Inspection Reports for
Height Street Skilled Care

The facility failed to provide necessary non-pharmacological interventions and adequate monitoring for Resident 1 after an increase in antidepressant dosage, resulting in Resident 1's death by suicide involving self-binding and suffocation. Multiple staff interviews and record reviews revealed lapses in monitoring and documentation of behavioral health interventions and medication side effects.

The facility was found deficient in maintaining a sanitary environment, timely development of baseline care plans with fall prevention interventions, ensuring fall prevention measures such as keeping beds in the low position, and managing resident pain appropriately. These deficiencies posed potential risks for resident discomfort, falls, and injury.

The complaint investigation found substantiated issues with call light response times, with residents experiencing waits up to 45 minutes or longer, which was deemed unacceptable by the Director of Nursing.

The facility failed to answer call lights timely for two of three sampled residents, resulting in potential delays in care and unmet needs. Interviews and record reviews confirmed prolonged wait times, with one resident reporting a 45-minute wait for assistance.

The facility failed to implement complete care plans for residents, including failure to reposition Resident 1 every two hours and lack of supervision for Resident 2 during meals, posing risks of pressure injury and choking. Additionally, the facility failed to notify the physician and administer medication as ordered for Resident 1's diarrhea, resulting in weight loss and potential adverse health outcomes.

The complaint involved delayed call light response times ranging from 5 minutes to up to 2 hours, causing anxiety and anger among residents. Another complaint involved a CNA singing loudly at 4 a.m., disturbing residents' sleep and disrespecting their dignity. The Director of Staff Development acknowledged complaints about the CNA's behavior and had instructed her to stop.

The facility failed to ensure timely response to call lights for three sampled residents, potentially impacting their physical and psychosocial health. Additionally, two residents were treated without dignity and respect when a CNA entered their room singing loudly at 4 a.m., disturbing their rest.

The facility failed to follow its policy on communicating the registered dietitian's recommendations to the physician for Resident 1, resulting in unaddressed weight loss and failure to liberalize the diet or increase nutritional supplements as recommended.

The complaint investigation substantiated failures in narcotic medication administration, reassessment, controlled medication storage and reporting, and failure to notify the state health department of narcotic diversion incidents.

The facility failed to administer narcotic medication according to physician orders and did not reassess pain medication effectiveness for a resident. Additionally, multiple controlled narcotic medications were found missing from the emergency kit and medication cart due to failures in reporting and handling by nursing staff. The facility also failed to report the narcotic diversion to the California Department of Public Health as required by policy.

The complaint investigation included issues of unclean resident rooms, excessive noise disturbing residents' sleep, missing personal property of a deceased resident, inadequate investigation and reporting of resident-to-resident abuse, and failures in medication administration and seizure care.

The facility failed to maintain cleanliness in resident rooms, resulting in potential infection risks; failed to maintain comfortable noise levels affecting residents' rest; failed to protect resident personal property after death; did not thoroughly investigate or report resident-to-resident abuse; and failed to administer medications properly, complete vital signs after seizures, and follow physician orders for medical devices.

The facility was found deficient in multiple areas including timely response to call lights, resident notification of room changes, completion of Advanced Beneficiary Notices, cleanliness and noise control in resident rooms, protection of resident property, discharge procedures, care planning, oral care, pressure ulcer prevention, restorative nursing program implementation, resident safety regarding smoking materials, catheter care, pain management, medication storage and administration, food safety, dish machine temperature, discharge summary documentation, infection control practices, and maintenance of resident rooms.

The investigation was complaint-driven, focusing on allegations of falsified therapy documentation, inadequate therapy services, and failure to provide necessary medical equipment and care, resulting in actual harm to Resident 1 and potential harm to others.

The facility failed to implement change of condition policies, accurately document therapy services, obtain necessary medical equipment, and ensure therapy staff provided the ordered amount of therapy. This resulted in actual harm to Resident 1 and potential harm to other residents due to falsified therapy documentation and inadequate therapy services.

The facility failed to complete an elopement risk evaluation for Resident 1, resulting in the resident eloping and potential for injury. The evaluation form was incomplete, missing responses to key questions, and the facility's staff acknowledged the expectation to complete the entire form.

The facility failed to follow the care plan to ensure call lights were within reach and did not provide adequate supervision for Resident 1, who has cognitive communication deficits. This failure led to Resident 1 sustaining an injury to her left eye under unknown circumstances while left alone in the dining/activity room.

