View Heights Conv Hosp

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's orthostatic blood pressures (blood pressures taken to help healthcare providers determine if the body is struggling to regulate blood pressure when moving to an upright position) were obtained for one of four sampled residents (Resident 1) according to the facility's established procedure for a resident who suffered a recent fall with injury. This failure had the potential to prevent identification of orthostatic hypotension (a drop in blood pressure when standing up) as a contributing factor to Resident 1's fall, delayed clinical interventions to reduce dizziness, and placed Resident 1 at risk for subsequent falls with injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure orthostatic blood pressure measurements (blood pressures taken to help healthcare providers determine if the body is struggling to regulate blood pressure when moving to an upright position) were accurately documented for one of three sampled residents (Resident 2). This failure had the potential to result in the delayed identification of orthostatic hypotension (a drop in blood pressure when standing up), delayed clinical interventions to reduce dizziness, and placed Resident 2 at risk for subsequent falls with injury.

Inspectors wroteBased on interview and record review, the facility failed to employ a dietary supervisor (DS) that met the qualifications of having an associate's degree or higher in food service management or in hospitality, was a certified dietary manager, certified food service manager or had national certification for food service management and safety. This deficient practice had the potential to affect 145 residents residing in the facility by potentially not receiving the nutritional assistance and guidance required to attain their highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Properly wash dishware using water temperature lower than manufacturer specifications.2. Practice standard hygienic practices in the kitchen when [NAME] 1 failed to wear a beard restraint during food preparation.3. Practice standard hygienic practices when [NAME] 2 wore 11 pieces of jewelry during food preparation. These deficient practices had the potential to result in harmful bacterial growth that could lead to foodborne illness (a disease caused by consuming food or drinks that are contaminated by germs or toxins) in 145 of 145 residents.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedure (P&P) titled Informed Consent, dated 12/2025, for three of three sampled residents (Resident 18, Resident 97, and Resident 24) when: 1. Informed consent was not obtained when Resident 18's dose of Clozapine (an antipsychotic [work by altering brain chemistry to help reduce psychotic symptoms like hallucinations, delusions and disordered thinking] medication) was increased on [DATE].2. Resident 97's informed consents for Clozapine, Seroquel (an antipsychotic medication), Haldol (an antipsychotic medication), and lithium carbonate (a mood stabilizer and an antimanic agent) were not obtained or renewed every six (6) months.3. Resident 24's informed consent for Clozapine and lithium carbonate were not renewed every six (6) months. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two sampled resident's (Resident 89 and Resident 54) responsible parties were provided the opportunity to be involved in their care. This deficient practice resulted in Resident 89's Responsible Party (RP 1) and Resident 54's Public Guardian (PG, a court-appointed public official or agency responsible for managing the personal, medical, or financial affairs of individuals deemed legally incapacitated), PG 6, being unaware of changes in the residents' conditions and unable to provide input in the plan of care and decision-making process.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of two sampled residents (Resident 54 and Resident 89) were permitted to make choices about their diets and snack preferences. This deficient practice resulted in Resident 89 and Resident 54 reporting they did not receive enough food to feel full after meals, reported experiencing unaddressed hunger, and denial of additional food when requested.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician of abnormal laboratory results for two of two sampled residents (Resident 89 and Resident 57) when:1. Resident 89 had:a. An abnormal valproic acid level (the level of valproic acid [an anticonvulsant medication] in the bloodstream) on 8/6/2025.b. An abnormal triglyceride level (amount of fat in the blood) and valproic acid level on 10/23/2025.c. An abnormal valproic acid level on 1/23/2026.d. Abnormal blood urea nitrogen (BUN, a waste product that forms as your body breaks down proteins) and creatinine (a measure of how well the kidneys are doing their job of filtering waste from the blood) levels on 4/23/2026.2. Resident 57 had abnormal valproic acid levels on 5/8/2025, 9/2/2025, and 10/24/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate monitoring of psychotropic medications (any drug that changes brain function resulting in alteration to mood, thoughts, feelings or behavior) for four of seven sampled residents (Resident 5, Resident 18, Resident 57 and Resident 109) when the facility failed to: 1. Monitor Resident 5's behaviors of manic speech (speaking urgently and rapidly often jumping between unrelated topics) and rapid thought process. 2. Ensure adequate behavior monitoring for Resident 18's use of ativan (a medication that works to slow down the nervous system and create a calming effect), lithium carbonate (used as a mood stabilizer to treat and prevent manic and depressive episodes in bipolar disorder), and clozapine (a medication used to treat mental health conditions).3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a Minimum Data Set ([MDS]- a resident assessment tool) for a significant change was completed within fourteen (14) days for one of two sampled residents (Resident 30) after the resident experienced significant weight loss. This deficient practice resulted in delayed assessment and transmitting Resident 30's significant change in condition to the Centers for Medicare and Medicaid Services (CMS) and had the potential to negatively affect the resident's care planning, and delivery of necessary care and services to address significant weight loss. Cross Reference F657 and F692Findings: During a review of Resident 30's admission Record, the admission Record indicated Resident 30 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Minimum Data Set (MDS, a resident assessment tool) was accurately coded following a fall for one of one sampled resident (Resident 57). This deficient practice created the potential for Resident 57 to not receive the necessary care and interventions to prevent further falls and possible injuries.

