City View Post Acute

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to sanitize food contact surfaces, store food, and maintain clean food equipment and kitchen environment in accordance with professional standards for food service safety when:The chemical sanitizing dishmachine was used with low sanitizer strength;Food contact surfaces of food preparation equipment were not sanitized according to sanitizer manufacturer instructions;Refrigerators storing resident food were not clean;Juice machine parts were not clean;The kitchen floor was not maintained clean around the ice machine area;These failures had the potential to result in contamination of food and food utensils with inadequate sanitizing and attraction of pests leading to food related illness for 167 residents who ate food by mouth and received food from the kitchen and/or who could have perishable food brought [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate maintenance and/or repair of: 1. Two refrigerators used for holding resident food which resulted in low refrigerator temperatures;2. An ice machine drainpipe which resulted in water actively dripping and pooling on the kitchen floor;3. Three drainpipes for an ice machine were not maintained clean; and4. A hotbox (food warming equipment) used to hold food for residents, which resulted in inadequate holding temperatures. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services for two of 34 sampled residents (Residents 194 and 114) when:1.a. A hand splint was applied without a physician's order; b. The facility failed to identify podiatry needs to maintain level of comfort and care plan was not developed to address resident's mycotic (long, thick and yellowish) toenails; and2. The facility did not follow the physician order for the administration of Tylenol. These deficient practices presented a potential risk of residents not maintaining the highest achievable level of wellbeing which could lead to diminished quality of life. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication rate did not exceed 5% for 2 of 9 sampled residents (Resident 139 and 199).1. For Resident 139, a Licensed Vocational Nurse (LVN) administered the Resident's Nephro-Vite, a renal-specific multivitamin (vitamin C, B-Complex, & Folic Acid) formulated primarily for individuals with chronic kidney disease, not in accordance with the Physician's Order.2. For Resident 199, the LVN did not administer the Resident's metformin, a medication used to treat high blood sugar levels, as ordered by the physician.3. For Resident 199, the LVN did not administer the Resident's memantine, a medication used to treat memory loss, as ordered by the physician.4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff competency when:Two Diet Aides were not competent testing the dishmachine sanitizer;Three staff (one Diet Aide, one Cook, and the Dietary Manager) were not competent in 3-compartment sink procedures including testing the sanitizer strength and length of time for sanitizing items cleaned in the sink; andOne [NAME] was not competent testing the red bucket food contact surface sanitizer The failure to ensure staff competency for 6 out of 27 staff regarding use of the three-compartment sink and sanitizing tasks had the potential to result in contamination of food and/or utensils and equipment leading to illness caused by pathogens (any microorganism that causes disease).

