Federal inspectors found the resident's arteriovenous fistula — a surgically created connection between an artery and vein used for dialysis — seeping reddish drainage through bandages on February 24. The cotton ball placed on top of the gauze was soaked with blood. More than 30 minutes later, inspectors returned to find the same bloody dressing unchanged.
The facility's Director of Nursing told investigators that if the bleeding had continued, "it would have been an emergency because Resident 36 could have bled out."
Licensed Vocational Nurse 9 acknowledged that the patient "could have hemorrhaged from his AV-shunt because it was not assessed after he returned to the facility." The Treatment Nurse said fresh blood on the dressing should have prompted immediate intervention — reinforcing the bandage with additional pressure to stop bleeding.
The resident receives hemodialysis three times weekly and has active orders requiring staff to monitor his access site for bleeding every shift. The facility's own policy mandates checking graft sites for bleeding every four hours after dialysis treatment.
California Post-Acute Care on Imperial Highway houses 146 residents and faces multiple medication management failures alongside the dialysis oversight breakdown, according to the February 28 inspection report.
Medication Errors Exceed Federal Limits
Inspectors documented a medication error rate of 7.14 percent for one resident — well above the federal maximum of 5 percent. The errors involved wound healing supplements that were either unavailable or administered without proper dosing instructions.
Resident 62, who has a leg ulcer, was supposed to receive Arginaid powder twice daily to promote healing. Licensed Vocational Nurse 3 told inspectors the medication "was not in stock at the facility" and "should have been reordered."
The same nurse administered ProHeal protein supplement to the resident for months without knowing the correct dosage. "The physician order did not clarify the amount," she said, explaining she had been giving 30 milliliters based on manufacturer instructions rather than doctor's orders.
"The risk of administering a medication without a dosage could result in overdosing and delay of wound healing," the nurse told inspectors.
Residents Miss Critical Medications
Resident 4 went two days without his bladder medication because staff failed to reorder oxybutynin chloride in time. The resident told inspectors he "became upset because he did not receive his medication" and felt "unimportant to have nurses know he was low on medication but did not bother to reorder."
Licensed Vocational Nurse 8 confirmed the medication shortage, saying nurses must reorder when five pills remain. "It was important to have residents' medication available to keep the resident's medical condition under control," the nurse said.
Resident 99 experienced a three-day gap in his chronic pain medication when his Norco supply ran out. The facility's controlled drug policy requires reordering when 14 doses remain, but staff waited until after the last pill was given on February 23 to request a refill.
"I felt frustrated the facility could not ensure his Norco was readily available when he had pain," the resident told inspectors. During the shortage, he received Tylenol instead, which "would not relieve all his pain."
The Director of Nursing said Norco should have been reordered February 19 to prevent the shortage. "Resident 99 had a history of chronic back pain and Norco was the most effective in treating Resident 99's pain."
Wrong Medication Purposes Create Safety Risks
Staff administered seizure medication to Resident 277 for the wrong condition for months. The facility's records showed pregabalin prescribed "for seizures," but the Director of Nursing later discovered the resident actually takes it for diabetic nerve pain.
"Administering pregabalin for the wrong indication placed Resident 277 at risk for unmanaged pain control due to the licensed nurses assessing Resident 277 for seizures and not for pain," the director explained.
Two residents on blood-thinning medications lacked proper monitoring orders despite facility policy requiring staff to watch for bleeding signs every shift. Registered Nurse 2 said both residents "were at risk of bleeding" and should be monitored for "any kind of bleeding, which could be an indication of a more serious medical condition."
Family Transfer Request Ignored for Two Months
Social services staff failed to follow up on a family's request to transfer their father to a locked psychiatric facility, leaving Resident 97 in inappropriate care for two months.
The resident has schizophrenia, Alzheimer's disease and severely impaired cognitive skills. His daughter requested the transfer during a December 13 care team meeting, but the Social Services Assistant said she "did not have knowledge of the IDT conference" and never followed up.
The daughter told inspectors "the facility never updated her with the status of her father's transfer to locked or psychiatric facility."
Kitchen Safety Violations Affect All Residents
Dietary staff served scrambled eggs instead of omelets as listed on the February 27 menu, affecting all 124 residents served breakfast. The Dietary Manager said she wasn't notified of the substitution and must approve all menu changes to ensure proper nutritional value.
Food storage violations throughout the kitchen created contamination risks. Inspectors found unlabeled items in refrigerators and freezers, empty cans and cracker wrappers in dry storage, and a dietary aide who didn't change gloves between tasks.
The facility lacked whole eggs for more than a month, preventing residents from getting fried eggs when requested. "Many residents requested fried eggs but received scrambled eggs," Dietary Cook 1 said. Only liquid pasteurized eggs were available.
Fresh fruit supplies were nearly depleted, with one apple remaining and no oranges available despite requirements for 10 pounds of each.
Medical Equipment Left Unlabeled
An oxygen patient's nasal cannula had no date or label indicating when it was installed, violating infection control protocols. The Infection Preventionist Nurse said unlabeled oxygen tubing "can become dirty with a build up of mucus and cause irritation to the nose" and "could lead to infection."
Facility policy requires changing nasal cannulas every seven days and labeling them with the resident's name, room number and date changed.
The facility also lost medication review documentation prior to December 2024, preventing staff from tracking whether pharmacy recommendations were implemented. The Director of Nursing said records should be retained for five years but she "could not locate the MRR prior to December 2024."
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.