Inspectors wroteBased on interview and record review, the facility failed to develop a care plan for psychotropic medications (medications that affect the mind, emotions, and behavior) for one of five residents sampled for unnecessary medication review (Resident 18). This deficient practice had the potential to result in Resident 18 not receiving non-pharmacological (non-medicinal) interventions to address his lack of sleep, for which staff were administering Trazodone (a prescription medication, with sedative properties, typically used to treat major depressive disorder [a serious, common mood disorder characterized by at least two weeks of persistent, severe low mood, sadness, or loss of interest in activities]).

Inspectors wroteBased on interview and record review, the facility failed to revise the comprehensive care plan and interventions for one of two sampled residents (Resident 30) after the resident experienced a significant weight loss. This deficient practice had the potential to result in Resident 30 not receiving individualized and updated nutritional interventions to address significant weight loss, placing the resident at risk for continued weight loss, nutritional decline, and further decline in health status. Cross Reference F637 and F692Findings: During a review of Resident 30's admission Record, the admission Record indicated Resident 30 was admitted to the facility on [DATE]. Resident 30's diagnoses included schizoaffective disorder (a mental illness that can affect thoughts, mood, and behavior) and bipolar disorder (sometimes called manic-depressive disorder; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders for orthostatic (measures changes in blood pressure and heart rate when moving from lying down to standing up) blood pressure monitoring and recording by failing to accurately obtain, document, and evaluate orthostatic blood pressure readings for three of three sample residents (Resident 57, Resident 124, and Resident 2). This deficient practice had the potential to place Residents 57, 124, and 2 at risk for undetected orthostatic hypotension, dizziness, syncope (fainting), falls, injury, delayed medical intervention, and adverse cardiovascular complications related to changes in blood pressure upon position changes.

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate nutritional interventions were implemented and evaluated for one of two sampled residents (Resident 30) after the resident experienced significant weight loss. This deficient practice had the potential to place Resident 30 as risk for further weight loss and could lead to harm.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure the physician orders for metoprolol tartrate ([treats increased heart rate] medication administered for tachycardia [abnormally high resting heart rate]) included heart rate parameters (specific, clinical rules (like dose ranges, lab results, or symptom thresholds) that dictate how, when, or if a drug should be safely) prior to administration for one of one sampled resident (Resident 121). This deficient practice placed Resident 121 at risk for adverse cardiovascular complications, including bradycardia (slow heart rate), hypotension (low blood pressure), dizziness, syncope (faintness), and potential decline in condition related to the unsafe administration of Metoprolol without clear physician guidance.

