COMPTON, CA - State health inspectors documented multiple violations at Santa Fe Heights Healthcare Center during a February 2025 inspection, including failures to obtain proper consent for psychotropic medications, unsafe feeding practices, and inadequate monitoring protocols.
Psychotropic Medication Consent Failures Affected Vulnerable Residents
The facility administered powerful psychotropic medications to two residents without properly obtaining informed consent, state investigators found. Both residents lacked the mental capacity to make their own medical decisions, yet the facility failed to establish appropriate decision-making procedures before starting or continuing these medications.
One resident with schizoaffective disorder, adult failure to thrive, and swallowing difficulties received haloperidol 5 mg daily—a potent antipsychotic medication. According to the resident's medical records dated February 10, 2025, the attending physician documented that this individual lacked capacity to understand and make medical decisions. Despite this documented incapacity, the facility had no valid informed consent on file for the haloperidol that had been prescribed since March 2024.
The Social Services Director confirmed during the inspection that this resident had neither a responsible party nor a public guardian appointed to make medical decisions. According to the facility's own policies, when a resident cannot consent and has no representative, the bioethics committee must convene to make medical decisions on the resident's behalf. This critical safeguard never occurred before psychotropic medications were administered.
A second resident with schizophrenia, anxiety disorder, and depression experienced similar consent violations. Medical records from August 2023 documented this resident's inability to make medical decisions, yet the facility failed to initiate a public guardianship application that should have been started that same year. The resident's informed consent form for Risperdal 0.5 mg—prescribed for psychosis—was left incomplete, with the section identifying who provided consent left entirely blank.
Even more concerning, when this resident was later prescribed haloperidol 5 mg intramuscular injections for agitation in September 2024, staff documented that consent was obtained from the resident directly—despite clear documentation that this individual lacked decision-making capacity. A Licensed Vocational Nurse acknowledged during the inspection that she had incorrectly obtained and documented this consent.
Psychotropic medications carry significant risks, including movement disorders, metabolic changes, cardiovascular effects, and cognitive impairment. These medications alter brain chemistry and can cause serious adverse effects, particularly in older adults. Proper informed consent ensures that someone who understands the resident's values and medical situation can weigh these risks against potential benefits. When residents cannot provide their own consent, federal regulations require facilities to identify appropriate surrogate decision-makers who can be educated about medication risks and benefits.
The California Department of Public Health's regulations specifically require that when physicians cannot identify appropriate surrogate decision-makers, facilities must pursue court appointment of a conservator with medical authority or refer the case to the Public Guardian. When disagreements arise among potential decision-makers, facilities must seek assistance from ethics committees and social services. None of these required procedures were followed for either resident.
Distracted Feeding Created Aspiration Risk
Inspectors observed a certified nursing assistant feeding a resident with known swallowing difficulties while simultaneously watching TikTok videos on her personal phone with earphones in both ears. The CNA sat with her back to the room entrance, eyes fixed on her phone screen, as she spooned food into the resident's mouth.
This resident had multiple conditions that increased aspiration risk, including dysphagia and adult failure to thrive. The resident's care plan specifically noted aspiration risk and instructed staff to assist with feeding, monitor during meals, and check the resident's mouth afterward for pocketed food—all measures designed to prevent food from entering the lungs instead of the stomach.
Aspiration occurs when food, liquid, or other material accidentally enters the airway and lungs rather than being swallowed into the esophagus and stomach. This can cause aspiration pneumonia, a serious and potentially fatal lung infection that develops when foreign material triggers inflammation and bacterial growth in lung tissue. Older adults with swallowing difficulties face particularly high risk, as their protective reflexes may be diminished.
Proper feeding technique for residents with dysphagia requires constant visual monitoring to observe signs of difficulty swallowing, coughing, choking, or respiratory distress. Staff must watch for facial expressions indicating discomfort, changes in breathing patterns, or food remaining in the mouth. They must also listen for sounds that might indicate food entering the airway, such as a wet or gurgly voice quality, coughing, or throat clearing.
When the surveyor finally gained the nursing assistant's attention on the third attempt, the CNA acknowledged that her actions were unacceptable. During the subsequent interview, she stated she would not have been able to see or hear if the resident choked, that her feeding method was unsafe for any resident, and that watching her phone while feeding did not honor the resident's dignity and well-being.
The facility's own care plan required staff to assist with and feed this resident at meals and check for pocketed food afterward—interventions impossible to perform properly while distracted by entertainment media. The care plan existed precisely because this resident could not safely eat without assistance and monitoring.
Call Light Access Violations Compromised Resident Safety
Inspectors documented that two residents identified as fall risks had call lights positioned out of reach, violating both the residents' care plans and facility policies. One resident with diabetes, chronic kidney disease, muscle wasting, and mobility difficulties wore a yellow fall precaution bracelet. This resident's care plan specifically stated goals of remaining free from falls and included interventions to ensure the call light remained available and within reach, with prompt staff responses to requests for assistance.
Despite these documented precautions, surveyors observed this resident's call light hanging from the nightstand drawer on multiple occasions, completely out of reach for someone lying in bed. A certified nursing assistant acknowledged the call light should have been on the bed next to the resident so the individual could call for water, medications, or help during an emergency. The Licensed Vocational Nurse confirmed the call light needed to be within reach to enable the resident to request assistance and prevent falls.
A second resident with severe dementia, swallowing difficulties, muscle wasting, and major depressive disorder required maximum staff assistance for all activities of daily living and transfers. This resident's call light was observed on the floor behind the bed, completely inaccessible, on multiple occasions during the inspection. The resident's care plan intervention specifically stated staff would provide the call light within reach.
Call lights serve as residents' primary means of requesting assistance from staff. When residents cannot reach their call lights, they face a difficult choice: wait indefinitely for staff to check on them, or attempt to meet their own needs independently. For residents with mobility limitations and fall risk factors, attempting to get out of bed or move without assistance significantly increases fall risk.
Falls represent one of the most serious safety risks in nursing facilities. They can result in fractures, head injuries, hospitalization, functional decline, and death. Fall prevention programs rely on residents being able to summon help before attempting potentially unsafe movements. When call lights remain out of reach, this critical safety system fails.
The facility's own policies required call lights to remain within easy reach when residents are in bed or confined to chairs. Job descriptions for certified nursing assistants specifically listed keeping the call system within easy reach as a core responsibility. Licensed nursing staff were designated as responsible for checking that call lights remained within resident reach.
Additional Issues Identified
Beyond these major violations, the inspection revealed the facility failed to notify a physician about a resident's subtherapeutic phenobarbital blood level. Phenobarbital is an anti-seizure medication that requires specific blood concentrations to effectively prevent seizures. When levels drop too low, residents face increased risk of seizure activity, which can cause serious injury from falls, loss of consciousness, or the seizure itself.
The facility maintained policies stating residents would be treated with dignity and respect at all times, with assistance in maintaining self-esteem and self-worth. The observed violations—particularly the distracted feeding and failures to obtain proper consent for mind-altering medications—directly contradicted these policy commitments.
Federal regulations governing nursing facilities require that residents receive treatment and care in accordance with professional standards of quality, that facilities protect residents from accidents and hazards, and that facilities reasonably accommodate resident needs and preferences. The documented violations represented failures in each of these fundamental requirements.
The inspection occurred February 13, 2025, at the 2309 N Santa Fe Avenue facility in Compton, California. The facility's deficiency report documented these findings as causing minimal harm with potential for actual harm to residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Santa Fe Heights Healthcare Center, LLC from 2025-02-13 including all violations, facility responses, and corrective action plans.
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