Deficiency Records for Pacific Hills Manor
Updated as of June 01, 2023
This is not the most recent data for Pacific Hills Manor. For the most recent information, click here.
A list of the most recent deficiencies for Pacific Hills Manor. 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? |
|---|---|---|---|---|
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-11-09 | 2022-12-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-07 | 2022-12-07 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-01-27 | 2022-02-14 | 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 | 2021-10-20 | 2021-11-05 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-12 | 2021-08-11 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-07-12 | 2021-08-11 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-07-12 | 2021-08-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-07-12 | 2021-08-11 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-07-12 | 2021-08-11 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-07-12 | 2021-08-11 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-07-12 | 2021-08-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-12 | 2021-08-11 | 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 | 2021-07-12 | 2021-08-11 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-07-12 | 2021-08-11 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-07-12 | 2021-08-11 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-07-12 | 2021-08-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-12 | 2021-08-11 | 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 | 2021-07-12 | 2021-08-11 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-07-12 | 2021-08-11 | 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 | 2021-07-12 | 2021-08-11 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-07-12 | 2021-08-11 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-07-12 | 2021-08-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-12 | 2021-08-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-12 | 2021-08-11 | 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 | 2021-07-12 | 2021-08-11 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-02 | 2021-07-30 | Y |
| 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 | 2021-07-02 | 2021-07-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-30 | 2021-07-30 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-06-30 | 2021-07-30 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-06-30 | 2021-07-30 | Y |
| List the names and contact information of those in the facility. | Fire Safety | 2021-07-13 | 2021-07-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-07-13 | 2021-07-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-07-13 | 2021-07-22 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-06-04 | 2021-06-25 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2021-03-18 | 2021-04-12 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-03-04 | 2021-04-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-01-12 | 2021-02-05 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-10-16 | 2019-11-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-10-16 | 2019-11-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-16 | 2019-11-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-16 | 2019-11-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-16 | 2019-11-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-10-16 | 2019-11-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-10-16 | 2019-11-04 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-06 | 2019-09-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-09-06 | 2019-09-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-06 | 2019-09-30 | 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 | 2019-09-06 | 2019-09-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-06 | 2019-09-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-06 | 2019-09-30 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2018-11-08 | 2018-12-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-11-08 | 2018-12-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-08 | 2018-12-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-11-08 | 2018-12-12 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2018-11-08 | 2018-12-12 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2018-11-08 | 2018-12-12 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2018-11-08 | 2018-12-12 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-11-08 | 2018-12-12 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2018-08-10 | 2018-09-09 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-08-10 | 2018-09-09 | 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 | 2018-08-10 | 2018-09-09 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2018-08-10 | 2018-09-09 | 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 | 2018-08-10 | 2018-09-09 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-08-10 | 2018-09-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-08-10 | 2018-09-09 | N |