Inspectors wroteBased on interview and record review, the facility failed to ensure Lisinopril (a medication used to treat hypertension ([HTN- high blood pressure) was administered within the ordered parameters (specific, measurable, and objective clinical criteria set by a healthcare provider that dictate when a medication should be given, withheld, or adjusted) for one of one sampled residents (Resident 60). This deficient practice increased Resident 60's risk of hypotension (low blood pressure) and bradycardia (slower heart rate) that could cause dizziness, fainting, weakness, or sudden cardiac arrest (when the heart suddenly and unexpectedly stops pumping).

Inspectors wroteBased on observation, interview, and record review, the facility failed to:1. Ensure Resident 89's discontinued trazadone hydrochloride (HCl) (drug used to treat depression and anxiety disorders) was removed from one of three inspected medication carts (North Station Medication Cart 2) and properly disposed.2. Ensure an expired bottle of Rybelsius (drug used to help lower blood sugar and slow digestion) was removed from one of three inspected medication carts (North Station Medication Cart 2) and labeled with the resident's name.3. Ensure three different medications were not transferred into another container found in one of three inspected medication carts (North Station Medication Cart 2).4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of nine sampled residents observed during dining observations (Resident 105) received meals in accordance with their preferences when: 1. Resident 105's diet order was not updated following the Registered Dietician's (RD) recommendations for double portions of protein on 4/7/2026. 2. Resident 105 was provided with milk and fish for lunch on 5/5/2026, which were documented as food items he disliked. 3. Staff did not follow Resident 105's diet order for double portions of protein during lunch on 5/6/2026. These deficient practices had the potential to negatively impact Resident 105's meal intake and placed him at risk of not receiving the nutrients and calories needed to maintain a stable body weight. These deficient practices also negatively impacted Resident 105's overall satisfaction during meals.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' Public Guardian ([PG]- a court-appointed public official responsible for managing a person's financial assets and making medical decisions) information was reviewed and updated in the medical record for two of two sampled residents (Resident 109 and Resident 105). This deficient practice had the potential to result in delayed communication with Resident 109 and 105's PG and may affect timely notification, consent, and involvement in Residents 109 and 105's care planning and treatment decisions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 4 performed hand hygiene in between residents during medication preparation. This deficient practice had the potential to place all residents at risk of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure privacy curtains were in place for one of one sampled residents (Resident 15). This deficient practice had the potential to not honor Resident 15's right to privacy.

Inspectors wroteBased on interview and record review, the facility failed to notify the physicians and residents' conservators (a person or organization legally appointed to manage the affairs, finances, or property of someone deemed incapable of doing so) of a change of condition following a resident's allegation of sexual abuse for three of three sampled residents (Resident 1, Resident 2, and Resident 3), after Resident 1 alleged Resident 2 and Resident 3 sexually abused her. These deficient practices limited the involvement of Resident 2 and Resident 3's conservators in care decisions and had the potential to result in a delay in timely safety interventions, placing residents at risk for harm.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement interventions for two of three sampled residents (Resident 2 and Resident 3), after Resident 1 alleged Resident 2 and Resident 3 sexually abused her. These deficient practices resulted in a delay of the implementation of safety measures and monitoring for Resident 2 and Resident 3, which placed residents at risk for harm.

Inspectors wroteBased on interview and record review, the facility failed to maintain resident clinical records that was complete, accurate and readily accessible for one of three sampled residents (Resident 1), who went Out on Pass (OOP, a temporary, authorized leave from a long-term care facility, allowing residents to leave and return for continued treatment) on 10/18/2025. This failure had the potential for Resident 1 to have gone OOP without proper assessment and placed the resident's safety in jeopardy while OOP which can lead to accidents and hospitalizations.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's responsible party (RP 1) was notified following the resident's involvement in a physical altercation with another resident and of an interdisciplinary team (IDT) conference for one out of three sampled residents (Resident 1). This deficient practice resulted in RP 1 not being informed of Resident 1's physical altercation with Resident 2 on 7/25/2025 nor informed of an IDT conference following the incident on 7/28/2025, placing Resident 1 at risk for uncoordinated care and decisions without input from RP 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the lump (abnormal bumps or swellings on or under the skin) at the back of neck of one of four residents (Resident 1), was assessed timely and reported to the resident's physician. This deficient practice had the potential to result in the delay of care and services necessary to treat Resident 1's back of neck lump and had the potential to cause worsening condition of the lump.

