Deficiency Records for California Post-Acute Care
Updated as of May 01, 2024
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Deficiency Records for California Post-Acute Care
A list of the most recent deficiencies for California Post-Acute Care. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for California Post-Acute Care. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-02-23 | 2024-03-19 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-02-23 | 2024-03-19 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-02-23 | 2024-03-19 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-02-23 | 2024-03-19 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-02-23 | 2024-03-19 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-02-23 | 2024-03-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-23 | 2024-03-19 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-02-23 | 2024-03-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-23 | 2024-03-19 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-02-23 | 2024-03-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-23 | 2024-03-19 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-02-23 | 2024-03-19 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-02-23 | 2024-03-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-02-23 | 2024-03-19 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2024-02-23 | 2024-03-19 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-02-23 | 2024-03-19 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-02-23 | 2024-03-19 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2024-02-23 | 2024-03-19 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-02-23 | 2024-03-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-23 | 2024-03-19 | N |
| Dispose of garbage and refuse properly. | Health | 2024-02-23 | 2024-03-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-23 | 2024-03-19 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-02-26 | 2024-03-15 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-02-26 | 2024-03-15 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2024-02-26 | 2024-03-15 | N |
| Construct fire resistant interior walls. | Fire Safety | 2024-02-26 | 2024-03-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-02-26 | 2024-03-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-02-26 | 2024-03-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-02-26 | 2024-03-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-02-26 | 2024-03-15 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-11-01 | 2023-11-10 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-08-30 | 2023-09-18 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-05-19 | 2023-06-09 | Y |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2023-05-17 | 2023-06-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-17 | 2023-06-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-17 | 2023-06-09 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-05-17 | 2023-06-09 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-05-15 | 2023-06-05 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-04-26 | 2023-05-20 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-04-25 | 2023-05-12 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-19 | 2023-05-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-05 | 2023-05-04 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-04-15 | 2023-04-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-02-10 | 2023-03-13 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-22 | 2023-03-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-17 | 2023-03-03 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-02-17 | 2023-03-03 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-01-20 | 2023-01-30 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-10-22 | 2022-11-28 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-10-22 | 2022-11-28 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-21 | 2022-11-15 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-10-20 | 2022-11-15 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-09-12 | 2022-10-18 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-09-12 | 2022-10-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-12 | 2022-10-18 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-09-12 | 2022-10-18 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-06-10 | 2022-07-14 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-06-10 | 2022-07-14 | Y |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-05-25 | 2022-07-12 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-05-24 | 2022-07-09 | Y |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2022-04-22 | 2022-06-24 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-04-22 | 2022-06-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-21 | 2022-06-23 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-05 | 2022-04-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-20 | 2022-01-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-06-23 | 2021-07-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-06-23 | 2021-07-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-06-23 | 2021-07-20 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-06-15 | 2021-07-13 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-06-15 | 2021-07-13 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-06-15 | 2021-07-13 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-06-15 | 2021-07-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-15 | 2021-07-13 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2021-06-15 | 2021-07-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-15 | 2021-07-13 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-06-15 | 2021-07-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-15 | 2021-07-13 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-06-15 | 2021-07-13 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-06-15 | 2021-07-13 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-06-15 | 2021-07-13 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-06-15 | 2021-07-13 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-06-15 | 2021-07-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-15 | 2021-07-13 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2021-06-15 | 2021-07-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-15 | 2021-07-13 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-06-15 | 2021-07-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-23 | 2019-12-05 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-09-23 | 2019-12-05 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-10-07 | 2019-11-06 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-10-07 | 2019-11-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-10-07 | 2019-11-06 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2019-10-07 | 2019-11-06 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-10-07 | 2019-11-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-07 | 2019-11-06 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-10-07 | 2019-11-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-07 | 2019-11-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-10-07 | 2019-11-06 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-10-07 | 2019-11-06 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2019-10-07 | 2019-11-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-07 | 2019-11-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-10-07 | 2019-11-06 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-23 | 2019-11-05 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-09-23 | 2019-11-05 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-09-23 | 2019-11-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-09-23 | 2019-11-05 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-09-23 | 2019-11-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-09-23 | 2019-11-05 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-09-23 | 2019-11-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-09-23 | 2019-11-05 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-09-23 | 2019-11-05 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-09-23 | 2019-11-05 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-09-23 | 2019-11-05 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-09-23 | 2019-11-05 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-09-23 | 2019-11-05 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-09-23 | 2019-11-05 | N |
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