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California Post-acute Care: Mental Health Failures - CA
This screening error had cascading effects on the resident's care....
Latest reports, citations, and penalties from CMS data
This screening error had cascading effects on the resident's care....
The licensed vocational nurse assigned to the cart admitted she had gone to a resident's room and failed to properly lock the medication cart....
The resident's care plan, updated in January 2025, explicitly stated that a mechanical lift must be used for all transfers with two staff members present....
The 36-year-old resident, admitted in February 2024 with dementia and neurogenic bladder dysfunction, required an indwelling catheter....
The combination medication, prescribed to manage chronic respiratory conditions, had expired on March 17 but remained in the facility's medication cart....
The fall resulted in a fractured right femur requiring surgical repair....
## Critical Insulin Administration Failures The most serious violations involved improper administration of insulin to diabetic residents....
## Dangerous Call Light Response Times The most concerning findings involved extended delays in responding to resident call lights....
Despite his preference for assisted living, staff discharged him to a homeless shelter against his wishes....
Despite these clear requirements, the nursing assistant attempted a manual transfer that resulted in the resident falling to the floor....
## Repeated Food Preference Violations The most significant issues centered on the facility's failure to honor resident meal requests and dietary preferences....
This citation represents a continuation of problems first identified during a previous survey that ended February 8, 2024....
Two residents developed advanced stage pressure injuries due to inadequate care protocols and staff oversight failures....
This lack of proper orientation poses significant safety risks for residents with visual impairments....
## Critical Mobility Equipment Failures The absence of proper mobility devices represents a significant safety and dignity concern for nursing home residents....
Direct hand contact with food can introduce harmful bacteria, viruses, and other pathogens that cause foodborne illnesses....
The family delivered these orders directly to facility staff....
During the investigation, facility staff acknowledged tracking missed alert charting notes and skilled notes through medical records audits....
This type of bathroom denial constitutes a form of neglect that can lead to serious medical complications....
These reviews serve multiple critical functions in maintaining care standards and ensuring resident safety....