Inspectors wroteBased on interview and record review, facility staff failed to ensure one of four sampled residents (Resident 2) was monitored for verbal and physical aggression, as ordered by the physician. This deficient practice created the risk for Resident 2, who hit another resident in the face on 4/16/2025, to commit repeat physical aggression towards other facility residents with possible physical injury and psychosocial harm.

Inspectors wroteBased on observation, interview and record review, the facility did not provide a diet that met the nutritional needs for all facility residents by: 1. Not ensuring residents received a breakfast that offered a nutritional value. 2. Not ensuring a system was in place to ensure meal substitutes and alternatives provided were of equal or nutritive value for all facility residents. These deficient practices had the potential to impact resident's nutritional status and could result in all residents sustaining undesired weight loss and malnutrition.

Inspectors wroteBased on interview and record review, the facility failed to employ a dietary supervisor (DS) that met the qualifications of having an associate's degree or higher in food service management or in hospitality, was a certified dietary manager, certified food service manager or had national certification for food service management and safety. This deficient practice had the potential to affect 146 residents residing in the facility by potentially not receiving the nutritional assistance and guidance they needed to attain their highest practicable well-being.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure dietary staff followed the dietary menus for 146 residents out of 146 sampled residents by failing to: 1. Ensure dietary staff provided a breakfast sandwich with sausage. 2. Ensure the Dietary Supervisor (DS) checked the food before it was provided to residents. These deficient practices had the potential to impact resident's nutritional status and placed all residents at risk for unintentional weight loss.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe and sanitary food storage practices in the kitchen that affected 146 residents out of 146 sampled residents when: 1. The walk -in refrigerator contained lettuce with no in date (the date when the food was placed in the refrigerator), no use by date (date the food item must be consumed by) and cheese with no use by date. 2. The dry storage room did not have a thermometer to monitor room temperature. 3. The walk-in refrigerator had three bags of expired spinach. These deficient practices had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to food borne illnesses in all residents who received food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to include the selection of a venue that was convenient to both parties in the Arbitration Agreement (an agreement between the facility and the resident where they would resolve any disputes through a neutral person rather than going to court). This deficient practice had the potential to cause bias in venue selection process for residents who enter into a binding arbitration agreement and want to resolve a dispute.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled Water Temperature Policy For Facility Laundry and Preventative Maintenance Policy by failing to: 1. Monitor the washer water temperature on 2/14/2025. 2. Clean the dyer lint trap (a mesh filter located inside a dryer that caught lint and fabric fibers from clothes during the drying cycle) on 2/14/2025. This deficient practice had the potential to increase the risk of infection which could increase the morbidity (the amount of disease in a population) and mortality (the state of being subject to death) among 146 residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate residents in the dining room during mealtimes by not ensuring: 1. The dining room offered enough space for all residents to sit down at the same time for mealtime. 2. Residents were sent to not their rooms to wait until a seat became available. 3. Residents were asked to form a line to wait for a seat to become available. This deficient practice had the potential to affect Resident's self-esteem and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a dining experience that maintained or enhanced resident's dignity and respect during mealtimes for facility residents by not ensuring: 1. The dining room offered enough space for all residents to sit down at the same time for mealtimes. 2. All residents sitting at the same table were served food at the same time. 3. All residents received their breakfast at the same time. 4. Residents were not served food on disposable plates and bowls. This deficient practice had the potential to affect Resident's self-esteem and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) prior to administration of psychotropic medication (medications that affect the mind, emotions, and behavior) for three of eight sampled residents (Residents 31, 16, and 347) by failing to: 1. Ensure informed consent was obtained from Resident 31's conservator (a person who has been appointed by the court to make decisions for another person who is deemed incompetent) prior to Resident 31's initial administration of Trazodone (an antidepressant [a medication used to treat depression, which is a mood disorder that causes a persistent feeling of sadness and loss of interest] and a sedative [a medication used to help an individual fall asleep]) on 7/30/2024. