LYNWOOD, CA - California Post-acute Care faced significant safety violations during a February 2025 state inspection, with regulators documenting failures in resident supervision, medication management, and basic care protocols that placed vulnerable residents at risk.
Supervision Failures Created Safety Hazards
The most serious violations involved a resident with severe cognitive impairment who repeatedly accessed used razors from unsecured medical waste containers. Resident 97, diagnosed with schizophrenia, Alzheimer's disease, and dementia, was observed walking through facility hallways carrying a razor without any staff supervision on multiple occasions.
Despite having physician orders for continuous one-to-one monitoring since October 2024, staff failed to provide the required supervision. The resident had a documented history of self-harm incidents, including cutting himself with razors in November and December 2024, yet continued to access sharp objects from unlocked shower rooms.
"Resident 97 told her he stuck his hand inside of the sharps container, located inside of shower room A to grab a disposable razor," facility staff reported. The resident admitted he would "take a disposable razor from the shower room sharps container every time staff confiscated a disposable razor from him."
Licensed Vocational Nurse staff acknowledged the severity of the situation, stating there was "potential for Resident 97 to inflict harm unto other residents and staff members and expose others and himself to blood borne pathogens."
Critical Medical Monitoring Gaps
Inspectors identified dangerous lapses in monitoring residents with serious medical conditions. Resident 327, who had sepsis and required dialysis, experienced a fever of 101.4°F and extremely high blood sugar levels of 450 mg/dL without proper reassessment protocols being followed.
Nursing staff administered fever-reducing medication and insulin but failed to recheck the resident's temperature within the required timeframe. The blood sugar level, which was nearly five times the normal range, was not rechecked before the resident left for dialysis or immediately upon return.
This monitoring failure violated the facility's own policies requiring physician notification for blood glucose levels above 300 mg/dL, respiratory rates above 28 breaths per minute, and temperatures above 100.5°F. Resident 327's respiratory rate was documented at 36 breaths per minute, significantly above normal ranges.
The medical significance of these oversights cannot be understated. Uncontrolled blood sugar levels can lead to diabetic coma, while sustained high fevers in sepsis patients can indicate worsening infection requiring immediate medical intervention. Proper monitoring serves as an early warning system to prevent medical emergencies and allows for timely physician notification and treatment adjustments.
Pressure Ulcer Prevention Equipment Misused
The facility failed to properly configure specialized pressure-relieving mattresses for four residents, potentially increasing their risk of developing painful pressure sores. Low air loss mattresses, designed to prevent skin breakdown by distributing body weight evenly, were incorrectly set according to residents' actual weights.
Resident 110, weighing 102.4 pounds, had her mattress set to 180 pounds initially and later adjusted to 130 pounds - still significantly higher than appropriate. Resident 60, weighing 126 pounds according to medical records, had his mattress set to 330 pounds. These incorrect settings defeat the therapeutic purpose of the specialized equipment.
Pressure ulcers represent a serious medical concern, particularly for bedridden residents. When mattresses are improperly calibrated, they can become too firm or too soft, creating pressure points that cut off blood circulation to tissue. Stage 4 pressure ulcers, which Resident 110 already had, involve full-thickness tissue loss with exposed bone or muscle and can be life-threatening if they become infected.
Pain Management Failures
Two residents experienced inadequate pain management despite having physician orders for appropriate medications. Resident 117, a hospice patient with paralysis and chronic pain conditions, consistently reported pain levels of 10 out of 10 on standard pain scales but received insufficient pain relief.
Despite having multiple pain medications available including morphine for severe pain, nursing records showed Resident 117 received no pain medication on 11 days during February 2025. The hospice physician noted that proper assessment of medication effectiveness was impossible because "the nurses were not giving the pain medications as ordered."
Resident 99 was denied his prescribed Norco medication for chronic back pain because the facility's supply had run out. Although the medication was available in the emergency medication kit, nursing staff chose to substitute less effective Tylenol instead. This violated both the resident's care plan and facility protocols for accessing emergency medications when regular supplies are unavailable.
Pain management in nursing homes requires careful attention to both assessment and medication administration. Uncontrolled pain can lead to depression, decreased mobility, poor sleep, and reduced quality of life. For hospice patients, effective pain control is a fundamental aspect of compassionate end-of-life care.
Additional Issues Identified
The inspection revealed numerous other safety and care violations:
Infection Control Problems: Catheter care was inadequate for multiple residents, with urine collection bags left on floors, improper monitoring of catheter-related infections, and missing physician orders for catheter use. One resident's condom catheter collection bag was observed "overly full and bloated with urine" while lying on the floor.
Respiratory Safety: A resident receiving oxygen therapy lacked required signage indicating oxygen use, creating potential fire hazards in areas where smoking might occur.
Neurological Monitoring: After an unwitnessed fall, required 72-hour neurological checks were discontinued prematurely, potentially missing signs of brain injury that can develop gradually after head trauma.
Environmental Hazards: Used medical sharps were improperly secured in containers accessible to residents, and smoking safety protocols were not consistently followed during supervised smoke breaks.
These violations collectively demonstrate systemic breakdowns in basic nursing home safety protocols. The facility's own policies addressed most of these requirements, but implementation and oversight were inadequate to protect residents from preventable harm.
The California Department of Public Health classified these violations as causing "minimal harm or potential for actual harm," but the cumulative effect represents serious gaps in resident protection. Proper implementation of existing policies could have prevented most of these safety failures.
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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