Deficiency Records for Pacific Haven Subacute and Healthcare Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Pacific Haven Subacute and Healthcare Center. 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 and appropriate respiratory care for a resident when needed. | Health | 2023-12-22 | 2024-01-20 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-12-22 | 2024-01-20 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-07-17 | 2023-08-16 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-06-29 | 2023-07-28 | Y |
| 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 | 2022-11-23 | 2022-12-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-11-23 | 2022-12-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-23 | 2022-12-16 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-11-23 | 2022-12-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-23 | 2022-12-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-23 | 2022-12-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-21 | 2022-12-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-21 | 2022-12-09 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-11-21 | 2022-12-09 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-11-21 | 2022-12-09 | N |
| Use approved construction type or materials. | Fire Safety | 2019-06-05 | 2019-06-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-05 | 2019-06-18 | N |
| Provide activities to meet all resident's needs. | Health | 2019-04-17 | 2019-05-17 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-17 | 2019-05-17 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-04-17 | 2019-05-17 | 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 | 2019-04-17 | 2019-05-17 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-04-17 | 2019-05-17 | 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 | 2019-04-17 | 2019-05-17 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-04-17 | 2019-05-17 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-04-17 | 2019-05-17 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-04-17 | 2019-05-17 | 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 | 2019-04-17 | 2019-05-17 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-04-17 | 2019-05-17 | 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 | 2019-04-17 | 2019-05-17 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2019-04-17 | 2019-05-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-17 | 2019-05-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-17 | 2019-05-17 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2018-07-19 | 2018-08-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-07-19 | 2018-08-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-07-19 | 2018-08-02 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-07-19 | 2018-08-02 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-05-02 | 2018-06-07 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-05-02 | 2018-06-07 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-05-02 | 2018-06-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-05-02 | 2018-06-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-05-02 | 2018-06-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-05-02 | 2018-06-07 | 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 | 2018-05-02 | 2018-06-07 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-05-02 | 2018-06-07 | 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 | 2018-05-02 | 2018-06-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-05-02 | 2018-06-07 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-05-02 | 2018-06-07 | 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 | 2018-05-02 | 2018-06-07 | 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 | 2018-05-02 | 2018-06-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-05-02 | 2018-06-07 | N |
| Dispose of garbage and refuse properly. | Health | 2018-05-02 | 2018-06-07 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-05-02 | 2018-06-07 | 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 | 2018-05-02 | 2018-06-07 | N |
