Park View Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food under sanitary conditions and in accordance with professional standards for a census of 116 when:Nonstick pans used in food preparation were visibly scratched, compromising the integrity of the cookware and increasing the risk of nonstick coating flaking into food;A manual can opener had missing metal on the tip, creating a potential physical contaminant hazard during food preparation; andItems in the refrigerators were not marked with an open date or delivery date. These failures had the potential to contribute to the spread of foodborne illnesses among a vulnerable resident population.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect resident health information for a census of 116 when dietary tickets were disposed of in the facility's regular trash. This failure decreased the facility's potential to protect and safeguard resident confidentiality and personal privacy. During a concurrent observation and interview on 3/2/26 at 9:17 a.m. with the Food & Nutrition Director (FND), in the kitchen dishwashing area, a dietary aid (DA) was observed removing trays from the soiled tray carts to prepare them to be washed. The DA sorted the tray contents and threw residents' dietary tickets into the garbage can along with scraps of food. The FND stated residents' dietary tickets were thrown into the garbage with food scraps. An observation of the contents of the garbage can included 8 dietary tickets. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure Resident Rights were honored when two of two sampled residents (Resident 82 and Resident 5) were not provided with privacy during routine care and while accommodating the resident's expressed preference for minimal coverings. This failure resulted in exposure of both residents in a state of undress to passers by, undermining dignity and placing residents at risk for psychosocial harm. A review of Resident 82's admission record indicated she was last admitted on 10/25 with the primary diagnosis of Unspecified sequelae of cerebral infarction (long-term health problems caused by a stroke). A review of Resident 82's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 1/19/26 indicated, an interview could not be conducted with the resident for the resident is rarely/never understood. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor the choices and preferences for two out of two residents (Resident 113, and Resident 111) sampled for choices, when,Resident 113 requested to have her emergency inhaler, Albuterol HFA ( an inhaled respiratory medication for shortness of breath), at her bedside on admission for timely use when short of breath and staff did not honor her request. Resident 111 reported stressors related to roommate and requested a room change and staff did not respond. This failure undermined both residents' right to make choices about care and aspects of their life in the facility and contributed to feelings of anxiety and stress. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an appropriate indication for use of an antipsychotic medication for one of five residents sampled for unnecessary medication review (Resident 48). This failure placed Resident 48 at risk for unnecessary psychotropic medication (any drug that affects behavior, mood, thoughts or perception) use. A review of Resident 48's face sheet (demographics) indicated an admission date of 11/1/22, age in her 90s, and medical diagnoses including a fall with multiple fractures of the spine and Unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, among others. A review of Resident 48's physician order, dated 12/24/25, indicated Seroquel (an antipsychotic medication) 12.5 mg (milligrams) by mouth two times a day for dementia with behavioral disturbance. [...]

Inspectors wroteBased on interview and record review, the facility failed to promptly notify the State Mental Health Authority, Department of Health Care Services (DHCS), for one of two sampled residents (Resident 13), when Resident 13 experienced a significant change in mental health status and received a new diagnosis indicating serious mental illness, requiring referral for Preadmission Screening and Resident Review (PASRR - a federal assessment requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are placed in facilities that can provide the appropriate care). This failure hindered the facility's ability to ensure Resident 13 had an up to date PASRR determination after the new serious mental illness diagnosis, creating the potential for inappropriate placement and delays in identifying and providing necessary specialized behavioral health services. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure ongoing accurate clinical assessment and documentation for one resident (Resident 78) when no wound assessments for a head wound were documented. This failure made it difficult to determine the wounds progression, response to treatment, and healing trajectory, when there were no assessments available for comparison. This failure had the potential for poor wound response and non- healing to go unnoticed and untreated. A review of Resident 78's admission record indicated he was admitted on [DATE] with diagnoses of Vascular (having to do with the blood vessels and circulation) Dementia (a progressive state of decline in mental abilities), and Dysphagia (difficulty swallowing). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement supervision and monitoring interventions for one of one sampled resident (Resident 6) when the facility did not prevent the resident from exiting beyond the secured patio on 3/2/26 despite her severe cognitive impairment, documented history of exit seeking, and care planned interventions such as door alarms and frequent checks. This failure resulted in Resident 6's elopement beyond the secured patio and exposed Resident 6 to significant hazards with potential for serious injury. A review of Resident 6's admission record indicated she was last admitted 4/25 with the diagnoses of Unspecified Intrascapular Fracture of Left Femur (broken hip on the left side), generalized muscle weakness, unsteadiness on feet, and Alzheimer's Disease with Late Onset. [...]

