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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....
## 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....
The family delivered these orders directly to facility staff....
According to the inspection report, the resident's oxygen saturation levels dropped to 88% and then to a critically dangerous 70%....
The resident's medical history revealed years of abuse by the family member, including verbal, emotional, financial, and physical mistreatment....
The incident occurred on April 9, 2024, when LPN #1 observed the injury but made assumptions about its cause rather than following proper assessment protocols....
A medication technician who witnessed the encounter reported that the housekeeper "got in his face" and stated: **"Fuck you!...
This classification indicates systemic issues within the facility's care delivery and management systems that require ongoing monitoring and evaluation....
This suggests the current pain management approach was inadequate....
More concerning, the CNA stated they were unaware that the facility even had an Abuse Coordinator position....
The inspection conducted on March 7, 2025, revealed widespread temperature control failures that put elderly residents at significant risk of severe burns....
Missing even a single dose of blood thinners can significantly increase the risk of stroke or pulmonary embolism....
The resident told Licensed Practical Nurse Staff A that they felt their roommate was "trying to kill" them and had put a blanket over their face....