A list of the most recent deficiencies for Pacific Villa, Inc. 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? |
|---|---|---|---|---|
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-02-02 | 2024-02-20 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-01-05 | 2024-02-01 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2024-01-05 | 2024-02-01 | 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 | 2024-01-05 | 2024-02-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-05 | 2024-02-01 | 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 | 2024-01-05 | 2024-02-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-05 | 2024-02-01 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-01-05 | 2024-02-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-05 | 2024-02-01 | 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 | 2024-01-05 | 2024-02-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-01-05 | 2024-02-01 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-01-05 | 2024-02-01 | 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 | 2024-01-05 | 2024-02-01 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2024-01-05 | 2024-02-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-05 | 2024-02-01 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-01-05 | 2024-02-01 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-01-05 | 2024-02-01 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-01-05 | 2024-02-01 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-01-05 | 2024-02-01 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-05 | 2024-02-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-01-05 | 2024-02-01 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-08 | 2024-02-01 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-12-11 | 2024-01-17 | Y |
| Honor the resident's right to choose his or her attending physician. | Health | 2023-12-11 | 2024-01-17 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-12-11 | 2024-01-17 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-12-11 | 2024-01-17 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-12-11 | 2024-01-17 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-12-11 | 2024-01-17 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-28 | 2023-05-16 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-02-16 | 2023-03-09 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-02-16 | 2023-03-09 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-02-16 | 2023-03-09 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-02-16 | 2023-03-09 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-02-16 | 2023-03-09 | N |
| 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 | 2023-02-16 | 2023-03-09 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-02-16 | 2023-03-09 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-02-16 | 2023-03-09 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-02-16 | 2023-03-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-16 | 2023-03-09 | 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 | 2023-02-16 | 2023-03-09 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-02-16 | 2023-03-09 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-16 | 2023-03-09 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-16 | 2023-03-09 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-16 | 2023-03-09 | 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 | 2023-02-16 | 2023-03-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-16 | 2023-03-09 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-16 | 2023-03-09 | 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 | 2023-02-16 | 2023-03-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-16 | 2023-03-09 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-02-16 | 2023-03-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-16 | 2023-03-09 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2023-02-16 | 2023-03-09 | N |
| Keep all essential equipment working safely. | Health | 2023-02-16 | 2023-03-09 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-02-14 | 2023-02-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-02-14 | 2023-02-22 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-02-14 | 2023-02-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-28 | 2022-02-14 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-15 | 2019-12-13 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-11-15 | 2019-12-13 | 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 | 2019-11-15 | 2019-12-13 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-11-15 | 2019-12-13 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-11-15 | 2019-12-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-11-15 | 2019-12-13 | 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 | 2019-11-15 | 2019-12-13 | 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 | 2019-11-15 | 2019-12-13 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-11-15 | 2019-12-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-15 | 2019-12-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-15 | 2019-12-13 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-11-14 | 2019-12-05 | N |
