A list of the most recent deficiencies for Santa Clara 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 appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-09 | 2024-01-09 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-12-11 | 2024-01-05 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-12-11 | 2024-01-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-30 | 2023-12-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-18 | 2023-12-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-29 | 2023-12-13 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-11-20 | 2023-12-07 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-26 | 2023-11-17 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-11 | 2023-09-30 | Y |
| Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. | Health | 2023-06-06 | 2023-07-07 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-03-21 | 2023-04-30 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-12-28 | 2023-02-18 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-28 | 2023-02-18 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-14 | 2023-01-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-29 | 2022-12-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-05 | 2022-10-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-03 | 2022-10-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-27 | 2022-10-30 | 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 | 2022-09-27 | 2022-10-30 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-27 | 2022-10-30 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-18 | 2022-09-09 | Y |
| Develop and implement policies and procedures to ensure (1) employees report any suspicion of a crime against any resident, according to timelines; (2) post the notice of employee rights; and (3) prohibit and prevent retaliation for reporting. | Health | 2022-07-01 | 2022-08-04 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-05-03 | 2022-06-16 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-05-03 | 2022-06-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-03 | 2022-06-16 | 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 | 2022-05-03 | 2022-06-16 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-05-03 | 2022-06-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-05-03 | 2022-06-16 | 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 | 2022-05-03 | 2022-06-16 | 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 | 2022-05-03 | 2022-06-16 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-05-03 | 2022-06-16 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-05-03 | 2022-06-16 | 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 | 2022-05-03 | 2022-06-16 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-05-03 | 2022-06-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-05-03 | 2022-06-16 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-05-03 | 2022-06-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-03 | 2022-06-16 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-05-03 | 2022-06-16 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-05-03 | 2022-06-16 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-05-03 | 2022-06-16 | Y |
| Establish policies and procedures for medical documentation. | Fire Safety | 2022-05-03 | 2022-05-13 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-05-03 | 2022-05-13 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-05-03 | 2022-05-13 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-05-03 | 2022-05-13 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-05-03 | 2022-05-13 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-05-03 | 2022-05-13 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2022-05-03 | 2022-05-13 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2022-05-03 | 2022-05-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-05-03 | 2022-05-13 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-05-03 | 2022-05-13 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-05-03 | 2022-05-13 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-05-03 | 2022-05-13 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-05-03 | 2022-05-13 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-05-03 | 2022-05-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-01-26 | 2022-02-28 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-26 | 2022-02-28 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-01-05 | 2022-01-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-05 | 2022-01-27 | Y |
| Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-01-05 | 2022-01-27 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-03 | 2021-12-19 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2021-12-01 | 2021-12-12 | Y |
| 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 | 2021-11-19 | 2021-12-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-19 | 2021-12-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-11-19 | 2021-12-03 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-11-10 | 2021-12-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-09 | 2021-10-01 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-09-15 | 2021-10-01 | 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 | 2021-09-15 | 2021-10-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-15 | 2021-10-01 | Y |
| 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 | 2021-09-15 | 2021-10-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-15 | 2021-10-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-13 | 2021-07-24 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2021-07-13 | 2021-07-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-07-02 | 2021-07-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-21 | 2021-05-05 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-09-09 | 2019-10-09 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-09-09 | 2019-10-09 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-09-09 | 2019-10-09 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-09-09 | 2019-10-09 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-09-09 | 2019-10-09 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-09-09 | 2019-10-09 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-09-09 | 2019-10-09 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2019-09-09 | 2019-10-09 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2019-09-09 | 2019-10-09 | N |
| Meet Health Care Facilities Code mechanical requirements. | Fire Safety | 2019-09-09 | 2019-10-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-09 | 2019-10-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-09-09 | 2019-10-09 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-07-12 | 2019-08-02 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2019-07-12 | 2019-08-02 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-07-12 | 2019-08-02 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-12 | 2019-08-02 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-07-12 | 2019-08-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-07-12 | 2019-08-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-07-12 | 2019-08-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-07-12 | 2019-08-02 | 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 | 2019-07-12 | 2019-08-02 | 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 | 2019-07-12 | 2019-08-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-07-12 | 2019-08-02 | 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 | 2019-07-12 | 2019-08-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-12 | 2019-08-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-12 | 2019-08-02 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-07-12 | 2019-08-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-09-11 | 2018-09-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-09-11 | 2018-09-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2018-09-11 | 2018-09-28 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-09-11 | 2018-09-28 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2018-09-11 | 2018-09-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-09-11 | 2018-09-28 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-09-11 | 2018-09-28 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-06-15 | 2018-07-07 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-06-15 | 2018-07-07 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-06-15 | 2018-07-07 | 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 | 2018-06-15 | 2018-07-07 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-06-15 | 2018-07-07 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-06-15 | 2018-07-07 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-06-15 | 2018-07-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-06-15 | 2018-07-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-06-15 | 2018-07-07 | 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 | 2018-06-15 | 2018-07-07 | 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 | 2018-06-15 | 2018-07-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-06-15 | 2018-07-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-06-15 | 2018-07-07 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-06-15 | 2018-07-07 | N |
