The resident, identified as Resident 97, had been ordered continuous one-to-one supervision since October 7, 2024. His care plan specifically required staff to "remove all potentially harmful objects such as sharp objects, cords, and medications from the resident's environment."
Instead, an inspector observed him at 4:15 p.m. on February 24 "walking with a fast pace in the hallway (unsupervised) with a razor in his right hand."
The next morning, the Director of Staff Development found him shaving unsupervised in his bathroom. The resident told her he had "stuck his hand inside of the sharps container, located inside of shower room A to grab a disposable razor."
Resident 97's psychiatric history included multiple diagnoses: schizophrenia, Alzheimer's disease, dementia, and an immunocompromised condition. His cognitive skills for daily decision-making were severely impaired.
On December 2, 2024, he had tied the strings of his hooded sweatshirt tightly around his neck, became agitated, demanded a fork and stated, "I can do whatever I want, and nobody can stop me." He then motioned his hands as if pretending to shoot a gun. Staff called 911 and sent him to the hospital.
Upon his return that evening, there was no documentation showing he received the required one-to-one supervision.
The facility had assessed him as high risk for elopement in October 2024. On February 23, 2025, Registered Nurse 3 witnessed him run into the lobby and attempt to leave the facility. She told inspectors the facility "did not have sitters" to provide the required continuous supervision.
During three separate observations on February 24 and 25, inspectors found Resident 97 without the required one-to-one supervision. A nursing assistant confirmed he did not have a wander guard device that should have been placed on his wrist or ankle.
When inspectors examined his room on February 25, they found two long electrical cords plugged into wall outlets and nail clippers on his bedside table. The items remained there during subsequent observations on February 26 and 27.
The Director of Nursing acknowledged the facility failed to follow the suicide prevention care plan. "The nursing staff should have carried out the order for one-to-one supervision (since 10/7/2024) because it was still considered an active order," she told inspectors. "There was potential for Resident 97 to elope the facility because the care plan interventions were not implemented."
She also confirmed the facility "did not follow Resident 97's Suicidal Ideation Care Plan if there had been two cords and nail clippers left in his room. There was potential for Resident 97 to use those items to harm himself or others."
The violations extended beyond Resident 97's case. Inspectors found the facility systematically failed to develop required care plans for multiple residents with serious medical conditions.
Resident 8, who had diabetes and weakness on one side of his body, lost nearly nine pounds over six months without any care plan addressing the weight loss. His weight dropped from 180.4 pounds in August 2024 to 171.8 pounds by February 2025.
The Director of Nursing admitted Resident 8 "did not have a care plan for weight loss" despite facility requirements. "A care plan must be developed when a resident has weight loss," she said. "If a resident did not have a care plan, the nursing staff would not have a plan of care to follow and would not know a resident had a weight loss problem."
Resident 36, who suffered from congestive heart failure and kidney failure requiring dialysis, was placed on oxygen therapy February 22 but never received a care plan for oxygen use. The resident required oxygen at two liters per minute via nasal cannula for shortness of breath, with orders allowing staff to adjust the flow between two to four liters per minute.
The Minimum Data Set Nurse told inspectors she "could not find an oxygen care plan in Resident 36's chart." She acknowledged the care plan was "somehow overlooked" after the oxygen was initiated over a weekend.
"The care plan was important because this document was the road map of how to plan the resident's care," she explained. "If there was no care plan a lot of things could go wrong because there was nothing to follow regarding the resident's care."
Resident 115, who smoked cigarettes, had no smoking care plan despite facility policy requiring such plans for all smoking residents. The facility's own smoking policy stated that "any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan."
The Director of Nursing said the missing smoking care plan "could result in inadequate supervision and injuries."
Resident 81, who took the blood-thinning medication apixaban daily, also lacked a required care plan. The drug carries a black box warning from the FDA about potential life-threatening bleeding risks.
The Director of Nursing explained that "apixaban had a black box warning and the care plan would reflect the additional monitoring necessary to administer apixaban safely." Without proper monitoring, she said, "Resident 81 was at risk of undetected bleeding, which could lead to hospitalization and further medical treatment."
Resident 99, whose primary language was Spanish, had no care plan addressing his language needs. The Director of Nursing acknowledged this could lead to "miscommunications and Resident 99 could be left frustrated."
The facility's own policy required comprehensive, person-centered care plans with "measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs" for each resident.
Licensed Vocational Nurse 2, who had worked at the facility and witnessed Resident 97's December incident, told inspectors the facility "should have done a better job at supervising (from 12/2/2024 to 2/2025) Resident 97 due to his medical psychiatric diagnoses, history of suicidal ideation, and behavioral issues."
The inspection found that after Resident 97's elopement attempt on February 23 and his discovery with the razor on February 24, the facility failed to revise his care plan to address these escalating safety incidents.
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.