California Post Acute

In the surveyor’s words

From the most serious findings on record at California Post Acute, in the surveyor’s own words.

• Immediate jeopardy, widespreadF689Dec 7, 2023

  Based on interview and record review, the facility failed to ensure residents environment remained free of accident hazards for one of three sampled residents (Resident 1) and by failing to: 1. Monitor and supervise Resident 1 after Resident 1 lit an incense using a lighter inside a drawer and the drawer caught fire on 11/19/2023 at 11:45 a.m. and had another two fire incidents on 11/20/23 at 12 a.m. and 12:30 a.m. The facility was aware Resident 2 (Resident 1's roommate) was on continuous oxygen therapy on 11/19/2023 and 11/20/2023. 2. Inspect and inventory Resident 1's belongings and investigate the fire incident on 11/19/2023 at 11:45 a.m by Resident 1 to prevent another resident caused fire incident in the facility. 3. […]

• Immediate jeopardy, patternF759Mar 14, 2022

  Based on observation, interview, and record review, the facility failed to ensure that its medication error rate was less than five percent (%). Fourteen medication errors out of 29 total opportunities contributed to an overall medication error rate of 48.28 % affecting four of four sampled residents observed for medication administration (Residents 4, 9, 21, and 42.), by failing to: -Ensure Licensed Vocational Nurse 1 (LVN 1) did not crush and mix six medications for administration through a gastrostomy tube (g-tube - a surgically implanted tube used to deliver food or medication directly to the stomach) for Resident 4. -Ensure LVN 1 followed Resident 4's physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Immediate jeopardy, patternF760Mar 14, 2022

  Based on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 4) observed for medication administration was free of significant medication errors by failing to administer [MEDICATION(S)] (a medication used to treat or prevent seizures [a sudden uncontrolled electrical disturbance in the brain]), [MEDICATION(S)] (an anticoagulant medication used to prevent blood clots) and sodium chloride (medication used for low salt level) according to physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Ensure Licensed Vocational Nurse 1 (LVN 1) crushed the medications individually, including [MEDICATION(S)], and administered separately through a gastrostomy tube (g-tube , a surgically implanted tube used to deliver food or medication… […]

• Immediate jeopardy, isolatedF678Jul 26, 2025

  Based on interview and record review, the facility failed to ensure one of three sampled resident (Resident 61) for closed record review was immediately provided with cardiopulmonary resuscitation (CPR, a lifesaving emergency procedure for a victim who has signs of cardiac [heart] arrest [a situation when a victim becomes unresponsive, no normal breathing, and no pulse], consisting of a combination of chest compressions, mouth-to-mouth, or mechanical breathing [a device used to help someone breathe]) in accordance with the facility's policy and procedure titled, Cardiopulmonary Resuscitation (CPR) by failing to: 1. Verify Resident 1's code status (a set of instructions for medical staff about what to do or not do in a medical emergency) from the hospital record, dated 5/21/2025. […]

• Immediate jeopardy, isolatedF698Jul 26, 2025

  Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 61) who required hemodialysis (HD, a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) received HD care and services in accordance with Resident 61's Medical Director 1 (MD1) orders, care plan, and the facility's policies and procedures by failing to: -Ensure the licensed nurses (in general) and the Social Services Director (SSD) had ongoing communication and collaboration with Dialysis Center 1 (DC1) to coordinate Resident 61's HD care and services when the transportation did not pick up Resident 61 as scheduled on [DATE] at 11 AM. […]