Inspectors wroteBased on observation, interview, and record review the facility failed to follow the planned menu when incorrect serving sizes were given to residents on pureed diets. This failure had the potential to result in inadequate and/or inappropriate calories and nutrients served to residents leading to nutrient related medical complications for 20 residents who received pureed food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve food at a palatable temperature. This failure had the potential for decreased food intake leading to nutrient related complications for 5 residents who received Chicken Noodle Soup from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Gradual Dose Reductions (GDRs) were attempted for psychotropic medications (a group of drugs prescribed to affect the mind, emotions or behavior) for one of 5 sampled residents when Resident 9 continued to receive olanzapine (a type of psychotropic medication indicated for psychosis) and trazodone (a psychotropic medication used to promote sleep) without documented clinical contraindications to not attempting any GDRs. This failure resulted in the potential for unnecessary medication use and avoidable adverse effects. Clinical record review indicated Resident 9 was initially admitted to the facility from the acute care hospital in February 2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS - a resident assessment tool) was completed for one of 34 sampled residents (Resident 194) after readmission. This failure had the potential for Resident 194 not to receive appropriate treatment and services. Resident 194 was readmitted on [DATE] with diagnoses that included aphasia (a neurological disorder caused by brain damage that impairs a person's ability to communicate, affecting speech, writing, and comprehension of language), hemiplegia (a severe or complete paralysis of one side of the body) and hemiparesis (weakness, numbness, or reduced motor function on one side of the body), hypertension (high blood pressure), and contracture (permanent tightening of the muscles, tendons, skin, and nearby tissues that causes the joints to shorten and become very stiff). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a standard resident assessment tool) was accurately completed to reflect two of 34 sampled residents' (Resident 200 and Resident 10) skin condition when:1. Resident 200's Skin Conditions in the MDS was incorrectly coded as having no pressure injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence), and2. Resident 10's Skin Conditions in the MDS was coded as having stage 4 pressure injury instead of a surgical wound. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to coordinate Pre-admission Screening and Record Review (PASRR) for one of seven sampled residents (Resident 97) with a diagnosis of psychotic disorder (severe mental illness that cause individuals to lose touch with reality, characterized by hallucinations [false perceptions] and delusions [false beliefs]). This deficient practice could potentially result in Resident 97 not receiving specialized care and services appropriate for her condition. According to medicaid.gov, Preadmission Screening and Resident Review (PASRR) is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care. PASRR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for serious mental illness (SMI) and/or intellectual disability (ID); [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a written summary of the baseline care plan (BCP, an interim written plan implemented within 48 hours of admission that details the resident's immediate health and safety needs) to two of seven sampled residents (Resident 198 and Resident 197) or their representative. This failure could leave residents or their representatives not fully informed of the treatment plan and unable to participate in their care, putting them at risk for errors or unmet needs. 1. Resident 198 was admitted on [DATE] with diagnoses that included urinary tract infection (an infection in the bladder/urinary tract) and Alzheimer's disease (a disease characterized by a progressive decline in mental abilities). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe resident environment for a census of 173 residents when Resident 147's Over The Counter (OTC) medications were left unsecured in an area accessible to other residents. This failure exposed residents to the risk of accidental ingestion and avoidable harm. During an observation of Resident 147's room on 4/28/26 at 9:46 AM, three bottles of OTC medications were observed on the resident's bedside table, which included folic acid (a synthetic form of vitamin B9), zinc (a mineral that supports immune health), and men's multivitamin (a combination of different vitamins and minerals in one pill). These medications were unsecured and accessible to other residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmacy services were maintained for a census of 173 residents when non-controlled medications (medications with less risk of addiction and harm) were disposed of in a sharps container (a hard, puncture resistant box used to safely throw away items that can cut or poke someone, such as needles and syringes), which resulted in the improper disposal of medications. During an inspection of medication cart 3A on 4/27/26 at 9:43 AM, Licensed Vocational Nurse (LVN) 6 was observed finding and placing two unidentified loose pills in the sharps container which was on the side of the medication cart. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Consultant Pharmacist (CP) identified, recommended, and followed up on necessary medication regimen changes for one of 5 sampled residents (Resident 9) when the facility did not address the need for a Gradual Dose Reduction (GDR) of olanzapine (a type of psychotropic medication indicated for psychosis) and trazodone (a psychotropic medication used to promote sleep) for Resident 9This failure resulted in Resident 9 receiving psychotropic medications (a group of drugs prescribed to affect the mind, emotions, or behavior) for over 14 months. Clinical record review indicated Resident 9 was initially admitted to the facility from the acute care hospital in February 2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored according to the manufacturers' specifications for a census of 173, when:1. A bottle of brimonidine eye drops, an eye medication used to treat high pressure inside the eye, was stored in the medication refrigerator, which had the potential to result in medication degradation and reduce efficacy.2. An expired vial of insulin glargine, a medication used to lower blood sugar levels, was available for use in the medication cart which put Resident 12 at risk of receiving expired and ineffective medication. 1. [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to provide: An entree of similar nutritive value to one resident (Resident 111) who chose not to eat the entree listed on the planned menu. The failure to provide substitute food of similar nutritive value to the food on the planned menu had the potential for a resident to receive inadequate nutrients. Meals that reflected Resident 150's preferences and failed to ensure adequate nutritional intake to reduce the resident's dependence on enteral feedings for one of one sampled residents (Resident 150). This failure resulted in ongoing inadequate meal consumption and repeated meal refusals, placing Resident 150 at risk for unintentional weight loss, nutritional decline, and continued reliance on tube feeding.1. Review of the Diet Spreadsheet Menu: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 133 entered into a legally binding arbitration agreement only after fully understanding its terms. (Resident affected). The facility did not provide the required explanation of the agreement in a form and manner the resident could understand. This failure has the potential to result in residents signing legally binding documents without informed understanding of their rights, including the right to rescind or the fact that signing is not required to receive care. During a concurrent observation and interview on 05/01/2026 at 1:41 PM, in Resident 133's room, Resident 133 and Resident 133's friend (RF 1) were presented with a paper copy of the Arbitration Agreement that Resident 133 had signed on 04/09/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection prevention and control measures for one of 34 sampled residents (Resident 195) when Resident 195's urinary catheter tubing and urine drainage bag were touching the floor. This deficient practice placed Resident 195 at risk for transmission of infectious organisms from the floor to the urinary tract. Resident 195 was admitted on [DATE] with diagnoses that included dementia (a progressive decline in mental ability, including memory, reasoning, and behavior, severe enough to interfere with daily life) and urinary retention (the inability to fully or partially empty the bladder, causing urine to remain in the bladder even when one feels the need to urinate). [...]

