Deficiency Records for California Pacific Medical Ctr- Davies Campus Hosp
Updated as of March 01, 2024
A list of the most recent deficiencies for California Pacific Medical Ctr- Davies Campus Hosp. 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? |
|---|---|---|---|---|
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-28 | 2023-05-31 | N |
| Dispose of garbage and refuse properly. | Health | 2023-04-28 | 2023-05-31 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-04-28 | 2023-05-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-28 | 2023-05-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-28 | 2023-05-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-28 | 2023-05-23 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-05-03 | 2023-05-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-03 | 2023-05-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-05-03 | 2023-05-17 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-21 | 2022-04-05 | N |
| Report COVID19 data to residents and families. | Health | 2022-01-21 | 2022-04-05 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-11-19 | 2019-12-10 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2019-11-19 | 2019-12-10 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-11-19 | 2019-12-10 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-11-19 | 2019-12-10 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-11-19 | 2019-12-10 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-11-19 | 2019-12-10 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-11-19 | 2019-12-10 | N |
| Use approved construction type or materials. | Fire Safety | 2019-11-19 | 2019-12-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-11-19 | 2019-12-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-11-19 | 2019-12-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-11-19 | 2019-12-10 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-11-19 | 2019-12-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-11-19 | 2019-12-10 | 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 | 2019-09-12 | 2019-11-18 | 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 | 2019-09-12 | 2019-11-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-12 | 2019-11-18 | N |
| Keep all essential equipment working safely. | Health | 2019-09-12 | 2019-11-18 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-09-12 | 2018-12-19 | 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 | 2018-09-12 | 2018-12-19 | 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 | 2018-09-12 | 2018-12-19 | 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 | 2018-09-12 | 2018-12-19 | 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 | 2018-09-12 | 2018-12-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-09-12 | 2018-12-19 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2018-09-12 | 2018-12-19 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-09-12 | 2018-12-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-09-12 | 2018-12-19 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-11-30 | 2018-12-18 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-11-30 | 2018-12-18 | N |
| Develop a communication plan. | Fire Safety | 2018-11-30 | 2018-12-18 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-11-30 | 2018-12-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-11-30 | 2018-12-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-11-30 | 2018-12-18 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-11-30 | 2018-12-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-11-30 | 2018-12-18 | N |
