Height Street Skilled Care

Inspectors wroteBased on observation, interview and record review, the facility failed to:1. Maintain an environment free of accident hazards for four of 41 sampled residents (Resident 86, Resident 110, Resident 111, Resident 85) when Resident 86, Resident 110, Resident 111, Resident 85 were allowed to keep cigarette lighters in their rooms unsecured. This failure had the potential for residents who wandered to access the cigarette lighters and potentially start fires in the facility and jeopardizing the safety of all residents, visitors and staff members. 2. Follow their policy and procedure (P&P) titled, Elopement [when a resident leaves the facility premises without staff knowledge or permission] and Wandering [when a resident walks around aimlessly, unsupervised] when:a. [...]

Inspectors wroteBased on interview and record review, the facility failed to review and accurately complete the annual Pre-admission Screening Assessment and Resident Review (PASRR-federal requirement to help ensure that individuals are not incorrectly placed in nursing homes or long-term care instead of a psychiatric setting) for one of 18 sampled residents (Resident 38). This failure had the potential for Resident 38 to be placed in an inappropriate setting and not receive required services.

Inspectors wroteBased on interview and record review, the facility failed to communicate with methadone (medication used to help people reduce or quit opiates [pain medication]) outside clinic when one of one sampled resident (Resident 86) was admitted to the hospital for overdose. This failure had the potential not to meet resident needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure effective communication for one of one sampled resident (Resident 3) with a hearing deficit, when a communication board was not utilized. This failure resulted in Resident 3's inability to understand the information conveyed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with activities of daily living (ADL - tasks required for self care such as bathing, eating. dressing, transferring, toileting and continence) for one of 18 sampled residents (Resident 4) when nail care and shaving was not provided to a dependent resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure treatments were administered as ordered by the physician for one of three sampled residents (Resident 6). This failure had the potential to result in Resident 6 developing skin breakdown.

Inspectors wroteBased on interview, and record review, the facility failed to implement a physician order for one of three sampled residents (Resident 10) when a Registered Dietician (RD) consult was not completed. This failure had the potential to negatively impact on Resident 10's nutritional status and overall health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 6) head of bed was elevated to prevent aspiration (when food or liquid enters the airway or lungs instead of going into the stomach) while receiving enteral tube feeding (liquid nutrition is given directly into the stomach through a tube). This failure had the potential to result in serious harm, including aspiration pneumonia (lung infection that occurs when food or liquid enters the lungs), respiratory compromise (lungs unable to work well enough and can make breathing difficult) and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer medications according to physician orders for one of seven sampled residents (Resident 2) when Resident 2 had an order for the administration of one inhalation (drawing the medication into the lungs) of Breo Ellipta Inhalation Aerosol Powder (a medication to treat inflammation of the lungs) 200-25 MCG (micrograms-unit of measurement)/ACT (actuation - refers to a single spray, puff, or activation of an inhaler) and Resident 2 inhaled two doses of the medication. This failure resulted in Resident 2 receiving twice ordered the dose of Breo Ellipta Inhalation Aerosol Powder 200-25 MCG/ACT and placed Resident 2 at risk of medication overdose.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure:1. One of 41 sampled residents (Resident 86)'s medication was securely stored. This failure had the potential for medication to be accessed by unauthorized staff and residents.2. Medications were labeled for one of seven sampled residents (Resident 64) when Resident 64's insulin pen (a multi-use vial of medication to treat high blood sugar in the format of a pen which uses a needle for administration of the medication) was not labeled with Resident 64's identification. This failure had the potential for Resident 64 to use another resident's insulin pen or vice versa, placing Resident 64 and other residents at risk of the spread of blood/borne diseases (diseases spread through the blood).