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to prevent pests from entering the kitchen when there was a gap between one open window and the window screen. This failure had the potential for pests to enter the kitchen and contaminate food and food equipment and utensils.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program when:Cockroaches were found in rooms [ROOM NUMBER]. Staff complained of cockroaches in residents' rooms on the second floor. A resident reported seeing cockroaches in his room during a resident council meeting. This failure created an unsanitary environment for residents, staff, and visitors, and can contribute to the spread of infections and foodborne illnesses. During an observation on 12/4/25, at 2:29 PM in room [ROOM NUMBER], a live cockroach was observed crawling on the floor and on top of the trash bin adjacent to Resident B's bed. Additionally, three dead cockroaches were found on the floor next to the nightstand. Furthermore, food particles and brownish discolorations were observed on the floor. [...]

Inspectors wroteBased on interview and record review, the facility failed to safeguard the personal property for one of four sampled residents (Resident A) whose black pouch containing cash was reported missing on 11/10/25. Furthermore, the facility failed to update and document in the inventory of personal effects after a Certified Nursing Assistant (CNA) verified that Resident A had $1,000 in the missing pouch. These failures resulted in the loss of Resident A's cash, causing emotional distress, including feelings of distrust towards staff, tearfulness, and sadness. [...]

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate Resident A's report of a missing black pouch with cash on 11/10/25. Furthermore, the facility did not take action after a Certified Nursing Assistant (CNA) verified that Resident A had $1,000 in the missing pouch. These failures resulted in the loss of Resident A's cash, causing emotional distress, including feelings of distrust towards staff, tearfulness, and sadness. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure self-administration of medications was clinically appropriate when one of four sampled residents (Resident 2) was allowed to do so without the assessment and approval of the interdisciplinary team (facility staff members who coordinate the care provided to the residents). This failure had the potential to result in unsafe medication administration or omission of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide necessary care and services to one of four sampled residents (Resident 1) when Resident 1's fingernails were not kept clean. This failure had the potential for Resident 1's fingernails to harbor germs and bacteria that could contribute to spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide needed care and treatment for two of three sampled residents (Resident 1 and Resident 2) when: 1. The facility failed to provide a therapeutic environment conducive for sleep and address difficulty sleeping for Resident 1. 2. The facility failed to implement interventions for insomnia (persistent problems falling asleep and staying asleep), paranoia (excessive mistrust and suspicion of others) that could have contributed to the consistent yelling and screaming for Resident 2. The facility failure resulted to ongoing difficulty sleeping for Resident 1, and ongoing behavioral problems with Resident 2.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to refer the resident to the appropriate state-designated authority for Level II PASARR evaluation after the resident was identified to have a newly evident mental illness diagnosis for 2 (Resident #56 and Resident #86) of 7 sample residents reviewed for preadmission screening and resident review (PASARR).

