A list of the most recent deficiencies for California Post Acute. 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 pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-20 | 2024-01-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-07 | 2023-12-28 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-12-07 | 2023-12-28 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-06 | 2023-12-18 | Y |
| 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 | 2023-12-06 | 2023-12-18 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-06 | 2023-12-18 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-01 | 2023-12-01 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-07-29 | 2023-11-08 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-11-02 | 2023-11-03 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-07-29 | 2023-10-10 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-09-13 | 2023-09-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-13 | 2023-09-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-13 | 2023-09-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-13 | 2023-09-15 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-07-29 | 2023-07-31 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-07-29 | 2023-07-31 | Y |
| 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 | 2023-07-29 | 2023-07-31 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-29 | 2023-07-31 | Y |
| 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 | 2023-05-16 | 2023-06-07 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-05-02 | 2023-05-25 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-02-21 | 2023-03-03 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-01-30 | 2023-02-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-14 | 2022-12-28 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-14 | 2022-12-28 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-22 | 2022-12-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-16 | 2022-11-28 | 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 | 2022-08-23 | 2022-09-13 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-08-22 | 2022-08-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-18 | 2022-08-31 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-06-17 | 2022-08-04 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-06-17 | 2022-08-04 | Y |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-03-14 | 2022-06-13 | N |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2022-05-06 | 2022-05-27 | 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 | 2022-05-04 | 2022-05-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-04 | 2022-05-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-04-27 | 2022-05-13 | 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 | 2022-04-27 | 2022-05-13 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-14 | 2022-04-28 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-03-14 | 2022-04-28 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-03-14 | 2022-04-28 | 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 | 2022-03-14 | 2022-04-28 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-03-14 | 2022-04-28 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-03-14 | 2022-04-28 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-14 | 2022-04-28 | N |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2022-03-14 | 2022-04-28 | N |
| Provide activities to meet all resident's needs. | Health | 2022-03-14 | 2022-04-28 | 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 | 2022-03-14 | 2022-04-28 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-14 | 2022-04-28 | 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 | 2022-03-14 | 2022-04-28 | 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 | 2022-03-14 | 2022-04-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-14 | 2022-04-28 | 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 | 2022-03-14 | 2022-04-28 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-03-14 | 2022-04-28 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-03-14 | 2022-04-28 | 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 | 2022-03-14 | 2022-04-28 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2022-03-14 | 2022-04-28 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-14 | 2022-04-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-14 | 2022-04-28 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-03-14 | 2022-04-28 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-03-14 | 2022-04-28 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-03-14 | 2022-04-28 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2022-03-10 | 2022-03-10 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-03-10 | 2022-03-10 | N |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2022-03-10 | 2022-03-10 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-03-10 | 2022-03-10 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-03-10 | 2022-03-10 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-03-10 | 2022-03-10 | 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 | 2022-03-10 | 2022-03-10 | N |
| Construct fire resistant interior walls. | Fire Safety | 2022-03-10 | 2022-03-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-03-10 | 2022-03-10 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-03-10 | 2022-03-10 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2022-03-10 | 2022-03-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-10 | 2022-03-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-03-10 | 2022-03-10 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-03-10 | 2022-03-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-10 | 2022-03-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-03-10 | 2022-03-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-03-10 | 2022-03-10 | N |
| Ensure that sources of ignition are removed from patients receiving respiratory therapy. | Fire Safety | 2022-03-10 | 2022-03-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-16 | 2022-02-23 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-16 | 2022-02-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-11 | 2021-10-21 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-10-15 | 2019-11-15 | 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 | 2019-10-15 | 2019-11-15 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-10-15 | 2019-11-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-10-15 | 2019-11-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-15 | 2019-11-15 | N |
| Provide activities to meet all resident's needs. | Health | 2019-10-15 | 2019-11-15 | 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 | 2019-10-15 | 2019-11-15 | 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 | 2019-10-15 | 2019-11-15 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-10-15 | 2019-11-15 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-10-15 | 2019-11-15 | N |
| Post nurse staffing information every day. | Health | 2019-10-15 | 2019-11-15 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-10-15 | 2019-11-15 | 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 | 2019-10-15 | 2019-11-15 | 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 | 2019-10-15 | 2019-11-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-10-15 | 2019-11-15 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-10-15 | 2019-11-15 | 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 | 2019-10-15 | 2019-11-15 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2019-10-15 | 2019-11-15 | 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 | 2019-10-15 | 2019-11-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-15 | 2019-11-15 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-10-15 | 2019-11-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-15 | 2019-11-15 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-10-11 | 2019-11-14 | 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 | 2019-10-11 | 2019-11-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-11 | 2019-11-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-10-11 | 2019-11-14 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-10-24 | 2018-11-28 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-10-24 | 2018-11-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-10-24 | 2018-11-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-10-24 | 2018-11-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-10-19 | 2018-10-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-10-19 | 2018-10-22 | 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 | 2018-10-19 | 2018-10-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-10-19 | 2018-10-22 | 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 | 2018-10-19 | 2018-10-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-10-19 | 2018-10-22 | 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 | 2018-10-19 | 2018-10-22 | 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 | 2018-10-19 | 2018-10-22 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2018-10-19 | 2018-10-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-10-19 | 2018-10-22 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-10-15 | Not Fixed | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-10-19 | Not Fixed | N |