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment entry on the Minimum Data Set ([MDS], a resident assessment tool) was accurate for one of seven sampled residents (Resident 31) when the MDS did not indicate Resident 31 was on hypoglycemic medication (medication used to lower blood sugar levels). This failure had the potential to negative affect Residents 31's plan of care and delivery of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure a care plan for addressing the behavior of self-isolation, for which Cymbalta (a medication used to treat depression) was administered, was developed for one of five sampled residents (Resident 3). This deficient practice placed Resident 3 at risk of receiving unnecessary doses of Cymbalta, and subsequent side effects associated with psychotropic medications (a drug or other substance that affects how the brain works) such as nausea, drowsiness, agitation, and headache. Cross-reference F-tag F758.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 1 documented medication administration accurately for one of 18 sampled residents (Resident 56), in accordance with professional standards. This failure had the potential to delay Resident 56 in reaching her care goals due to the documentation of medication that was not given.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure quality of care was provided for two of three sampled residents (Residents 31 and 16) by failing to: 1. Clarify the monitoring of Resident 31's blood glucose (amount of sugar in the blood) prior to the administration of Insulin Glargine (a hormone that removes excess sugar from the blood, can be produced by the body or given artificially via medication). This deficient practice resulted in Resident 31's blood glucose being unmonitored prior to being administered Insulin Glargine on 2/8/2025, 2/9/2025, 2/10/2025, 2/11/2025, and 2/12/2025. This deficient practice also had the potential to result in Resident 31 becoming hypoglycemic (a condition when the blood sugar level drops too low) and symptomatic with dizziness, shakiness, and confusion. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct an Interdisciplinary Care Team (IDT, a group of healthcare professionals who worked together to provide care for residents in a nursing home) conference after a witnessed fall on 12/19/2024 for one of seven residents (Resident 112). This deficient practice had the potential to increase the possibility of recurrent falls for Resident 112.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered as ordered for two of 18 sampled residents (Resident 56 and Resident 49) when: 1. Licensed Vocational Nurse (LVN) 1 administered five doses of Ozempic (a prescription injectable medication used to treat type 2 diabetes mellitus [DM, a disorder characterized by difficulty in blood sugar control and poor wound healing] in adults) to Resident 56 from an Ozempic injection pen that was 35 days beyond its use by date. 2. LVN 1 administered Metformin (a medication used to treat high blood sugar levels caused by DM) to Resident 49 greater than one hour before the scheduled administration time. These failures created the potential for Resident 56 to not achieve the desired weight loss the Ozempic was indicated for, due to decreased effectiveness of the expired medication. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of five sampled residents (Resident 3 and Resident 31) were free from unnecessary medications when: 1. Staff failed to monitor for the presence of self-isolating behaviors for Resident 3, and ensure a gradual dose reduction (GDR, stepwise tapering of a medication dose) was attempted for her Cymbalta (a medication used to treat depression and anxiety), which was initiated in March 2024. 2. Staff failed to provide behavior manifestations for hallucinations of Resident 31's use of haloperidol (an antipsychotic medication [a medication that affects the mind, emotions, and behavior]). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of medication for one of 18 sampled residents (Resident 56) when: 1. An Ozempic (a prescription injectable medication used to treat type 2 diabetes mellitus [DM, a disorder characterized by difficulty in blood sugar control and poor wound healing] in adults) injection pen was kept in the North Station medication cart beyond its use-by date of 12/31/2024. 2. Licensed Vocational Nurse (LVN) 1 failed to label an Ozempic injection pen with the correct open date. These failures created the potential for Resident 56 to receive Ozempic with reduced potency and effectiveness, possibly causing a delay in the effectiveness of the ordered therapy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents' food preferences were respected, alternates were provided, and food allergy was noted on the diet card (a document that listed a resident's dietary needs, including allergies, preferences, and restrictions) for three of 29 sampled residents (Resident 97, Resident 51, and Resident 81) when: 1. Resident 97 was not provided with an alternative lunch substitute on 2/11/2025, and Resident 97's preference for two quesadillas for lunch and dinner was not documented timely in the medical record. 2. Resident 51's preference for a snack of fresh fruit, was documented timely in the medical record from admission. 3. Resident 81's preference of not having beans was not honored on 2/13/2025 during lunch. 4. Resident 81's shrimp allergy was not documented on the diet card on 2/13/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled Nourishment Policy for two of two residents (Resident 56 and Resident 81) by failing to: a. Provide Resident 56 snacks when requested. b. Provide Resident 81 snacks. This deficient practice violated Resident 56 and 81's rights to eat as they wanted to.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents' (Resident 21) conservator (a person who has been appointed by the court to make decisions for another person who is deemed incompetent) understood the Arbitration Agreement (an agreement between the facility and the resident where they would resolve any disputes through a neutral person rather than going to court) in a language Conservator 1 understood. This deficient practice resulted in Conservator 1 not understanding what entering a binding Arbitration Agreement meant.

