LYNWOOD, CALIFORNIA - A state inspection at California Post-Acute Care uncovered serious safety violations including the facility's failure to properly respond when a resident called police feeling unsafe after confrontations with staff, inadequate monitoring of a resident with documented suicide risks who was found with dangerous items including razors and cords, and multiple assessment failures that left vulnerable residents without appropriate care plans.
Staff Member Continued Working After Resident Reported Feeling Unsafe
The facility violated federal safety protocols when administrators allowed a certified nursing assistant to complete her shift on February 26, 2025, after a resident reported feeling threatened and unsafe. According to the inspection report, Resident 103 called the police that evening stating she felt unsafe in the facility after an interaction with CNA 1.
The resident, who had intact cognitive abilities and could make her own decisions, told the registered nurse on duty that the staff member was "very prejudice" against her and made her feel unsafe. The resident specifically stated "That lady threatening" and "I do not feel safe" when describing the incident to nursing staff.
Despite the facility's own policy requiring immediate removal of any employee alleged to have committed abuse, CNA 1 was permitted to finish her shift and continue caring for other residents. The facility's Director of Nursing acknowledged interviewing the resident, who reported that "The CNA was in my face and was being smart with me," prompting the 911 call.
The Administrator later admitted that CNA 1 should have been sent home immediately after the allegation surfaced. He stated that "suspending CNA 1, while the facility conducted a thorough investigation, would ensure no other potential abuse could occur" and acknowledged that "allowing CNA 1 to continue working put other residents in her care at risk for abuse."
The facility's written policy explicitly states that employees alleged to have committed acts of abuse must be "immediately removed from duty, pending investigation" to protect residents from further harm. This clear violation of their own protocols demonstrates a fundamental breakdown in resident protection systems.
Resident with Documented Suicide Risk Found with Razor and Cords
Multiple dangerous oversights occurred in the care of Resident 97, who had documented histories of suicide attempts and self-harm behaviors. Despite having three separate care plans addressing elopement risk, self-harm prevention, and suicidal ideation, staff failed to implement critical safety measures.
On February 23, 2025, the resident attempted to leave the facility without authorization, triggering his "Attempted Elopement Care Plan" that had been in place since October 2024. This plan required hourly location monitoring, one-on-one supervision, and placement of a wander guard device. None of these interventions were implemented following the elopement attempt.
The following day, February 24, 2025, the resident was observed with a razor in his possession, despite having a Self-harm Care Plan initiated in December 2024 that mandated one-to-one monitoring at all times. During the inspection, surveyors discovered two cords and nail clippers in the resident's room - items that should have been removed under his Suicidal Ideation Care Plan dated December 21, 2024.
This resident's diagnoses included schizophrenia, Alzheimer's Disease, and severe cognitive impairment. The repeated failures to implement documented safety protocols created opportunities for potentially fatal self-harm. When residents with known psychiatric conditions and documented risks are not properly monitored, the consequences can be catastrophic. Standard psychiatric care protocols require immediate implementation of safety measures following any elopement attempt or discovery of potentially dangerous items.
Critical Mental Health Assessments Never Completed
Four residents with serious mental illnesses went without required psychiatric evaluations for months, potentially missing essential mental health services. Federal regulations mandate Preadmission Screening and Resident Review (PASRR) evaluations to ensure facilities can provide appropriate care for residents with mental health conditions.
Resident 97, diagnosed with schizophrenia and experiencing active psychiatric symptoms, required a Level II PASRR evaluation in December 2024. The Department of Health Care Services attempted multiple contacts with the facility within 48 hours of the initial screening but received no response. The facility never followed up, and the evaluation remained incomplete at the time of inspection in late February 2025.
The Director of Nursing acknowledged that "there was a possibility that Resident 97 has not received the proper psychiatric services or care since the first day of Resident 97's admission" in September 2024. This five-month gap in psychiatric evaluation for a resident with schizophrenia and behavioral issues represents a serious failure in mental health care delivery.
Similar failures occurred with three other residents diagnosed with conditions including bipolar disorder, schizophrenia, and dementia. The Admissions Coordinator confirmed that without these evaluations, residents might remain in facilities unable to provide appropriate care for their conditions.
PASRR evaluations determine whether nursing homes can meet the specialized needs of residents with serious mental illnesses or if alternative placement is necessary. These assessments identify required services such as psychiatric medication management, behavioral interventions, and specialized therapies. Without completed evaluations, facilities cannot ensure they have the resources and expertise to safely care for residents with complex psychiatric needs.
Medical Implications of Assessment and Care Plan Failures
The inspection revealed systemic breakdowns in fundamental nursing home operations that create cascading risks for resident health and safety. When facilities fail to complete required assessments, they lack critical information needed to develop appropriate care strategies. This knowledge gap becomes particularly dangerous for residents with cognitive impairments, psychiatric conditions, or complex medical needs.
Quarterly assessments using the Minimum Data Set tool track changes in residents' physical and cognitive functioning. Two residents went without these mandatory evaluations for over a month past their due dates. These assessments identify declining mobility, cognitive changes, nutritional issues, and other concerns requiring intervention. Delays in assessment mean delays in recognizing and addressing health declines.
Care planning failures create direct safety hazards. One resident who smoked cigarettes had no smoking assessment completed, meaning staff had not evaluated whether she could smoke independently or required supervision. Without this assessment, the facility could not provide appropriate safety equipment such as smoking aprons or determine supervision levels. Fire-related injuries remain a significant risk in nursing homes, particularly for residents with cognitive or physical limitations affecting their ability to respond to emergencies.
Another resident receiving apixaban, a powerful anticoagulant medication, had no care plan addressing bleeding risks. Anticoagulants prevent blood clots but significantly increase bleeding risk from falls, cuts, or internal bleeding. Standard protocols require regular monitoring for signs of bleeding, fall prevention measures, and staff education about bleeding symptoms. Without a documented care plan, staff may not recognize dangerous bleeding until it becomes life-threatening.
Additional Issues Identified
The inspection uncovered several other violations affecting resident care quality. A resident experiencing weight loss had no nutritional care plan developed to address this concerning symptom. Unintended weight loss in elderly residents often signals underlying medical problems, inadequate nutrition, or difficulty eating that requires prompt intervention.
A resident requiring supplemental oxygen lacked a care plan for this critical medical intervention. Oxygen therapy requires specific safety protocols, monitoring parameters, and equipment maintenance procedures to prevent fires and ensure therapeutic effectiveness.
Language barriers affected care delivery when the facility failed to develop a care plan for a Spanish-speaking resident. Without documented communication strategies, staff cannot ensure the resident understands medical information, can express needs and preferences, or participate in care decisions.
The facility also failed to complete statutorily required assessments within mandated timeframes. One resident's quarterly assessment, due in January 2025, remained incomplete at the time of the February inspection. The MDS Nurse admitted overlooking the assessment because it was not on her calendar, describing it as "an oversight" that "was not caught."
These violations demonstrate systematic failures in basic nursing home operations including assessment completion, care planning, safety protocols, and communication systems. Each failure represents a missed opportunity to identify and address resident needs before they develop into serious health or safety problems.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for California Post-acute Care from 2025-02-28 including all violations, facility responses, and corrective action plans.
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