Pacific Heights Transitional Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure three out of three sampled staff employee files, (Unlicensed Staff A, Unlicensed Staff B and Unlicensed Staff C) had annual performance reviews or evaluations (systemic [entire organization], periodic process that assesses an employee's job performance, skills, and accomplishments against established company goals) performed for the year(s) 2025 and 2026. These failures had the likelihood for missed opportunities to provide specific education-based training for unlicensed staff members to capture potential safety concerns and improve outcomes like improving resident care concerns. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure their walk-in freezer and walk-in refrigerator were maintained in a sanitary manner and a container of thickening powder was dated and labelled. These failures had the potential for food to be stored in an unsanitary manner and for residents to be exposed to expired food products.

Inspectors wroteBased on interview and record review, three issues were identified regarding dialysis communication books for Resident 7 and 27, two out of four resident receiving outpatient dialysis.1. Resident 7's dialysis communication book was missing important information. 2. Two medications were administered by dialysis staff to Resident 7. One was not clarified and both were not communicated to the physician and/or dietitian.3. Residents 27's dialysis communication book was left at the dialysis center and information regarding the latest dialysis session was not charted in the nursing notes. These failures had the potential to negatively impact continuity of care for Residents 7 and 27.

Inspectors wroteBased on interviews, and record reviews, the facility failed to ensure the accountability of controlled medications (medication with high potential for abuse and addiction) when the Controlled Drug Record (CDR, accountability records, an inventory sheet that keeps records of the usage of controlled medications) for one of six sampled residents (Resident 66) did not reconcile with the Medication Administration Record (MAR). This failure resulted in inaccurate accountability and the potential for abuse and diversion of controlled medications. Review of Resident 66's Physician's Order, dated 1/20/26, indicated oxycodone (a controlled narcotic medication for pain) 5 mg (milligram, unit of measurement), Give 1 tablet (5 mg) by mouth every 6 hours as needed for breakthrough pain (moderate pain 4-7 [pain scale]). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a bed / bedroom was accessible to one of three sampled residents (Resident 1) when Resident 1 did not have a bed to sleep on for the night. The facility failure resulted to Resident 1 sitting up on the wheelchair in the facility lobby for over thirteen (13) hours during the night until the next day.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to notify the physician when medications were not available for administration to 1 (Resident #38) of 1 resident reviewed for notification of change and 2 (Resident #308 and Resident #96) of 5 residents reviewed for unnecessary medications.

Inspectors wrote2. An admission Record indicated the facility admitted Resident #308 on 08/02/2024. According to the admission Record, the resident had a medical history that included a diagnosis of type two diabetes mellitus with hyperglycemia (high blood sugar). An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 08/08/2024, revealed Resident #308 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had intact cognition. Per the MDS, the resident had received six insulin injections during the seven days prior to the assessment. The MDS revealed the physician had not changed the resident's insulin orders in the previous seven days. Resident #308's care plan included a focus area, initiated on 08/02/2024, that indicated the resident was at risk for hypoglycemia (low blood sugar) and hyperglycemia. [...]

Inspectors wroteBased on observation, interview, and facility document and policy review, the facility failed to ensure each resident was provided a homelike environment, which affected 1 (Resident #55) of 2 residents reviewed for environmental concerns. Specifically, the facility failed to provide a window curtain upon Resident #55's request.

Inspectors wroteBased on record review, interview, facility policy review, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure the accuracy of a Minimum Data Set (MDS) assessment for 1 (Resident #2) of 5 residents reviewed for unnecessary medications. Specifically, the facility failed to code Resident #2's MDS assessment to reflect the use of an anticoagulant.

Inspectors wroteBased on interview, record review, facility policy review, and review of the California Department of Health Care Services Preadmission Screening and Resident Review (PASRR) Level I Assessment Guide, the facility failed to ensure a Level I PASRR was accurately completed for 1 (Resident #4) of 1 resident reviewed for PASRR requirements. Specifically, the facility failed to ensure Resident #4's Level I PASRR Screening reflected the presence of a serious diagnosed mental disorder.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure the use of an anticoagulant medication was addressed in the comprehensive care plan for 1 (Resident #96) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure urinary catheter care was completed in a sanitary manner to prevent possible infection for 1 (Resident #202) of 1 resident sampled for urinary catheter use.

Inspectors wroteBased on interview and record review, the facility failed to monitor for potential side effects or adverse drug reactions related to the use of an anticoagulant (blood thinner) for 1 (Resident #96) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on interview, record review, and facility policy review, facility failed to obtain laboratory testing as ordered by the physician for 1 (Resident #308) of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to follow procedures to prevent potential infections and cross-contamination during medication administration for 2 (Resident #305 and Resident #56) of 7 residents observed during medication administration.

