Deficiency Records for Pacific Heights Transitional Care Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Pacific Heights Transitional Care 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? |
|---|---|---|---|---|
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-09-12 | 2023-10-03 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-07-20 | 2023-08-18 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-07-03 | 2023-08-04 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-06-02 | 2023-08-04 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-03-30 | 2023-04-07 | Y |
| Keep all essential equipment working safely. | Health | 2023-03-30 | 2023-04-07 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-02-10 | 2023-04-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-10 | 2023-04-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-18 | 2023-02-06 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-07-19 | 2022-08-14 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-04-20 | 2022-06-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-01 | 2022-02-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-04-28 | 2021-06-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-28 | 2021-06-11 | 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 | 2021-04-28 | 2021-06-11 | 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 | 2021-04-28 | 2021-06-11 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-04-28 | 2021-06-11 | 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 | 2021-04-28 | 2021-06-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-28 | 2021-06-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-28 | 2021-06-11 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-05-05 | 2021-05-27 | N |
| Use approved construction type or materials. | Fire Safety | 2021-05-05 | 2021-05-27 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-05-05 | 2021-05-27 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-05-05 | 2021-05-27 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2021-05-05 | 2021-05-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-05-05 | 2021-05-27 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2020-02-06 | 2020-04-16 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-02-06 | 2020-04-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-02-06 | 2020-04-16 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2020-02-06 | 2020-04-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-02-06 | 2020-04-16 | N |
| Provide appropriate foot care. | Health | 2020-02-06 | 2020-04-16 | 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 | 2020-02-06 | 2020-04-16 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2020-02-06 | 2020-04-16 | 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 | 2020-02-06 | 2020-04-16 | 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 | 2020-02-06 | 2020-04-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-06 | 2020-04-16 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2020-03-03 | 2020-04-15 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2020-03-03 | 2020-04-15 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2020-03-03 | 2020-04-15 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2020-03-03 | 2020-04-15 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2020-03-03 | 2020-04-15 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2020-03-03 | 2020-04-15 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2020-03-03 | 2020-04-15 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2020-03-03 | 2020-04-15 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-03-03 | 2020-04-15 | N |
| Implement emergency and standby power systems. | Fire Safety | 2020-03-03 | 2020-04-15 | N |
| Use approved construction type or materials. | Fire Safety | 2020-03-03 | 2020-04-15 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2020-03-03 | 2020-04-15 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-03-03 | 2020-04-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-03-03 | 2020-04-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-03-03 | 2020-04-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-03-03 | 2020-04-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-03-03 | 2020-04-15 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2020-03-03 | 2020-04-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-03-03 | 2020-04-15 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2020-03-03 | 2020-04-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-03-03 | 2020-04-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-03-03 | 2020-04-15 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2020-03-03 | 2020-04-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2020-03-03 | 2020-04-15 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-03-12 | 2019-04-10 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-03-12 | 2019-04-10 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-03-12 | 2019-04-10 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-03-12 | 2019-04-10 | N |
| Use approved construction type or materials. | Fire Safety | 2019-03-12 | 2019-04-10 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-03-12 | 2019-04-10 | 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 | 2019-03-12 | 2019-04-10 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2019-03-12 | 2019-04-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-12 | 2019-04-10 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2019-03-12 | 2019-04-10 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-03-12 | 2019-04-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-03-12 | 2019-04-10 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-03-12 | 2019-04-10 | 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 | 2019-01-28 | 2019-03-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-01-28 | 2019-03-15 | 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 | 2019-01-28 | 2019-03-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-28 | 2019-03-15 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-01-28 | 2019-03-15 | N |
