In February 2019, the Department of Public Health (DPH) issued ten citations to Lakewood Healthcare Center, a skilled nursing facility in Downey owned and operated by Shlomo Rechnitz and his affiliates. The citations included six Class A citations and four Class B citations with fines totaling $156,000.
A complaint made by a registered nurse (RN) who worked at the facility appears to have triggered the extraordinary number and scope of the citations. One of the citations states she reported that residents had been injured during many unreported falls; one resident choked to death; the director of nursing (DON) was removing reports of incidents and nurses’ notes from resident’s records and asking the licensed nurses to alter their records to avoid trouble with DPH; the facility was understaffed; and residents were being left unsupervised, wet, and soiled for extended periods of time.
DPH issued four Class A violations involving residents who were seriously harmed due to falls. An 86-year-old resident was hospitalized for eight days and endured a two-part surgery after she fell out of her wheelchair and broke her hip. A 76-year-old male resident fractured three ribs while trying to get up from the toilet. Another resident who needed one to one care fell and hit his head on the headboard of his bed while left unattended, causing bleeding of the brain, a nasal fracture and resulting in a four-day hospital stay. A fourth resident broke his toe after falling on a wet hallway floor – a CNA reported the floors were always dirty and wet with urine. The facility did not report the residents’ injuries to DPH as required.
Two more Class A citations were issued due to choking incidents involving residents who were on pureed or mechanical soft diets. The residents choked on honeybuns obtained from the activity staff. One resident died and the other nearly did, requiring CPR and hospitalization for intubation. The facility did not report either of the choking episodes to DPH or investigate them.
The facility was also cited for actively impeding the DPH investigations. Investigators were denied requested records for hours. The DON stated that facility incident records, IDT progress notes and the nurses’ notes about the fall incidents and choking episodes were not in the residents’ clinical records and were nowhere to be found. The DON also failed to provide requested staff files, per orders from its Vice-President Officer. A CNA reported that all the staff were told by the DON and administrator to stay quiet and not to talk to the DPH team because they will lose their jobs if they did.
A paramedic who responded to a 911 call during the investigation reported that the facility staff call all the time, but when paramedics arrived the staff had not done any assessments on the residents and could not provide vital signs and medical histories.
Since 2016, the DPH has received 315 complaints and facility reported incidents on Lakewood Healthcare Center while issuing it 164 deficiencies and 29 citations (state fines), according to the DPH Cal Health Find website.
Rechnitz owns California’s largest nursing home chain. His facilities have often been cited for harming and mistreating residents and three of them were decertified following the deaths of residents due to neglect. Yet the Department of Public Health has allowed him and his companies to continue to operate over 20 nursing homes for years while it dickers over whether or not to approve their license requests.
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