Inspectors wroteBased on interview and record review, the facility failed to ensure:1. The licensed nurses notified the physician in a timely manner when one of four sampled residents (Resident 1) had a change of condition.2. The licensed nurses failed to administer a medication as ordered by the physician for one of four sampled residents (Resident 1). These failures resulted in Resident 1 having abdominal pain and going to the hospital due to delay in care.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse for one of four sampled residents (Resident 1) within 24 hours. This failure resulted in delayed investigation of abuse and had the potential to place Resident 1 at risk for further abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of three sampled residents (Resident 2 and Resident 3) were able to receive phone calls and outside confidential communication from services outside of the facility. This failure had the potential to violate Resident 2 and Resident 3's rights.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) received all their personal belongings upon discharge. This failure had the potential for Resident 2 to have missing items upon discharge.

Inspectors wroteBased on interview and record review, the facility failed to provide a home medication list for one of three sampled residents (Resident 1). This failure had the potential for Resident 1 not to understand how and when to take his needed home medications.

Inspectors wroteBased on interview and record review, the facility failed to follow the policy and procedure (P&P) on Psychotherapeutic Drug (medication used to treat mental health disorders) Management for one of ten sampled residents (Resident 1) when Resident 1:1. Was not provided non-pharmacological (without using medications) interventions when Resident 1 verbalized increased sadness.2. Was not monitored every shift for 72 hours after his Lexapro (antidepressant [medication that treat depression [persistent feeling of sadness and loss of interest]-Lexapro black box warning, which is the U.S. [United States] Food and Drug Administration [FDA] most serious warning for prescription drugs. The warning states that anti-depressants can increase the risk of suicidal thoughts [thoughts of ending one's own life] .) dosage was increased. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a sanitary environment for two of three residents (Resident 1 and Resident 2) when:Resident 1's bathroom had a foul smell. The bathroom tiles in three of four shower rooms used by Resident 2 and other residents were not cleaned. These failures had the potential for unpleasant experience for Resident 1 and Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to timely develop a baseline care plan with fall prevention interventions for two of three residents (Resident 1 and Resident 4) who were high risk for falls. This failure had the potential to place Resident 1 and Resident 4 at risk for falls and injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement the fall prevention intervention of keeping the bed in the low position for one of three residents (Resident 4) who was high risk for falls. This failure had the potential to place Resident 4 at the risk for falls and injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to manage the pain of one of three residents (Resident 4) when Resident 4 reported pain to Certified Nursing Assistant (CNA) A and CNA B but did not inform the Licensed Nurse (LN) C. This failure had the potential for Resident 4 suffering in pain.

Inspectors wroteBased on interview and record review, the facility failed to answer the call light timely for two of three sampled residents (Resident 1 and Resident 2). This failure had the potential for delay in care and needs not addressed promptly.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the care plan (is a comprehensive, personalized document that outlines the specific needs of an individual requiring care, detailing the type of support, how it will be provided, and the goals of the care) for two of three sampled residents (Resident 1 and Resident 2) when: 1. Resident 1 was not repositioned every two hours. This failure had the potential for Resident 1 to develop pressure injury (localized damage to the skin and underlying soft tissue usually over a bony prominence). 2. Resident 2 was not supervised during a meal. This failure had the potential for Resident 2 not to consume the proper nutrition and had the potential for choking.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of a change in condition and administer medication according to the physician's order for one of three sampled residents (Resident 1) when Resident 1 was having continuous loose stools/diarrhea. This failure had the potential for Resident 1 losing three lbs. (pounds-weight measurement) weight in one week and potential for adverse health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were answered timely for three of six sampled residents (Resident 1, Resident 2, and Resident 3). This failure had to potential to negatively impact Resident 1, Resident 2, and Resident 3, physical and psychosocial health.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of six sampled residents (Resident 2 ad Resident 3) were treated with respect and dignity when Certified Nursing Assistants (CNA 1) entered Resident 2 and Resident 3's room singing at 4 a.m. This failure resulted in Resident 2 and Resident 3 being woken up and not to be treated with dignity and respect.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) on Assessment and Management of Resident Weights for one of five sampled residents (Resident 1) when the registered dietitian (RD)'s recommendations were not communicated to the physician. This failure had the potential to result in Resident 1's weight loss.