Inspectors wroteBased on observation, interviews, including a Santa [NAME] Police Department Detective interview, and facility record reviews, the facility failed to protect one resident (Resident 1) of a census of 115 and sample of 77 interviewable residents, to be free from sexual abuse, when Licensed Staff B witnessed Unlicensed Staff A touching his exposed penis against Resident 1's naked body during care. This failure to protect Resident 1 from Unlicensed Staff A resulted in Resident 1 stating she told Unlicensed Staff A to stop, and it made her feel uncomfortable, and would make a reasonable person, who suffered from sexual assault by a facility staff member, to experience fear, guilt, shame, isolation, dehumanization and humiliation as a result of the sexual abuse. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored and maintained in accordance with professional standards of practice for one of five residents (Resident 1) when, two medications pills were found left unattended at the bedside of Resident 1 without authorization for bedside storage or self-administration. This deficient practice created the potential for medication errors, diversion, or harm to Resident 1 or other residents.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records in a complete and accurately documented manner for one resident out of four sampled residents (Resident 1) when vital signs (measurements of the body's functions that include heart rate, the amount of oxygen in the blood, breaths per minute and blood pressure [the force of blood as the heart pumps]), were recorded in the resident's medical record after the resident had been transferred out of the facility. This failure resulted in inaccurate documentation in Resident 1's medical record.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a resident centered care plan for one resident (Resident 1) out of four sampled residents when licensed nurse staff did not develop a care plan for Resident 1's use of a Bilevel Positive Airway Pressure (BIPAP- therapy for assisted breathing by delivering pressurized air through a mask). This failure decreased the facility's potential to provide resident centered care and ensure safety for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to provide care and services in accordance with professional standards of care for one resident (Resident 1) out of four sampled residents when: 1. A Licensed Nurse (LN) failed to notify the physician when Resident 1's Bilevel Positive Airway Pressure (BIPAP- therapy for assisted breathing by delivering pressurized air through a mask) machine became inoperable; and, 2. An LN did not notify the physician when Resident 1 was not administered an ordered medication. These failures had the potential to cause Resident 1's condition to deteriorate and complicate his clinical condition.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free of medication errors when one of three sampled residents (Resident 3) was not given the correct dosage of a medication, Uptravi (generic name selexipag) a medication used to treat pulmonary hypertension (high blood pressure in the arteries that carry blood from the heart to the lungs). This failure had the potential for Resident 3 to have a drug overdose causing physical problems ranging from pain, rashes, weakness, organ failure, (when organs in the body such as the heart, lungs, kidneys or liver are unable to perform their critical functions), seizures or even death.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure one of two sampled residents (Resident 1) received care in accordance with professional standards of practice when: 1. Resident 1 did not receive her six of her scheduled medications. 2. The physician was not notified when Resident 1 did not receive their scheduled medications. These failures could lead to worsening of condition, hospitalization, seizure (sudden burst of electrical activity in the brain) or even death.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure the contact enteric precaution (used when caring for residents with a suspected or confirmed infection caused by bacteria that spreads through fecal-oral transmission) on room [ROOM NUMBER] was followed when a speech therapist: 1. Did not perform hand hygiene (HH, washing hands with soap and water or using an alcohol-based hand sanitizer to prevent the spread of germs) prior to entering room [ROOM NUMBER], 2. Did not put on gloves prior to entering room [ROOM NUMBER], 3. Did not put on gown prior to entering room [ROOM NUMBER], 4. Did not wash hand with soap and water upon leaving room [ROOM NUMBER]. These failures could result to spread of infection between residents.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure the rights of five (5) unsampled residents (Resident 20, Resident 55, Resident 69, Resident 76 & Resident 63) and three (3) of 24 sampled residents (Resident 3, Resident 51 & Resident 42) were honored and respected, when: 1) facility staff did not answer or respond to call lights or call for assistance, making residents wait for 20 minutes or more; 2) the facility did not follow its Smoking Policy, when Resident 42 wheeled himself across the facility's parking lot to smoke without staff supervision, and; 3) facility staff entered and exited the building using the slider doors in the residents' rooms that opened to the back patio. These failures: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the survey binder was updated for three years, with the results of complaint and facility-reported incident investigations, and failed to ensure the residents were notified of its location. This failure resulted in the facility's residents not having access to the results of the most recent investigations completed by the Department.

