LYNWOOD, CA - Federal inspectors identified significant failures in mental health assessment and staffing transparency at California Post-acute Care during an April 16, 2025 inspection.
Critical Mental Health Screening Violations
The most serious violation involved a resident with multiple serious mental health diagnoses whose required screening documentation failed to accurately reflect their conditions. The resident had been admitted with diagnoses of schizophrenia, psychosis, and anxiety disorder, and was prescribed multiple psychotropic medications including Ativan and Chlordiazepoxide HCl.
However, the facility's Level I Preadmission Screening and Resident Review (PASRR) form - a critical document required for all Medicaid-certified nursing facility admissions - completely omitted these serious mental illness diagnoses and failed to document the prescribed psychotropic medications.
This screening error had cascading effects on the resident's care. Because the PASRR indicated no serious mental illness, facility records showed "a Level II Mental Health Evaluation was not required," despite the resident's documented need for specialized mental health services.
Missing Care Plans for Serious Mental Illness
Inspectors found the facility failed to develop individualized care plans for the resident's schizophrenia, anxiety disorder, or psychosis diagnoses. The Director of Nursing acknowledged these care plan deficiencies during interviews with surveyors.
Medical protocols require comprehensive care planning for residents with serious mental illness. Proper care plans should identify behavioral manifestations, outline non-pharmacological interventions to try before medications, and establish monitoring protocols for psychotropic drug effectiveness and side effects.
The facility's own policies required individualized care plans for residents receiving behavioral and psychotropic medications, including identification of mood or behavior problems and non-drug interventions.
Inadequate Behavioral Monitoring
The resident was receiving multiple psychotropic medications but lacked proper behavioral monitoring protocols. The facility failed to implement orders for tracking the behaviors these medications were intended to address, making it impossible to assess treatment effectiveness or identify needed adjustments.
Psychotropic medications carry significant risks including falls, excessive sedation, and altered mental status. Without proper monitoring, facilities cannot determine if medications are helping or causing harm to residents.
The Director of Nursing confirmed that behavioral monitoring "every shift" was required by facility policy to assess psychotropic medication effectiveness and determine if adjustments were needed.
Staffing Information Transparency Issues
In a separate violation, inspectors found the facility failed to properly post required nurse staffing information. Posted documents lacked the facility name, did not specify whether hours listed were projected or actual, and were not printed on required state-specific forms.
Accurate staffing information allows families to make informed decisions about care quality. The Director of Nursing acknowledged that "staffing affected the quality of care provided" and that residents and families had the right to know facility staffing levels.
Patient Safety Implications
These violations created multiple risks for the affected resident. The inaccurate PASRR screening could have resulted in placement at a facility unable to provide necessary mental health services. Missing care plans meant potential failure to implement appropriate non-medication interventions before resorting to additional psychotropic drugs.
Mental health care in nursing facilities requires specialized expertise and careful monitoring. Residents with conditions like schizophrenia and psychosis need comprehensive assessment, individualized treatment planning, and ongoing evaluation of both symptoms and medication effects.
The facility's own behavioral health services policy stated its commitment to provide "necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being."
Regulatory Requirements
Federal regulations require nursing facilities to ensure residents receive appropriate mental health services based on comprehensive assessments. The PASRR process specifically identifies residents who need specialized mental health services and appropriate facility placement.
Accurate documentation on PASRR forms directly impacts whether residents receive necessary mental health evaluations and services. These screenings determine facility capability to meet residents' behavioral health needs.
Both violations were classified as having potential for actual harm, indicating serious concerns about patient safety and care quality. The facility must submit correction plans to address these deficiencies and prevent similar occurrences.
California Post-acute Care, located at 3615 E. Imperial Highway in Lynwood, has not publicly responded to requests for comment regarding the inspection findings or corrective measures being implemented.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for California Post-acute Care from 2025-04-16 including all violations, facility responses, and corrective action plans.
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