LA CRESCENTA, CA - Federal inspectors cited La Crescenta Healthcare Center for significant care planning violations after a resident with dementia developed multiple bruises on both arms during an incident with registry staff, despite repeated family requests to avoid such assignments.
Resident Develops Bruises During Registry Staff Care
The February 25, 2025 inspection revealed that the facility failed to properly implement individualized care plans for a resident with severe cognitive impairment and documented behavioral challenges. The resident, who has diagnoses including dementia, cerebral infarction, and atrial fibrillation, developed dark purple and blackish bruises on both arms following a care incident on February 21-22, 2025.
According to the inspection report, the family member had filed multiple grievances requesting that registry staff not be assigned to provide care for the resident, citing the resident's non-compliance and agitation with temporary staff. Despite these documented concerns, the facility continued to assign registry personnel to the resident's care.
During the incident, three nursing assistants - including two registry staff members - were involved in changing the resident's clothing for a medical appointment. The resident reported being "forced" during the care, stating she "screamed help, help, help" during the process. She described feeling "very scared" and said "it felt like chili had been poured on her arms."
Care Plan Deficiencies Identified
Federal inspectors found that while the facility had developed multiple care plans addressing the resident's cognitive deficits, aggressive behaviors, and care resistance, none of these plans included the family's specific request to avoid registry staff assignments. The care plans also failed to document the reasons for this request or the behavioral manifestations that occurred when registry staff provided care.
The resident's care plans included interventions for: - Cognitive loss and dementia management - Aggressive behavior and striking out - Emotional and psychological deficits due to anxiety - Rejection of care and care resistance
However, none of these comprehensive plans addressed the documented issue with registry staff assignments, creating a gap between the family's expressed concerns and the facility's care planning process.
Medical Implications of Care Plan Failures
Proper care planning is essential for residents with dementia, as consistency and familiarity with caregivers can significantly reduce behavioral incidents and associated injuries. When residents with cognitive impairment experience agitation during care, physical restraint or forceful handling can result in bruising, particularly in elderly patients taking blood-thinning medications.
The resident was prescribed Clopidogrel 75mg, a blood thinner that increases bruising risk, and Atorvastatin, which can also affect blood clotting. These medications make proper gentle handling techniques crucial for preventing injury during routine care activities.
Additional Safety Concerns
Inspectors also identified a serious patient safety issue when the resident was found wearing an incorrect identification bracelet with another resident's name. The family member discovered this error during a visit in January 2025 and reported it to nursing staff. While the bracelet was eventually corrected, the incident highlighted potential risks for medication errors and care mix-ups.
Dietary Violations Compound Problems
The facility also failed to follow prescribed dietary orders for the same resident, who was ordered a very low-carbohydrate, double protein, 1200-calorie diet. Inspectors observed the resident being served meals that did not match the physician's orders, including: - Missing protein portions at breakfast - Serving juice despite orders for no juice with meals - Providing incorrect portion sizes
The dietary violations contributed to an unplanned 11.8% weight gain over six months, which the registered dietitian noted was "not beneficial or planned." Proper nutrition management is particularly important for residents with multiple medical conditions, as uncontrolled weight gain can exacerbate cardiovascular issues and diabetes management.
Staff Availability and Assignment Decisions
The inspection revealed that during the incident shift, seven nursing assistants were available, including three permanent facility staff members and four registry workers. Two licensed nurses were also on duty as potential alternatives for providing resident care assistance.
Despite having permanent staff available, the primary nursing assistant requested help from a registry staff member, knowing about the resident's documented care preferences. This decision occurred even though facility policy emphasizes individualized caregiver approaches that recognize resident needs.
Family Advocacy and Grievance Process
The family member had filed multiple grievances dating back to August 2024, requesting that registry staff not be assigned to the resident's care. The facility's response was that they would "try" to avoid registry assignments but could not guarantee it when permanent staff were unavailable.
During interviews with inspectors, the family member explained that the resident "fears registry staff" and had experienced previous negative incidents with temporary workers. The family specifically noted that certain care tasks, particularly dressing and brief changes, were more difficult when registry staff were assigned.
Industry Standards and Best Practices
Federal regulations require nursing homes to develop comprehensive care plans that address residents' medical, nursing, mental, and psychosocial needs. These plans must include interventions to manage risk factors and be regularly reviewed by interdisciplinary teams.
For residents with dementia and behavioral challenges, best practices include: - Consistent caregiver assignments when possible - Individualized approaches based on resident preferences - Clear documentation of triggers and effective interventions - Regular communication with families about care concerns
Facility Response and Corrective Measures
Following the grievance and inspection, the facility developed a new care plan titled "Alteration in Psychosocial due to Alleged Physical Abuse." However, this plan focused on reassuring the resident about reporting abuse rather than addressing the underlying staffing assignment issues that contributed to the incident.
The facility provided in-service training to staff and reported the incident to appropriate authorities, including police, the California Department of Public Health, and Ombudsman services.
Regulatory Impact
Both violations were cited at the minimal harm level, indicating that while no immediate jeopardy existed, the facility's practices had the potential to cause actual harm to residents. The citations require the facility to develop and implement corrective action plans to address the identified deficiencies.
The inspection demonstrates the importance of comprehensive care planning that incorporates family input and resident preferences, particularly for vulnerable populations with cognitive impairments who may be unable to advocate for themselves effectively.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for La Crescenta Healthcare Center from 2025-02-25 including all violations, facility responses, and corrective action plans.
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