High View Rehabilitation and Living Center

Inspectors wroteBased on interviews and personnel file reviews, the facility failed to ensure the Dietary Supervisors met the qualifications required to be a Food Service Director or Supervisor. This has the potential to affect all the residents.

Inspectors wroteBased on interviews, the facility failed to employ a qualified Activity Director (AD) to manage resident centered activities for all residents (33 residents). On 6/17/26 at 12:30 p.m., during an interview with a surveyor, the Administrator stated that the initial Activities Director's last day was 3/6/26. The Administrator confirmed with the surveyor that the staff member that filled the role on 3/8/26 was not qualified for the position and was terminated on 6/8/26. At this time the surveyor confirmed the facility does not currently have a qualified Activities Director, and that the previous staff member had not completed the State-approved program and was not qualified to be the AD.

Inspectors wroteBased on record review and interviews, the facility failed to inform a Resident in advance, of treatment risks and benefits, options, and alternatives related to the use of psychotropic medications (prescription drugs that alter brain chemistry, affecting mood, perception, thoughts, or behavior) for 1 of 5 sampled residents reviewed (Resident #23 [R23]).

Inspectors wroteBased on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, comfortable, and homelike environment for 3 of 3 days of survey (6/15/26, 6/16/26, and 6/17/26).

Inspectors wroteBased on record review and interviews, the facility failed to ensure that the Resident Representative (RR) received a written copy of the bed hold and transfer notice for 2 of 2 transfers and admissions to the hospital (3/23/26 and 4/20/26) for Resident #17 (R17)

Inspectors wroteBased on clinical record reviews and interview, the facility failed to follow physician orders for 1 of 2 residents reviewed for constipation (Resident #6 [R6]).

Inspectors wroteBased on interviews, observation, and record review, the facility failed to ensure transportation was provided timely for a wound care clinic appointment for 1 of 1 resident reviewed for leg and foot wound care (Resident #2 [R2]).

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure that a Resident Profile (Facesheet) contained accurate and complete information regarding a responsible party for 1 of 5 residents reviewed for Advance Directives (Resident #17 [R17]).

Inspectors wroteBased on record review and interview, the facility failed to complete and transmit a discharge Minimum Data Set 3.0 (MDS) electronically to the State MDS database for 1 of 1 sampled resident transferred to another long-term care facility. As of 6/16/26, this MDS was due to be completed and transmitted by 5/14/26, now 33 days late. On 6/15/26, R7's clinical record was reviewed and indicated that on 4/21/26, R7 was discharged to another long-term care facility, and a recapitulation of stay was in the clinical record. There was no evidence in the clinical record that the discharge MDS had been completed within 14 days from discharge and transmitted to the State MDS database within 14 days after completion. On 6/16/26 at 2:56 p.m., during an interview with the Minimum Data Set (MDS) Coordinator, a surveyor confirmed this finding.

Inspectors wroteBased on observations and interview, the facility failed to post the daily nurse staffing information in a prominent place, readily accessible and visible to all residents for 2 of 3 days of survey (6/15/26 and 6/16/26).

Inspectors wroteBased on personnel file reviews and interview, the facility failed to ensure staff received mandatory training on its Quality Assurance and Performance Improvement Program (QAPI), which included the staff's role and communication with the program, for 3 of 3 personnel files reviewed that had been employed greater than 1 year (Certified Nursing Assistant #1 (CNA1, CNA2, and CNA3).

Inspectors wroteBased on observations, review of facility's Bed Safety policy, clinical record reviews, and interviews, the facility failed to identify hazards in a resident's environment and implement interventions to prevent avoidable accidents/injuries. This failure resulted in Resident #3 (R3) obtaining a skin tear when hitting his/her right arm on the exposed, uncovered, square tubing on the bed frame that the mattress was not wide enough to cover, and failure to identify exposed areas of a bed frame that created a risk of entrapment for Resident #26 (R26). This created an Immediate Jeopardy (IJ) situation for all 35 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's bed dimensions were appropriate for a resident resulting in a 10 inch gap between the mattress and the bed rail. This failure created the potential for bodily injury including death by entrapment of body parts, for 1 of 35 residents [Resident #26 (R26]. In addition to the resident in immediate jeopardy, the facility's failure to regularly inspect and monitor bed rails resulted in the potential for harm for 35 out of 35 residents with bed rails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify the existing risk for entrapment of body parts through bed inspections, this failure created the potential for severe bodily injury including death by entrapment of body parts, for 3 of 35 residents [Resident #26 (R26), (R3) and (R13)]. In addition to the resident in immediate jeopardy, the facility's failure to implement an effective inspection of all resident bed equipment (bed frames, mattresses, and bed rails) to ensure that bed mattresses fit the bed frames to prevent entrapment of body parts, this has the potential to effect 35 out of 35 residents with bed rails.

Inspectors wroteBased on observations and interviews, the facility failed to maintain the building in good repair for 4 of 4 days of survey (3/31/25, 4/1/25, 4/2/25, and 4/3/25).

