COMPTON, CA - Federal inspectors documented dangerous safety violations at Santa Fe Heights Healthcare Center, including a certified nursing assistant watching TikTok videos on her phone while feeding a vulnerable resident.
Staff Member Watched Videos While Feeding Resident
During a February 2025 inspection, state surveyors observed a shocking breach of patient safety protocols. A Certified Nursing Assistant was seen feeding Resident 3, who required a pureed diet due to swallowing difficulties, while simultaneously watching TikTok videos on her personal phone with earphones in both ears.
The incident occurred on February 11, 2025, at 1:04 p.m. in the resident's room. Inspectors observed the CNA seated with her back to the room's entrance, watching her phone while mechanically spooning food into the resident's mouth. The staff member was so distracted that surveyors had to call her attention three times before she noticed them.
When interviewed, the nursing assistant acknowledged the dangerous practice. "It was not an acceptable practice because she would not have been able to see or hear if Resident 3 choked as it was not a safe way to feed any resident," the inspection report stated.
This violation is particularly concerning given the resident's medical condition. Resident 3 had been diagnosed with dysphagia, a serious swallowing disorder that significantly increases choking risk. The resident was on a physician-ordered pureed diet specifically because of difficulty swallowing solid foods.
Critical Medication Monitoring Failure Led to Seizures
Inspectors also uncovered a serious medication monitoring failure that directly contributed to a resident experiencing multiple seizures. Resident 10, who had epilepsy and a history of status epilepticus - a life-threatening seizure emergency - was prescribed phenobarbital, an anti-seizure medication requiring careful blood level monitoring.
Laboratory results from October 11, 2024, showed the resident's phenobarbital blood levels had dropped to dangerously low levels - 8 micrograms per milliliter, well below the normal range of 14-40 micrograms per milliliter. Despite the facility's care plan requiring staff to "monitor and report any subtherapeutic or toxic results to the physician," nursing staff failed to notify the resident's doctor of the critically low medication levels.
Four months later, on February 11, 2025, Resident 10 experienced two seizures lasting three and two minutes respectively. Emergency services were called, and the resident required oxygen support. During the inspection, nursing staff acknowledged the connection between the unreported low medication levels and the seizures.
"RN 1 stated there was a possibility that Resident 10's phenobarbital blood levels continued to remain subtherapeutic when Resident 10 suffered a seizure on 2/11/2025," the report documented. The Director of Nursing confirmed that proper physician notification could have allowed for medication adjustments that might have prevented the seizures.
Subtherapeutic phenobarbital levels significantly increase seizure risk in patients with epilepsy. When blood concentrations fall below therapeutic ranges, the medication cannot effectively prevent the abnormal electrical activity in the brain that causes seizures.
Resident-to-Resident Abuse Went Unreported
The facility also failed to properly handle a resident-to-resident abuse incident. On February 2, 2025, Resident 73 became angry because his roommate, Resident 69, had eaten his snacks. Resident 73 threw water at his roommate and called him profanity, stating "I'm going to hit him in the face."
The incident was witnessed by nursing staff, but they failed to report it to administrators or state authorities within required timeframes. Federal regulations require nursing homes to report abuse allegations to the California Department of Public Health within two hours and provide investigation results within five working days.
Licensed Vocational Nurse 6, who witnessed the incident, admitted she "did not report the resident to resident physical and verbal abuse to the DON, ADM, and/or the CDPH." She acknowledged this failure "could have prevented the risk of Resident 69 and other residents in the facility from being abused."
Resident 69, who has severe cognitive impairment and requires maximal assistance for daily activities, told inspectors the incident left him feeling "scared and sad."
Widespread Medication Safety Problems
Beyond the seizure medication failure, inspectors found the facility's medication error rate exceeded federal limits. Staff administered medications incorrectly to multiple residents, including:
- Giving a resident a chewable aspirin tablet without instructing them to chew it, potentially reducing the medication's effectiveness for stroke and heart attack prevention - Administering incorrect doses of antipsychotic medication due to discrepancies between physician orders and pharmacy packaging - Storing expired medications, including controlled substances for discharged residents
The facility stored 15 different controlled medications for discharged residents in medication carts, violating disposal requirements. Expired medications included insulin that lacked proper dating and eye drops stored at incorrect temperatures.
Food Safety and Kitchen Violations
Dietary operations showed multiple food safety failures. Kitchen equipment, including ice machines and dishwashing areas, had significant dirt and corrosion buildup. Staff demonstrated poor knowledge of proper sanitation procedures, unable to correctly state acceptable temperature ranges for dishwashing equipment or sanitizer concentrations.
Food preparation standards were compromised, with overcooked vegetables losing nutritional value and improper food storage creating contamination risks. The facility failed to follow its own menus, serving residents smaller portions than prescribed for their dietary needs.
Infection Control Breakdowns
Infection prevention protocols were routinely ignored. Housekeeping staff failed to wash hands after cleaning resident rooms, and nursing staff did not properly sanitize surfaces contaminated with body fluids.
One resident's nebulizer equipment for breathing treatments was found on the floor, undated and improperly stored, creating infection risks for respiratory conditions.
Facility Response and Ongoing Oversight
Santa Fe Heights Healthcare Center houses 88 residents in Compton, California. The facility must submit a correction plan to address all identified violations and demonstrate how it will prevent future occurrences.
The inspection findings highlight systemic breakdowns in basic patient safety protocols across multiple departments. From medication management to infection control, dietary services to staff supervision, the violations reveal widespread failures in fundamental nursing home operations.
Federal regulators will continue monitoring the facility to ensure compliance improvements protect resident health and safety. The documented violations occurred during a routine inspection, raising questions about daily care standards when inspectors are not present.
For families with loved ones at Santa Fe Heights Healthcare Center, these findings underscore the importance of staying actively involved in care oversight and immediately reporting any concerns to facility administration and state authorities.
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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