Inspectors wroteBased on interview, and record review, the facility failed to: 1. Report the facility's 24 Coronavirus Disease 2019 ([COVID-19] highly contagious viral infection) positive residents to the California Department of Public Health (CDPH) confirmed cases as indicated in the All facilities Letter 23-08 ([AFL] a letter from the Center for Health Care Quality (CHCQ), Licensing and Certification (L&C) Program to health facilities that are licensed or certified by L&C with information that include changes in requirements in healthcare, enforcement, new technologies, scope of practice, or general information that affects the health facility) dated 1/18/2023, which indicated to report outbreaks (the occurrence of cases of a disease or condition above the expected or baseline level, usually over a given period of time, in a geographic area or facility, or in a specific population) and unusual [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure allegation of physical abuse by a facility staff to one of three sampled residents (Resident 2), was reported to California Department of Public Health (CDPH) within two (2) hours, as indicated in the facility's policy and procedure (P&P) titled, Reporting Abuse. This failure resulted in the delay of investigation by CDPH and placed the resident and other residents at risk for further physical abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure safe planning for transfer and discharge was conducted, followed up and documented for one of five sampled residents (Resident 1). This failure resulted in delayed discharge as requested by the resident and family member, and had the potential to affect Resident 1 ' s psychosocial and emotional weelbeing.

Inspectors wroteBased on interview and record review, the facility failed to provide services that met professional standards of quality for two of three sampled residents (Resident 1and Resident 2) when: 1. Staff did not document one-to-one (1:1, close supervision) monitoring was performed for Resident 2 at 10 PM on 8/7/2024. 2. Staff documented the same assessments for Resident 2 over different time periods on 8/7/2024 and 8/8/2024. Staff documented the same assessments for Resident 1 over different time periods on 8/7/2024. 3. Staff did not update Resident 1 and Resident 2 ' s vital signs (measurements of the body's most basic functions) when there was a change in the resident ' s condition on 8/6/2024. These deficient practices had the potential to result in serious harm such as another episode of aggression towards others, and a delay of necessary treatments.