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a new Level I screening was completed for 1 (Resident #37) of 7 sampled residents reviewed for preadmission screening and resident review (PASARR).

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately reconcile post-discharge medications for one out of three sampled residents (Resident 1) when Resident 1 was discharged home with another resident's medication (Resident 2). This failure has the potential to result in a medication error after discharge if Resident 1 were to take medications that were not prescribed to them.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary care and services to one of three sampled residents (Resident 1) when the physician's order for magnetic resonance imaging (MRI, a medical imaging procedure that uses a magnetic field and radio waves to take pictures of the body's internal parts) was not carried out timely. This failure caused a delay in provision of services and had the potential to negatively impact Resident 1's physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure prescribed medication was available to administer to one of three sampled residents (Resident 1). This failure created a risk for poor health outcome to Resident 1.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident's care planning and implementation was communicated efficiently to the family when: 1. The son of Resident-A complained that the social worker (SW) did not return his calls on five different times. The complainant gave his telephone number, and texted the SW, but the SW never called back. 2. Resident -A's doctors' appointments were cancelled on 7/6/23 and 7/14/23 due to mismanagement of transportation arrangement by the facility. This failure resulted in the potential decline of Resident-A's clinical condition and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Resident 1's nutritional needs are met when: 1) Resident 1 was ordered CCHO Diet (Controlled Carbohydrate Diet) since admission when Resident 1 is not a diabetic 2) Resident 1 had a poor appetite and a significant weight loss of almost 10 lbs. from 9/24/23 to 11/17/23. This failure had the potential to result in decline of Resident 1's clinical health, poor appetite, and psychosocial well-being, including avoidable significant weight loss of 9.5 lbs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Resident 1 who had no diagnosis of diabetes mellitus was free from unnecessary drugs and interventions when: 1. Resident 1 was admitted to the facility on [DATE]. The resident had an order for a sliding scale of insulin Lispro (a rapid acting human insulin analog that works parenterally to lower blood glucose by regulating the metabolism of carbohydrates, proteins, and fats.). Resident 1 received Lispro on 9/26/23 1 unit for blood glucose of 160, on 10/9/23 1 unit, on 10/10/3 1 unit, on 10/11/23 1 unit, . 2. Resident 1's blood glucose was checked three times a day from September 25 to October 20, 2023, with her blood glucose range from 112 to 188. [...]

Inspectors wroteF 607 Develop/Implement Abuse /Neglect, etc. Policies Based on Interview and record review the facility failed to maintain and or implement the policies and procedure for Abuse, Neglect and Exploitation Training when the facility could not produce documentation.

Inspectors wroteBased on interview and record review the facility failed to Develop and Implement comprehensive care plan for resident 4, when there was no evidence of documentation of a completed care plan that would identify the needs for supervision and risk elopement for altered mental status resident.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide a discharge summary for Resident 1, when Resident 1 was sent home with no documentation where to discharge, no receiving responsible party teachings, no medications, no arrangements made for follow up care. This failure has the potential for Resident 1 not being cared for in the community, not able to adjust to new living situation.

Inspectors wroteBased on interviews and record review the facility failed to implement measures to relieve and prevent constipation in accordance with Physician ' s order and care plan for one Resident 1, when the patient experienced serious harm related to not having bowel movement for 4 days.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide annual training to their staff on preventing and training to address, forms of abuse, neglect, misappropriation of property, exploitation and dementia management of one staff when Staff 1, did not receive annual abuse training . This failure resulted in Resident 1 was financially abused by Staff 1.