Inspectors wroteBased on interview and record review the facility failed to follow their policy and procedure on Controlled Medication Storage when:1. Licensed Vocational Nurse (LVN) 4, LVN 5, and LVN 6 did not immediately report the missing controlled narcotic medications (medications that are highly addictive and have a significant potential for abuse, classified as a controlled substance under the law, meaning its manufacture, distribution, and possession are regulated). 2. LVN 1 did not keep the discontinued 15 tablets of controlled narcotic medications in the medication cart to be counted every change of shift (changing from one work shift to another, e.g., from day shift to night shift). [...]

Inspectors wroteBased on interview and record review the facility failed to follow their policy and procedure on Unusual Occurrence Reporting when missing narcotic controlled medications (medications that are highly addictive and has a significant potential for abuse, classified as a controlled substance under the law, meaning its manufacture, distribution, and possession are regulated) was not reported to the California Department of Public Health (CDPH). This failure had the potential for narcotic diversion (the use and/or distribution not intended to) and had the potential for medication errors affecting residents' safety. During an interview on 7/8/25 at 5:05 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to: 1. Administer narcotic (a strong pain medication) medication according to the physician's orders for one of 10 sampled residents (Resident 1). 2. Reassess and re-evaluate the effectiveness of narcotic medication given for pain for one of 10 sampled residents (Resident 1). These failures had the potential for Resident 1 suffering from uncontrolled pain and/or result in adverse health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. Three of three resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) were clean and sanitary. This failure had the potential to spread infectious diseases to residents, staff, and visitors. 2. Environment had comfortable noise levels for two of two sampled residents (Resident 134 and Resident 31). This failure resulted in residents not getting rest and sleep. 3. One of 44 sampled resident (Resident 81) personal property was protected from theft and loss. This failure resulted in Resident 81's personal property not to be accounted for.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe administration of medication for six of 16 sampled residents (Resident 46, Resident 183, Resident 23, Resident 47, Resident 7, and Resident 282) when medications were found at resident's bed side table. This failure had the potential for medications to be accessed by unauthorized staff and residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure of one of 26 sampled milk glasses were at appropriate temperature. This failure had the potential to result in the residents having foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) titled Dish Machine Temperature Recording, when dish machine's wash water was not at required temperature. This failure had the potential to result in unsanitary conditions of food utensils for foodservice safety and potential to place residents at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call light was answered timely for one of 32 sampled residents (Resident 134). This failure resulted in Resident 134 waiting for two hours with soiled brief which had the potential for skin breakdown and left Resident 134 feeling frustrated and depressed.

Inspectors wroteBased on interview, and record review, the facility failed to follow their Policy and Procedure (P&P) titled, Room or Roommate Change for one of one sampled resident (Resident 56) when Resident 56 was not notified before he was moved to a different room. This failure resulted in disruption, confusion and making Resident 56 upset.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Advanced Beneficiary Notice of Non-coverage (ABN - a form that provides information to the beneficiary so that he/she can decide whether or not to get the care that may not be paid for by the Medicare and assume financial responsibility) was completed for two of three sampled residents (Resident 66 and Resident 183). This failure had the potential to negatively affect Resident 66 and Resident 183's finances.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy and procedure (P&P) titled, Elder Abuse Prohibition and Prevention, when: 1. A thorough investigation of the resident-to-resident physical and verbal altercation for two of 44 sampled residents (Resident 16 and Resident 17) was completed. This failure had the potential for Resident 16 and Resident 17 not to be protected from further abuse. 2. A 5-day investigation report of the resident-to-resident physical and verbal altercation for two of 44 sampled residents (Resident 16 and Resident 17) was not submitted to the California Department of Public Health (CDPH) and the long-term care (LTC) ombudsman (advocate for the rights and well-being of residents in long-term care facilities). This failure had the potential for an incomplete investigation for Resident 16 and Resident 17.

Inspectors wroteBased on interview, and record review, the facility failed to implement their policy and procedure (P & P) titled, Discharge Against Medical Advice (AMA), for one of one sampled resident (Resident 79). This failure had the potential to result in being discharged to unsafe conditions.