Inspectors wroteBased on interview and record review, the facility failed to implement the care plan for two of three sampled residents (Resident 1 and Resident 2), when staff did not monitor Resident 1 and Resident 2 after a physical altercation on 8/6/2024. This deficient practice had the potential for residents to not receive appropriate care, treatment, and services.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician when a resident exhibited an episode of touching himself inappropriately in the hallway for one out of six sampled residents (Resident 1). This deficient practice led to a delay in medical evaluation and interventions for Resident 1's hypersexual behaviors. Cross-reference F656 and F600.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of six sampled residents (Resident 2) were free from sexual abuse from Resident 1, who had a known history of hypersexual behaviors (an intense focus on sexual fantasies, urges, or behaviors that can't be controlled), by failing to: 1. Immediately intervene and provide a safe distance between Resident 1 and Resident 2 when Resident 1 began masturbating (to pleasure onself sexually) in public. 2. Ensure the social services designee (SSD) notified and communicated with the licensed nurses when Resident 1 first exhibited hypersexual behaviors on 2/17/2024. These deficient practices resulted in Resident 1 masturbating while standing in close proximity to Resident 2 in the hallway on 7/20/2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to effectively implement care plan interventions to address a resident's hypersexual (an intense focus on sexual fantasies, urges or behaviors that can't be controlled) behaviors for one out of six sampled residents (Resident 1) when the facility failed to: 1. Document and encourage Resident 1 to attend therapeutic group meetings for healthy relationships, symptom management, and impulse control. 2. Model and role play appropriate behaviors for Resident 1. 3. Notify and communicate with licensed nurses and the physician when Resident 1 exhibited his first episode of publicly and inappropriately touching himself in the hallway on 2/17/2024. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a safe and sanitary food storage practice in the kitchen that affected 143 residents out of 143 sampled residents when: 1. The dry storage room contained opened food items with no use by date (date the food item must be consumed by) and the storage room did not have a temperature gauge to control temperature of the room. 2. The refrigerator contained opened food with no use by date. The refrigerator had bins of beans and salsa that were expired. The refrigerator had a bag of sausages that were expired. 3. The walk-in freezer's water pipe had hard ice buildup and inside of freezer door, over the top part of freezer door walkway, freezer floor, and the freezer's ceiling had ice buildup. The outside of the freezer door had brown rust on it. The freezer's door did not close. [...]

Inspectors wroteBased on interview and record review, the facility failed to include the selection of a venue that was convenient to both parties in the arbitration agreement (a contract that gives up the right to have disputes decided in a court of law before a jury and instead both parties agree to a private process where one or several individuals can make a decision about the dispute). This deficiency had the potential to cause bias in the venue selection process for residents who enter into a binding arbitration agreement at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the kitchen's freezer in a safe operating condition. The walk-in freezer's water pipe had hard ice buildup inside of the freezer door, over the top part of the freezer's door walkway, freezer floor, and the freezer's ceiling had ice buildup. The outside of the freezer door had brown rust on it. The freezer's door did not close. The walk-in freezer's floor was covered in ice causing it to be unsafe to walk into freezer. This failure had the potential to result in harmful bacteria growth and cross contamination that could lead to foodborne illness in residents that are medically compromised residents due to the potential of food exposure to fluctuating temperatures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide accurate and safe pharmaceutical services for one of three nurses' stations (North) and for one of five residents (Resident 29) when: 1. Prepoured medications (medications prepared prior to administration) in the North nurses' station were not secured and left unattended. 2. Resident 29 was administered medication when his systolic blood pressure ([SBP] maximum blood pressure during contraction of the ventricles) did not meet the medication parameters (when a medication is not administered based on a specific condition). 3. Resident 29's Order Summary Report and Medical Administration Record (MAR) indicated incorrect parameters for medication fludrocortisone acetate (medication for low blood pressure) tablet 0.1 milligrams (mg, unit of measurement) and nursing staff did not correct the order. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the following when one of two medication rooms (Medication Room A) and one of three medication carts (South Front Medication Cart) were inspected: 1. The expired Injectable and Sublingual (medications that dissolve under the tongue) emergency kit ([e-kit]- an emergency supply of medications) was removed from usage and returned to the pharmacy. 2. The Injectable and Sublingual Drugs emergency kit was securely fastened. 3. Ozempic (weekly injection that helps lower blood sugar) was labeled with the open and discard by date for four of four residents (Residents 7, 55, 77, and 111). [...]