Inspectors wroteBased on observations, interviews, and record review the facility failed: 1. To ensure one of six (6) sampled employees, (Certified Nurse Assistant CNA 1) was provided an in- service training on abuse before allowing to work. 2. To ensure the facility's Policy and Procedure (P&P) included the required components of abuse policy such as, Screening, Training, Prevention, Identification, and Protection. These deficient practices had the potential to negatively impact the care and services rendered to the residents.

Inspectors wroteBased on observation, interview and record review the facility failed to: 1. Investigate an allegation of abuse for one of four sampled residents (Resident 1) when the allegation of spanking the resident by a Certified Nurse Assistant, CNA 1) while changing the resident's adult brief. 2. Ensure one staff (CNA 1) was not allowed to return to work following the allegation of physical abuse. These deficient practices had the potential to place the resident's health and safety at risk and had the potential for further abuse to happen.

Inspectors wroteBased on interview and record review the facility failed to ensure the Minimum Data Set (MDS, an assessment tool) was accurately coded for one of three sampled residents (Resident 1) when, the Quarterly MDS dated [DATE] incorrectly coded the presence of chronic ulceration (areas in the body where the underlying tissue damage has caused skin loss which shows no tendency to heal after three months of appropriate treatment) on the resident's legs. This deficient practice had the potential to negatively affect the care and services rendered to the resident.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to provide the needed care and services for one of four sampled residents (Resident 1) when: 1. One staff (LVN 2) failed to perform an observation and document the signs and symptoms of the resident's respiratory problem and failed to check the resident's Vital Signs (VS, include the body temperature, pulse rate, respiratory rate, blood pressure and oxygen saturation which are indicators of the person's health status) before the resident was sent to the emergency room (ER) on 8/12/23. 2. The nursing staff failed to notify the physician when the O2 sat (oxygen saturation, amount of oxygen circulating in the blood) level de-saturating below 50% and failed to obtain a physician' order to place a non-rebreather mask (NRM, oxygen supplementation device that is used to provide continuous oxygen flow. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure one of three sampled residents (Resident 1) was provided with the appropriate resident-centered treatment and care when: 1. Multiple skin discoloration on Resident 1's back observed on 6/28/23 did not have a follow-up assessment, evaluation, and appropriate interventions by the Wound Care Team (Clinicians who develops and implements wound prevention, skin management, and wound care). 2. The Weekly Skin Assessments (WSK, supposed to be documented on the Comprehensive Skin Evaluation/Assessment, CSEA) form were not done for the months of May and June 2023. For the month of July 2023, the WSKs were done only on 7/6/23 and on 7/14/23, not on a weekly basis, as per policy. 3. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to ensure nursing staff had the competencies and skill to provide the nursing care and services for one of three sampled residents (Resident 1) when there was no assessment performed by a Registered Nurse to evaluate the resident when the resident's O2 sat (oxygen saturation, amount of oxygen circulating in the blood) level de-saturating below 50%. Resident 1 was sent out to the emergency room (ER) on 8/12/23. This deficient practice had the potential to place the resident's safety and well-being at risk of harm.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate the allegation of abuse for two of four sampled residents (Residents 2 and 3) after the facility was made aware of the allegation. This failure to thoroughly investigate the allegation of abuse had the potential to not ensure Residents 2 and 3 and other residents from possible abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure doses of the medication was received and administered in a timely manner for one out of three sampled residents (Resident 74), when the routine doses of Amlodipine (medication use to treat high blood pressure) three (3) tablets were not delivered by the contracting Pharmacy to the facility and were not administered during Med Pass (term used to describe the process through which medication is administered to residents) as ordered on 10/19/21. This failure had the potential to negatively affect the health and well being of the resident.