Inspectors wroteBased on interview and record review, the facility failed to notify the Ombudsman (advocate for the rights and well-being of residents in long-term care facilities) of transfer to hospital for one of one sampled residents (Resident 7). This failure had the potential for unsafe resident transfer and discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care plan was implemented for one of three sampled residents (Resident 29). This failure had a potential for unintended weight loss for Resident 29.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure medication was administered according to physician's order for one of five sampled residents (Resident 337). This failure had the potential to result in Resident 337 having adverse health outcomes. 2. Complete vital signs (temperature, heart rate, breathing rate, blood pressure, oxygen saturation [amount of oxygen in the blood], pain, and mental status) after seizure (sudden, uncontrolled electrical disturbance in the brain that can cause temporary changes in movement, awareness, or behavior) episodes for one of five sampled residents (Resident 85). This failure had the potential for Resident 85 to experience a delay in care due to an incomplete assessment. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide oral care to one of six sampled residents (Resident 28). This failure had the potential to result in oral and dental issues.

Inspectors wroteBased on interview, and record review facility failed to implement their policy and procedure (P&P) titled, Pressure Ulcer Prevention, to prevent a pressure injury (skin damage that result of prolonged pressure or friction such as hips, buttocks, and heels) from occurring for one of five sampled residents (Resident 7). This failure resulted in Resident 7 developing a pressure injury on coccyx area (buttocks).

Inspectors wroteBased on observation, interview, and record review, the facility failed to failed to follow the physician's order to provide RNA (Restorative Nursing Assistant program-provide specialized care that helps residents regain or maintain their physical abilities and independence) program to one of six sampled residents (Resident 28). This failure had the potential for Resident 28 experiencing worsening immobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safety for one of eight sampled residents (Resident 338) when smoking articles were left with the Resident 338 unattended. This failure had the potential to cause injury to residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a nephrostomy catheter (a tube placed through the skin into the kidney to drain urine when there's a blockage or other problem preventing normal drainage) collection bag was placed below the bladder for one of one sampled resident (Resident 28). This failure had the potential for bladder infection or leakage of the catheter bag.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician's order to ensure one of five sampled resident's (Resident 337) pain medications were given according to the pain rate parameter. This failure had the potential for Resident 337 experiencing unrelieved pain.

Inspectors wroteBased on interview and record review the facility failed to ensure that discharge summary was completed for one of one sampled resident (Resident 7) when a discharge summary was missing skin assessment. This failure resulted in Resident 7's discharge summary incomplete documentation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control standards of practice for one of 20 sampled residents (Resident 72) when staff didn't wear the proper Personal Protective Equipment (PPE-specialized equipment worn by staff to minimize exposure to infections or illness) when providing care. This failure had the potential to spread infectious diseases.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three residents' rooms (Resident 24)'s was in good repair. This failure had the potential for affecting residents quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of 11 sampled residents (Resident 1) received quality care when the facility failed to: 1. Implement their policy and procedure on a change of condition (an important change in a resident ' s baseline condition which includes physical, mental, emotional or functional changes that require a change in treatment to address) for one of 11 sampled residents (Resident 1). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide and accurately document physical therapy (PT - branch of healthcare for the treatment of disease, injury, or deformity by physical methods such as massage, heat treatment, and exercise), occupational therapy (OT -branch of healthcare that helps people adapt to challenges in their daily lives, like getting dressed, eating, or working, by improving their ability to perform those activities) services and speech therapy (branch of healthcare that helps people with difficulties talking, understanding language, or swallowing) services, when the facility therapy staff inaccurately documented the time spent providing therapy to 11 of 11 sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, Resident 5, Resident 6, Resident 7, Resident 8, Resident 9, Resident 10, Resident 11). [...]

