Pacific Heights Transitional Care Center

In the surveyor’s words

From the most serious findings on record at Pacific Heights Transitional Care Center, in the surveyor’s own words.

• Actual harm, isolatedF684Jan 29, 2025

  Based 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. Findings: A review of the admission records indicated Resident 1 was admitted with diagnoses including diabetes (abnormally high blood sugar level) and obesity (having too much body fat). […]

• Actual harm, isolatedF689Jan 18, 2023

  Based on interviews and record review, the facility failed to provide a sitter (a caregiver assigned to only one resident or patient to ensure safety), create and revise a Care Plan (a plan with a goal and interventions to achieve a goal for a resident) to prevent falls, and failed to implement interventions to prevent falls for two out of three (Resident 1, and Resident 2) residents reviewed. The facility failed to Implement fall risk interventions for Resident 1 on the day of his admission resulting in two falls. […]

• No harm, potential for more than minimal, widespreadF755Apr 28, 2021

  Based 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. […]

• No harm, potential for more than minimal, patternF730Mar 13, 2026

  Based 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.During an interview on 3/12/26 at 2:29 PM with Director of Staff Development (DSD), DSD stated they had been in the position with the facility for… […]

• No harm, potential for more than minimal, patternF812Mar 13, 2026

  Based 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.Findings:During a concurrent kitchen observation and interview with the Nutritional Service Supervisor (NSS) on 3/9/26 at 9:17 AM, these observations were made with the NSS:A clear plastic container, 1/2 full of a white powder was stored on a shelf next to the cook top. […]