Inspectors wroteBased on observation, interview, and facility document and policy review, the facility failed to ensure nurse staffing data was posted on a daily basis at the beginning of each shift, and failed to ensure the posting was in a prominent place readily accessible to residents. This deficiency had the potential to affect all residents residing in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a pest free environment and an effective pest control program when cockroaches were noted on 2/14/23 in residents' room. This failure can result to infection control problems.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to: 1. Ensure a device called glucometer (glucometer, measured the amount of sugar in the blood) and the supplies used to test blood glucose (sugar) were used properly by performing calibration (the process of configuring a device to provide accurate test results within an acceptable range) checks as instructed by the manufacturer and the United States Food and Drug Administration (or FDA is government agency responsible for protecting the public health by ensuring the safety and efficacy of drugs and medical devices) advisory in two out of four units (second and fourth floor units). 2. [...]

Inspectors wroteDefinitions: Central Line - also known as Central Venous Catheter (CVC), is a flexible tube inserted through the patient's skin and into their body through a peripheral vein or proximal central vein such as the internal jugular (neck), femoral vein (groin) or subclavian vein (upper chest) and used to give fluids, blood or medications. Intravenous (IV) - defined as within a vein or commonly, it refers to giving medicines or fluids through a needle or tube inserted into a vein. Peripherally Inserted Central Catheter (PICC) - a thin tube that is inserted through a vein in the arm and passed through to the larger veins near the heart used to administer medications, liquid nutrition or other intravenous (IV) treatments. Based on observation, interview, and record review, the facility did not ensure services provided by the facility adhered to professional standards of quality, when: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility's Consultant Pharmacist (CP- a pharmacist who oversee the pharmaceutical services in the facility) failed to: 1. Ensure review safe blood sugar monitoring practices and act on missing blood glucose (or sugar) test results for two of 22 sampled residents (Resident 42 and 64). 2. Ensure opioid (or narcotics, drug of concern for possible abuse) medication accountability log sheet (also called Controlled Drug Accountability or CDR where every use of narcotic medication documented) were matched with the Medication Administration Record (or MAR, a document in medical records that listed medication use) on four (Resident 44, Resident 45, Resident 88 and Resident 51) out of 22 sampled residents. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility had a 21.43% error rate when nine medication errors out of 42 opportunities were observed during a medication pass for Resident 61, Resident 45, Resident 51, and Resident 80. This deficient practice resulted in medications not given in accordance to the prescriber's orders and/or manufacturer's specifications which may result in residents not receiving the full therapeutic effect of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure discontinued and expired medications were removed from the active storage area and the medications were labeled with Beyond Use Date (or BUD, a date that no longer safe to use the medication) according to standards of practice or manufacturing information in two (Second and Fourth floor units) out of four medication storage units. 2. Ensure drugs were stored at required temperature according to manufacturer's instruction and facility's policy and procedure in one (second floor) out four medication rooms. 3. Ensure security of prescription medications in the medication storage room and not preventing storage of staff's personal items in one out of four medication rooms in the second floor. 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure boxed frozen waffles were stored on a shelf above two boxes of frozen uncooked Italian sausages. This deficient practice had a potential result for foodborne illness to medically compromised residents.

Inspectors wroteDefinitions: Transmission-Based Precautions (TBP) - infection control measures used to help stop the spread of infection. Yellow Zone - a designated area in the facility for symptomatic, suspected COVID-19, and residents awaiting test results; COVID-19 exposed residents; and newly-admitted or re-admitted residents under observation for COVID-19. N95 Respirator - a respiratory protective device designed to filter at least 95% of airborne particles. N95 Respirator, Extended Use - According to the Centers for Disease Control and Prevention (CDC), dated 3/27/20, retrieved on 5/4/21 from https://www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.html, Extended use refers to the practice of wearing the same N95 respirator for repeated close contact encounters with several patients, without removing the respirator between patient encounters . [...]

Inspectors wroteBased on interview, observation and record review the facility failed to identify an indication and appropriate duration of use for psychotropic (mind altering) medications on two (Resident 84 and Resident 44) out of 22 sampled residents as evidenced by: 1. When Resident 84 (Res 84) was admitted with a medication called quetiapine (or Seroquel- used to treat mental health problem or nerve pill) with conflicting indications in the medical chart affecting the care planning and behavior monitoring by nursing staff. 2. [...]