Inspectors wroteBased on interview and record review the facility failed to complete an elopement risk evaluation to identify risk for elopement for one of three sampled residents (Resident 1). This failure resulted in Resident 1 eloping and potential for sustaining injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the care plan to ensure call lights was within reach for one of three sampled residents (Resident 1) with a cognitive communication deficit (someone who has trouble communicating because of difficulties with thinking processes), when Resident 1 was left in the facility dining/activity room by herself without supervision and without the ability to call staff for help/assistance. This failure resulted in Resident 1 ' s injury to her left eye due to unknown causes and had the potential for negative health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the care plan (comprehensive documents outlining the care and services to be provided by the facility to residents) intervention of providing supervision during toilet transfers for one of three sampled residents (Resident 1), who had generalized muscle weakness, a history of falls, was at risk for falls, and had Alzheimer's Disease (memory loss), when Resident 1 got up unsupervised to use the toilet and fell in her room. This failure resulted in Resident 1 sustaining a fall with fracture (broken bone), requiring admission, and surgical intervention at the acute care hospital.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its own policy and procedure (P&P) when three of three sampled residents (Resident 1, Resident 2, and Resident 3) were not provided cigarettes during the scheduled smoking time. This resulted in Resident 1, Resident 2, and Resident 3 not being able to smoke and violated Resident 1, Resident 2, and Resident 3's rights.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of resident to resident altercation to CDPH (California Department of Public Health [state agency]) within 24 hours between two sampled residents (Resident 1 and Resident 2). This failure resulted in CDPH being unaware of the allegation, and had the potential to result in continual physical and psychosocial harm for both Resident 1 and Resident 2.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their policy and procedure for Neurological Assessment (a series of tests and questions that assess the function of the brain, spinal cord, and nerves also known as neuro checks) for one of five sampled residents (Resident 1). This failure had the potential for adverse health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to develop a plan of care for refusal of care for one of four sampled resident (Resident 1) when Resident 1 refused care for multiple times. This failure had the potential for the facility staff not addressing Resident 1 ' s needs and potential to result in adverse health outcomes.

Inspectors wroteBased on record review, the facility failed to address a change in condition for one of four sampled residents (Resident 1) when Resident 1 had a foul-smelling discharge and there was no documentation of change in condition, notification to physician of abnormal findings, and no documentation was provided by nurse. This failure had the potential for the facility staff not addressing Resident 1 ' s health care needs and potential to result in adverse health outcomes.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility ' s policy and procedure (P&P) on discharge of resident was followed for one of four sampled residents (Resident 1) when the facility did not make a follow up call to the acute hospital to determine the general status and condition of Resident 1. This failure had the potential to result in Resident 1 ' s suffering further injuries due to delay of care.

Inspectors wroteBased on interview and record review, the facility failed to revise the fall care plan for one of three sampled residents (Resident 1) after a fall incident. This had the potential to place Resident 1 at risk for injury and harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) had fresh water available at bedside. This failure had the potential for Resident 1 not to receive the necessary hydration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of four sampled residents (Resident 2 and Resident 3) had call light within easy reach. These failures had the potential for Resident 2 and Resident 3 not to be able to call for assistance and potential for unmet care needs.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to follow physician's orders for pressure ulcer treatment for 1 (Resident #4) of 1 residents reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, record review, and facility document and policy review, the facility failed to ensure enhanced barrier precautions were provided for 1 (Resident #4) of 2 residents observed for infection control practices.

Inspectors wroteBased on interview and record review, the facility failed to follow the physician ' s orders for one of four sampled residents (Resident 1). This failure had the potential for Resident 1 having adverse health outcomes.

Inspectors wroteBased on observation, interview and record review the facility failed to implement their neurological assessment (an assessment that evaluates the brain and nervous system function) for one of three sampled residents (Resident 1). This failure had the potential for any abnormality of the brain and/or nervous system to go unnoticed, delayed appropriate treatment, and lead to negative consequences up to and including death.

Inspectors wroteBased on interview and record review, the facility failed to implement their policy on abuse for one of three sampled residents (Resident 1). This failure had the potential for abuse to continue and for other residents to potentially be abused.