Inspectors wroteBased on interview and record review, the facility failed to obtain informed consent (process in which patients are given important information about a medical procedure or treatment including possible risks and benefits) prior to initiation and administration of psychotropic medication (medication that affects the mind, emotions, and behavior) for two of five sampled residents (Resident 3 and 51). This failure resulted in the removal of Resident 3's Public Guardian's (PG, a person who has been appointed by a court to make decisions for another person who is deemed incompetent) and Resident 51's conservator's (a person who has been appointed by the court to make decisions for another person who is deemed incompetent) right to make decisions about the care and treatments the residents received in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to keep resident valuables inside of the social services office to ensure the accountability and protection of resident valuables for one out of one sampled resident (Resident 34). This failure had the potential to result in the theft, loss, or bartering (exchanging of goods) of Resent 34's pearl necklace and rings.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Licensed Vocational Nurse (LVN) 4 signed the Medication Administration Record (MAR) immediately and accurately after administering medications for two of 18 residents (Residents 52 and 108). This failure resulted in LVN 4 documenting the administration of Atropine (medication that can be used for excessive drooling) when Resident 52 refused. This failure also had the potential to result in double administration of medication to Resident 52 and 108 that could lead to mental or mood changes or excessive sedation (decrease in consciousness where the resident cannot be aroused).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one resident (Resident 93) out of 7 sampled residents was seen and assessed by an optometrist (healthcare provider that examine, diagnose, and treat diseases and disorders that affect eyes and vision). This deficient practice potentially caused a delay in treatment for Resident 93.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow up on a dental referral for one of seven residents (Resident 90) when Resident 90 had a referral to see an oral surgeon. This failure had the potential to result in the delay in treatment and placed Resident 90 at risk for infection, pain, and degraded self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor the food choices and vegan diet (practice of abstaining from eating any food derived from animals and animal products) preference for one of one sampled resident (Resident 138). This deficient practice had the potential to impact the resident's nutritional status, quality of life and food dissatisfaction and insufficient food intake.

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance (QAA - develops and implements appropriate plans of action to correct identified quality deficiencies) Committee failed to meet at least quarterly. This deficient practice had the potential to increase the risk of an unsafe environment for all residents and staff members.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement effective infection prevention measures for one of nine residents (Resident 64) when Licensed Vocational Nurse (LVN) 5 did not wear gloves and handled Resident 64's medication with her bare hands. This failure had the potential to result in the transmission of infectious microorganisms and increase the risk of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor prescribed antibiotics (medications used to treat infections) and notate antibiotic usage in the Infection Prevention Control Surveillance Log (a tool used to monitor all antibiotics and infections) for three out of seven sampled residents (Residents 71, 130, and 139). This failure had the potential to result in the continued administration of unnecessary and inappropriate medications (incorrectly prescribed antibiotics for an infection), increased antimicrobial resistance (decrease of antibiotic effectiveness), unmonitored spread of infection, and physician notification delay regarding the worsening of symptoms during antibiotic treatment.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan addressing eating behaviors for one of one sampled resident (Resident 1). On 8/7/21, the Registered Dietician (RD) observed Resident 1 eating too quickly and not chewing food items thoroughly. The RD recommended to encourage slower eating, chew foods thoroughly and swallow. On 8/12/2021, the RD observed the resident eating quickly and not clearing her mouth between bites. The RD recommended Resident 1 be placed on mechanically soft finely chopped texture diet and 1:1 supervision during meals. There was no care plan developed for staff to implement the interventions of the RD. As a result of this deficient practice, on 8/26/2023 at approximately 12:15 p.m., LVN 1 found Resident 1 slumped over to her right side, in the dining room, unresponsive with food particles in her mouth. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to supervise one of one sampled resident (Resident 1) during meals by failing to: 1. Followthe facility ' s policy and procedure (P&P), titled High Risk Safety Monitoring, which indicated assigned staff for residents on 1:1 monitoring, will be within two feet ([ft] unit of measurement) from the resident. 2. Follow the Registered Dietitian (RD) recommendation, dated 8/12/21, to provide Resident 1 with 1:1 supervision (one staff supervising one resident only) during dining. 3. Follow the Physician ' s Order dated 6/14/23, to provide 1:1 supervision during mealtimes. [...]