The violations at View Heights Conv Hosp on South Avalon Boulevard emerged during a February inspection that revealed systematic failures in medication management, dietary services, and basic resident care.
Licensed Vocational Nurse 1 gave Resident 56 expired Ozempic injections throughout January and early February. The injection pen had been opened November 5, 2024, and should have been discarded December 31, 2024, according to manufacturer instructions. Instead, the nurse continued using it until February 11, 2025.
"The medication could have lost its potency," the Director of Nursing told inspectors. She said using Ozempic beyond its expiration date could prevent Resident 56 from achieving the desired weight loss the medication was prescribed for.
The same nurse documented administering Resident 56's February 11 Ozempic dose on the medication record, but actually gave the injection the following day. When confronted, LVN 1 admitted she "forgot to administer the dose after Resident 56 changed her mind" about taking it.
"Medications should not be documented as administered before they are given," the Director of Nursing stated.
Meanwhile, another diabetic resident received insulin injections for five consecutive days without required blood glucose monitoring. Resident 31's insulin order had been reduced from 24 units to 12 units on February 8, but the medication administration record failed to prompt nurses to check blood sugar levels before giving the injections.
LVN 1 told inspectors she was "confused why Resident 31's order did not include blood glucose monitoring" and should have clarified the order with the physician before administering any insulin. Without blood glucose checks, she said, residents could experience dangerous hypoglycemic symptoms including shakiness, dizziness, and confusion.
The medication problems extended beyond diabetes care. Resident 16, who had four staples in his scalp from a head injury, never received ordered daily wound cleaning. Two days after his readmission, dried blood remained visible around the staples.
"Since his fall no staff had cleansed his scalp," Resident 16 told inspectors. The physician's order to cleanse the wound with soap and water daily was never transcribed to the medication administration record.
Dietary failures compounded the facility's problems. Kitchen staff served breakfast sandwiches without the required sausage meat to all 146 residents on February 13. The cook told inspectors she "did not have any sausage in the kitchen" and had notified the Dietary Supervisor, who served the incomplete meals anyway.
"She did not know the sandwich had to have meat," inspectors noted about the Dietary Supervisor. The facility's own recipe specified the breakfast sandwich required one sausage patty along with egg and cheese.
The Dietary Supervisor lacked proper qualifications for the position. She was enrolled in food service classes but had not completed required education. The Director of Nursing acknowledged "the DS was not qualified to work as a DS because she was still in school."
The registered dietician was present only one day per week, leaving no qualified supervisor in the kitchen most days. The facility also lacked a system to ensure meal substitutes provided equal nutritional value when residents refused planned meals.
Residents faced additional barriers to adequate nutrition. The dining room contained only 40 chairs for 50 residents, forcing some to wait in line or return to their rooms until seats became available.
"The dining room did not have enough space for all residents to sit down and eat together," a nursing assistant explained. Staff routinely told residents to "go back to their room" and wait for available seating.
Three residents' food preferences and allergies were ignored. Resident 97 repeatedly requested cheese quesadillas instead of meals she found unappetizing, but staff offered only peanut butter sandwiches, grilled cheese, or salad as alternatives. Kitchen staff had ingredients to make quesadillas but the option wasn't included on substitute request forms.
Resident 81's shrimp allergy disappeared from his diet card, and staff served him black beans despite a physician's order specifying he didn't want beans and needed protein replacement. When residents requested snacks between scheduled times, nurses told them snacks weren't available "if it was not on paper."
Food safety violations pervaded the kitchen. Inspectors found expired spinach bags in the walk-in refrigerator, cheese without use-by dates, and unlabeled lettuce. The dry storage room lacked a required thermometer for temperature monitoring.
The facility's laundry operation also posed infection risks. Water temperature monitors on washing machines had been broken "for the past few days," preventing staff from ensuring proper disinfection. The maintenance supervisor said staff checked temperatures "by feeling how hot the outside of the washer viewing glasses was."
Dryer lint traps weren't cleaned as required, with no documentation of cleaning on the morning of inspection despite policy requiring removal twice per shift.
Administrative failures extended to resident contracts. The facility provided arbitration agreements only in English to a Spanish-speaking conservator who "spoke very little English and was unable to explain what arbitration was." The agreements also lacked required venue selection provisions.
A resident who fell in December never received a required interdisciplinary team conference to prevent future falls. The Director of Nursing confirmed no conference occurred despite facility policy calling for investigation and intervention after incidents.
Psychotropic medications were prescribed without proper monitoring. Resident 3 received Cymbalta for "self-isolative behavior" but staff never documented monitoring for the behavior the medication was supposed to treat. Monthly assessments showed she exhibited no depression for months, yet no gradual dose reduction was attempted.
The inspection revealed a facility struggling with basic care standards across multiple departments. From expired medications and inadequate nutrition to infection control failures and administrative oversights, the violations painted a picture of systemic neglect affecting the facility's 146 residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for View Heights Conv Hosp from 2025-02-14 including all violations, facility responses, and corrective action plans.