Inspectors wroteBased on interview and record review, the facility did not ensure four of twenty-four sampled residents (Resident 2, Resident 3, Resident 63 & Resident 51) experienced a comfortable noise level at the facility. This finding had the potential to result in inability for the residents to rest and sleep, necessary for the body's renewal and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Resident Council knew how to file a grievance. This failure could potentially result in residents' issues going unresolved.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards of practice were followed, when: 1. A Licensed Vocational Nurse (Licensed Staff A) left several medications in a resident's bedside table without a physician order, and; 2. Licensed Vocational Nurses were signing for the administration of intravenous medications they had not administered. These findings had the potential to result in inaccurate medical records, medication errors, and harm to the residents of the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that three of six sampled residents (Resident 78, Resident 33 and Resident 4), who did not participate in social activities, were provided with activities of interest, and supplies to engage in these activities (For resident 78). This failure had the potential to result in boredom, depression and frustration to the residents involved.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the safety and functional environment in the kitchen, when cracks and missing tile on the kitchen floor were not repaired. This failure could cause dirt to build up on the floor, attracting cockroaches and rodents, and could cause trips and falls among the kitchen staff.

Inspectors wroteBased on interview and record review, the facility did not have a system to track staff compliance in mandatory trainings. This finding had the potential to result in inadequate staff competency to care for the residents, within professional standards or practice, poor quality of care, and harm to the residents of the facility.

Inspectors wroteBased on interview and record review, the facility failed to notify the Long-term Care Ombudsman's office of one of three residents sampled for a closed record review, Resident 209, when he was hospitalized . This failure could potentially prevent the Ombudsman from advocating for a vulnerable resident who may require advocacy services.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure one (1) of twenty-four (24) sampled residents (Resident 78) and one (1) of four (4) discharged residents (Resident 209) had comprehensive care plans developed when: 1. Resident 78 did not have a comprehensive care plan for activities that reflected her admission activities assessment, and; 2. Resident 209 did not have a comprehensive care plan developed for a broken arm. These findings had the potential to result in boredom and frustration for Resident 78, for not participating in her activities of interest. For Resident 209, this finding had the potential to result in inability for staff to care for his broken arm properly, poor quality of care and harm.

Inspectors wroteBased on interview and record review, the facility failed to accurately assess the fall risk of one of three residents sampled for closed record review (Resident 209). This failure could have potentially contributed to Resident 209 falling when his risk level was inaccurate.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow its Nursing Staff Competency Policy, Facility Assessment Policy and Resident rights Policy, for one sampled Resident (Resident 306), as evidenced by: 1. Licensed Staff B did not have updated annual competencies for Change of Condition assessment and documentation. This failure had the potential to result in Resident 306 not receiving emergency care in a timely manner and for Residents in the facility being potentially at risk due to incompetent staff.

Inspectors wroteBased on observation, interview and records review, the facility failed to ensure the sanitary storage of a resident's portable plastic urinal after use. This failure had the potential to increase the risk of infection and disease transmission from bacteria and other microbes, breeding inside the portable urinal.

Inspectors wroteBased on observation, interview and record review, the facility failed to keep four of five residents' belongings safe in the facility. This failure caused the residents to lose items of sentimental and monetary value, causing the residents to feel upset.

Inspectors wroteBased on observation, interview and record review, the facility did not follow its Grievance policy when: 1) Multiple Confidential Resident's concerns with Resident 109's wandering behavior was not documented on the grievance log and was not investigated per policy; and 2) 4 of 5 Confidential Residents did not know how to file a grievance. These failures contributed to residents being upset, scared, and feeling their privacy had been violated, and potentially prevented facility staff from addressing and resolving resident's concerns.

Inspectors wrote3. The Department received an anonymous complaint on 11/1/2021 that indicated the facility had sent Resident 49 (who had dementia, lacked decision-making capacity, and was conserved by the Public Guardian's office) unaccompanied to Physician W's office (offsite at a Community Health Center). The complaint indicated Resident 49 traveled to Physician W's office to complete a POLST (Physician Orders for Life Sustaining Treatment; written form that tells health care providers want treatments an individual wants during a medical emergency). The complaint indicated when Resident 49 was at Physician W's office, she did not understand the purpose of the appointment and was placed in danger, as she was not provided supervision by the facility staff to and from the appointment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a restful environment for one of three residents sampled for resident-to-resident altercations when Resident 38's roommate, Resident 16, made anxious verbalizations day and night. This failure caused Resident 38 to feel mad, scream at Resident 16, and lose sleep.

