and resident-centered communication strategies in long-term care settings.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Green Acres Lodge from 2025-02-07 including all violations, facility responses, and corrective action plans.
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