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure the kitchen was maintained in a clean manner on 4 of 4 days of survey (3/31/25, 4/1/25, 4/2/25, and 4/3/25), the facility failed to label thawed nutritional shakes with a thaw date on 1 of 4 days of survey. (3/31/25), the facility failed to discard expired foods on 1 of 4 days of survey (3/31/25), the facility failed to label, and date opened foods for 1 of 4 days of survey (3/31/25). In addition, the facility failed to consistently monitor and document food temperatures for proper cooked temperatures and proper serving temperatures for 94 of 99 meals reviewed. (Food Temperature Log sheets for March and 2 days in April)

Inspectors wroteBased on facility policy review and interviews, the facility failed to notify the Centers for Disease Control and Prevention (CDC) of an outbreak of Norovirus in the facility. In addition, based on review of the facility's Legionella Water Management Program and interview, the facility failed to fully develop and implement a water management program to monitor for and prevent the growth and spread of Legionella and other water-borne pathogens.

Inspectors wroteBased on facility policy review, record reviews, Centers for Disease Control and Prevention (CDC) recommendations, and interview, the facility failed to offer the updated Pneumococcal vaccination to 3 of 5 residents (Resident #3 [R3], R22, and R29).

Inspectors wroteBased on interviews and observations, the facility failed to meet the reasonable needs of residents in the area of bed size for 1 of 35 residents reviewed for accommodation of needs (Resident #13 [R13])

Inspectors wroteBased on clinical record review and interviews, the facility failed to ensure physician orders were followed for 1 of 5 residents reviewed for unnecessary medications (Resident #27, [R27]).

Inspectors wroteBased on observations, manufacturer's instructions, facility policy review, and interview, the facility failed to provide oxygen therapy in a sanitary manner for 2 of 4 days of survey (2/10/25 and 2/11/25) for Resident #19 (R19).

Inspectors wroteBased on record review and interview, the facility failed to identify a resident's current diagnosis of Post-Traumatic Stress Disorder (PTSD) to determine what trigger(s) might cause re-traumatization for 1 of 1 sampled resident reviewed with a current diagnosis of PTSD (Resident #5 [R5]).

Inspectors wroteBased on observations, interviews, and record reviews, the facility's Quality Assurance Committee failed to ensure the plan of correction for identified deficiencies from the annual survey dated 5/1/24 was effective.

Inspectors wroteBased on record reviews and interview, the facility failed to ensure the physician was notified of a resident's change of condition prior to transfer to the hospital for 1 of 2 sampled residents (Resident #1 [R1]}.

Inspectors wroteBased on record reviews, facility reported incident and written statements review, and interviews, the facility failed to transfer a resident to the hospital timely, after a change in condition for 1 of 2 residents reviewed (Resident #1 [R1]).

Inspectors wroteBased on interviews, the facility failed to ensure they had a qualified Food Service Director for 3 of 3 days of survey (4/29/24, 4/30/24, and 5/1/24). This has the potential to affect all the residents.

Inspectors wroteBased on observations, and interviews, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety by not storing dishes in a sanitary manner for 1 of 3 days of survey (4/30/24), not storing food in a sanitary manner, not wearing hair nets or beard restraints while preparing food, and not maintaining the kitchen in a clean and sanitary manner for wall around oven for 2 of 3 days of survey (4/29/24 and 4/30/24), and not maintaining a clean kitchen floor for 3 of 3 days of survey (4/29/24, 4/30/24, and 5/1/24) .

Inspectors wroteBased on Infection Prevention Control Program (IPCP) review and interview, the facility failed to implement the elements of the Legionella Water Management Program for 1 of 1 Water Management Program reviewed.

Inspectors wroteBased on facility policy reviews, record reviews, Centers for Disease Control and Prevention (CDC) recommendations, and interview, the facility failed to offer the influenza vaccination to 4 of 5 residents reviewed (Resident [R]9, R15, R24, and R30) and failed to offer the updated Pneumococcal vaccination to 5 of 5 residents (R9, R15, R17, R24, and R30).

Inspectors wroteBased on clinical records review, facility policy review, Centers for Disease Control and Prevention (CDC) recommendations, and interview, the facility failed to follow the CDC guidelines and offer the updated 2023-2024 Coronavirus (COVID-19) vaccine doses for 4 of 5 residents reviewed (Resident [R]15, R17, R24, and R30).

Inspectors wroteBased on observation, record review and interview, the facility failed to notify the physician of a change in status for 1 of 1 sampled residents reviewed for a choking event, (Resident [R]1).

Inspectors wroteBased on record review and interview, the facility failed to identify the reason for a transfer on the transfer notice and failed notify the resident and/or the resident's representative in writing of the transfer/discharge to an acute care hospital for 1 of 1 residents sampled for hospitalizations (Resident [R]34).

Inspectors wroteBased on record review and interview, the facility failed to notify the resident and/or the resident's representative in writing of a bed hold notice after a transfer/admission to an acute care hospital for 1 of 1 residents sampled for hospitalizations (Resident [R]34).

Inspectors wroteBased on record review, facility protocol, and interviews, the facility failed to complete neurological (neuro) assessments for 1 of 1 residents reviewed who fell and hit their head (Resident [R]136) and the facility failed to ensure Physician orders were followed for 1 of 1 resident observed for Activities of Daily Living (ADL) care (the acts of bathing, dressing, and personal hygiene care), (Resident [R]16).

Inspectors wroteBased on record review and interview, the facility failed to ensure the pharmacist identified an irregularity for a psychotropic medication for 1 of 4 residents reviewed for the use of Psychotropic medications (Resident [R]28)

Inspectors wroteBased on record review and interview, the facility failed to ensure an Abnormal Involuntary Movement Scale (AIMS), used to monitor for potentially irreversible side effects of anti-psychotic medications, was completed every 6 months for 1 of 4 sampled residents reviewed for the use of Psychotropic medications (Resident [R] 28).