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? |
|---|---|---|---|---|
| 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 |
| Provide family notifications of emergency plan. | Fire Safety | 2018-09-12 | 2018-10-18 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-09-12 | 2018-10-18 | 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 | 2018-09-12 | 2018-10-18 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-09-12 | 2018-10-18 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2018-09-13 | 2018-10-16 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-09-13 | 2018-10-16 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2018-09-13 | 2018-10-16 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2018-09-13 | 2018-10-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-09-13 | 2018-10-16 | 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 | 2018-09-13 | 2018-10-16 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2018-09-13 | 2018-10-16 | N |
| Provide activities to meet all resident's needs. | Health | 2018-09-13 | 2018-10-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-09-13 | 2018-10-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-09-13 | 2018-10-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-09-13 | 2018-10-16 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2018-09-13 | 2018-10-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-09-13 | 2018-10-16 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-09-13 | 2018-10-16 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-09-13 | 2018-10-16 | 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 | 2018-09-13 | 2018-10-16 | 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 | 2018-09-13 | 2018-10-16 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2018-09-13 | 2018-10-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-09-13 | 2018-10-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-09-13 | 2018-10-16 | 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 | 2018-09-13 | 2018-10-16 | N |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2018-09-13 | 2018-10-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-09-13 | 2018-10-16 | N |
| Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. | Health | 2018-09-13 | 2018-10-16 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-09-13 | 2018-10-16 | N |
