A list of the most recent deficiencies for Petaluma Post-Acute Rehabilitation. 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? |
|---|---|---|---|---|
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2022-03-22 | 2022-04-11 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-03-22 | 2022-04-11 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-03-22 | 2022-04-11 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2022-03-22 | 2022-04-11 | N |
| Have an alternate power supply for its alarm system. | Fire Safety | 2022-03-22 | 2022-04-11 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-03-22 | 2022-04-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-03-22 | 2022-04-11 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-03-22 | 2022-04-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-03-22 | 2022-04-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-03-22 | 2022-04-11 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-03-11 | 2022-04-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-11 | 2022-04-08 | 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 | 2022-03-11 | 2022-04-08 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-03-11 | 2022-04-08 | N |
| Provide activities to meet all resident's needs. | Health | 2022-03-11 | 2022-04-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-03-11 | 2022-04-08 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-03-11 | 2022-04-08 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-03-11 | 2022-04-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-11 | 2022-04-08 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2019-06-26 | 2019-07-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-06-26 | 2019-07-16 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-06-26 | 2019-07-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-06-26 | 2019-07-16 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-04-26 | 2019-06-24 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-04-26 | 2019-06-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-26 | 2019-06-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-04-26 | 2019-06-24 | 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 | 2019-04-26 | 2019-06-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-04-26 | 2019-06-24 | 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 | 2019-04-26 | 2019-06-24 | 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 | 2019-04-26 | 2019-06-24 | 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 | 2019-04-26 | 2019-06-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-26 | 2019-06-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-04-26 | 2019-06-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-26 | 2019-06-24 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-05-11 | 2018-07-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-05-11 | 2018-07-05 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2018-05-11 | 2018-07-05 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2018-06-14 | 2018-06-28 | N |