Inspectors wroteBased on observation, interview, and record review, the facility failed to allow one of five residents sampled for activities (Resident 68) go to social activities, which was how she wanted to spend her day. This caused Resident 68 to remain in bed isolated when she would rather be up in the common areas around other people.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to maintain resident safety when: 1. The facility did not provide a safe and supervised smoking area for one sampled resident (Resident 74) and one unsampled resident (Resident 99); 2. The facility did not provide supervision for one of two residents sampled for accidents, Resident 49, a cognitively impaired and non-verbal resident who was sent to a physician appointment unattended; and 3. The facility did not provide supervision to prevent repeated wandering into other residents' rooms for one of three residents sampled for resident-to-resident altercations (Resident 109); These failures had the potential to cause accidental injuries to residents, including burns or fractures, and could result in a fire in dry, windy weather. [...]

Inspectors wroteBased on Observation, interview, and record review the facility failed to recognize medical changes for 2 of 22 sampled residents (Resident 33 and Resident 7) when: 1a) The staff did not identify Resident 33 had swelling on both legs. This failure had a potential delay of treatment for the underlying cause of swelling. 1b) The staff did not provide continuity of wound care for Resident 33. This failure had a potential delay of wound care which could lead to worsening of wound including wound infection. 1c) The staff did not have a process in identifying acute respiratory changes for Resident 33 who had a chronic cough related to COPD. This failure had a potential delay of respiratory treatment and affect Resident 33's daily routine (Reference F695). 2) Resident 7 had complaint of pain and was not medicated according to her level of pain (Reference F697).

Inspectors wroteBased on interview, and facility document review, the facility's Quality Assurance and Performance Improvement (QAPI) Program failed to identify quality deficiencies as evidenced by: 1) Residents were not supervised while smoking, residents did not have smoking care plans developed timely, and the designated smoking area did not contain a fire extinguisher (Cross Reference F689); 2) Resident food preferences were not consistently honored (Cross reference F800); 3) The facility did not develop a policy and procedure for emergency water treatment, storage, monitoring and safe accessing/use of the water (cross reference F880); and 4) Resident grievances were not documented (logged) and investigated per policy (cross reference F585). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement an Infection Prevention and Control Program (IPCP) when: 1. Staff did not wear appropriate mouth, nose, eye protection or isolation gowns when providing care to one resident (Resident 262) who had a medical status that required Infection Control Precautions (a set of standard recommendations used to reduce the risk of transmission of infectious agents from body fluids or environmental surfaces); 2. Health care personnel (HCP) did not remove and discard Personal Protective Equipment (PPE) (medical grade supplies used every day by (HCP) to protect themselves, patients, and others when providing care) as appropriate per national guidelines; 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to allow one of two residents sampled for choices (Resident 68) go to social activities, which was how she wanted to spend her day. This caused one resident to remain in bed when she would rather be up in the common areas around other people.

Inspectors wroteBased on Observation, interview, and record review the facility failed to assess acute respiratory changes for 1 of 22 sampled residents (Resident 33) when Resident 33 had a productive cough and not monitored for symptoms of possible respiratory infection. This failure had a potential delay of respiratory treatment and affect Resident 33's daily routine.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure effective pain management for one of 22 sampled residents (Resident 7) when: a) Resident 7 reported pain at a level of 8 to 10 using a numerical pain scale (A numerical scale from 0 to 10 based on self-reported data when 0 means no pain; 1-3 means mild pain; 4-7 is considered moderate pain and 8 and above is severe pain) and was given medication for moderate pain. b) Resident 7 reported pain medication given was ineffective on 10/10/21 and 10/22/21 and no additional intervention provided to manage Resident 7's pain. c) The facility did not develop a person-centered care plan incorporating Resident 7's desired level of pain. This failure had the potential to result in Resident 7 experiencing emotional distress by crying and refusing to get out of bed because of severe pain.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that medications were labeled, stored and destroyed according to the facility policy and procedure. This failure had the potential to cause residents to receive expired medications.

Inspectors wroteBased on observation, interview, and record review, the food preferences of two residents were not honored during tray line observation. This failure had the potential to result in decreased intake at meals, and for one resident to not get the extra calories she needed for her healing wound.