The complaint investigation found that Resident 1 fell on 1/21/25 while attempting to use the toilet unsupervised. The fall was unwitnessed by staff but witnessed by another resident. Resident 1 sustained a left hip fracture requiring surgical intervention. The facility's fall prevention care plan and risk evaluation were incomplete and interventions were not implemented as required. Staff monitoring was inadequate and documentation was lacking.

The facility failed to implement the care plan intervention of providing supervision during toilet transfers for Resident 1, who was at high risk for falls. This failure resulted in Resident 1 falling, sustaining a fracture, and requiring hospital admission and surgery. Documentation and fall prevention interventions were incomplete or not followed, and staff relied solely on bed alarms without adequate supervision.

The complaint was substantiated as the facility did not provide cigarettes to Resident 1, Resident 2, and Resident 3 during the scheduled smoking time on 2/10/25, confirmed by observation, interviews, and video review.

The facility failed to follow its own policy and procedure by not providing cigarettes to three residents during scheduled smoking times, resulting in a violation of their rights to smoke. Observations, interviews, and video review confirmed that the residents waited approximately one hour without receiving cigarettes.

The complaint investigation found that the facility did not report a resident-to-resident altercation involving verbal abuse and possible physical contact between Resident 1 and Resident 2 on 11/26/2024. The facility staff, including the Director of Nursing and Administrator, acknowledged the failure to report the incident to CDPH as required by policy.

The facility failed to report an allegation of a resident-to-resident altercation that occurred on 11/26/2024 between two residents. Interviews and record reviews indicated verbal and possible physical altercation, but the facility did not follow its abuse reporting policy, resulting in CDPH being unaware of the incident.

The facility failed to implement neurological assessments (neuro checks) for Resident 1 after a head injury sustained during a physical altercation, which had the potential for adverse health outcomes.

The facility failed to develop a care plan addressing refusal of care for one resident despite multiple refusals, and failed to document or notify the physician of a change in condition related to a foul-smelling discharge for the same resident. These deficiencies posed potential risks for adverse health outcomes.

The facility failed to follow its discharge policy for one of four sampled residents by not making a follow-up call to the acute hospital to determine the resident's general status and condition after hospital transfer, potentially risking further injury due to delayed care.

The complaint investigation found that Resident 1 had three falls since admission on 6/9/24, 7/31/24, and 8/7/24, but the fall care plan was not revised after these incidents as required. The facility policy mandates revising the care plan after each fall.

The facility failed to revise the fall care plan for Resident 1 after three falls, which had the potential to place the resident at risk for injury and harm. The Director of Nurses confirmed the care plan was not updated as required by facility policy.

The facility failed to ensure one resident had fresh water available at bedside, potentially affecting hydration. Additionally, two residents did not have call lights within easy reach, posing a risk for unmet care needs. Both deficiencies were noted with minimal harm and affected a few residents.

The complaint investigation revealed substantiated deficiencies related to pressure ulcer care and infection control practices for Resident #4.

The facility failed to follow physician's orders for pressure ulcer treatment for Resident #4, including improper wound packing and omission of collagen powder. Additionally, the facility did not implement enhanced barrier precautions for Resident #4, who had a Stage IV pressure ulcer, resulting in inadequate use of personal protective equipment during wound care.

The facility failed to follow physician orders for one of four sampled residents, specifically administering medications contrary to prescribed hold parameters, which had the potential for adverse health outcomes.

The complaint investigation found that Resident 1 had seizures on 10/24/23 and 11/1/23 causing injuries, but the neurological assessment checklist was not completed as required, indicating a failure in monitoring and documentation.

The facility failed to complete the required neurological assessments for Resident 1 following seizure-related falls, missing multiple assessments of pain, vital signs, level of consciousness, hand grips, and pupils as indicated by the facility's own checklist and policy. This failure posed a risk of negative health consequences including death.

The complaint involved Resident 1 alleging harassment by the facility Administrator in Training. The allegation was not reported to the California Department of Public Health as required by facility policy and state law.

The facility failed to implement its policy on abuse reporting when Resident 1 reported harassment by the AIT. The facility did not report the allegation to the California Department of Public Health as required, posing a risk of continued abuse.

The facility failed to ensure that one of four sampled residents (Resident 2) had her call light button within reach, posing a potential risk that her needs might not be attended to promptly. Interviews and record reviews confirmed the call light was out of reach and staff acknowledged the oversight.

The facility was found deficient in multiple areas including inaccurate resident assessments, failure to update care plans, non-implementation of physician orders, inadequate personal hygiene care, failure to monitor nutritional interventions and weight loss, incorrect diet portion sizes, unsafe food storage temperatures, improper ice machine sanitization, and failure to ensure proper use of personal protective equipment (PPE) in isolation rooms.