Deficiency Records for The Pillars of North County Health and Rehab Center
Updated as of March 01, 2024
A list of the most recent deficiencies for The Pillars of North County Health and Rehab 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? |
|---|---|---|---|---|
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-12-19 | 2024-01-10 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-11-01 | 2024-01-10 | Y |
| 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 | 2023-11-01 | 2023-12-20 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-12-19 | 2023-12-19 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-11-01 | 2023-12-19 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-11-01 | 2023-12-19 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-11-01 | 2023-12-18 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2023-11-01 | 2023-12-01 | N |
| Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid. | Health | 2023-11-01 | 2023-12-01 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-11-01 | 2023-12-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-01 | 2023-12-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-01 | 2023-12-01 | 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 | 2023-11-01 | 2023-12-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-11-01 | 2023-12-01 | 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 | 2023-11-01 | 2023-12-01 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-11-01 | 2023-12-01 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-11-01 | 2023-12-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-01 | 2023-12-01 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-11-01 | 2023-12-01 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2023-11-01 | 2023-12-01 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-11-01 | 2023-12-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-01 | 2023-12-01 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-11-01 | 2023-12-01 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2020-10-06 | 2020-11-10 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2020-10-06 | 2020-11-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-10-06 | 2020-11-10 | N |
| Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. | Health | 2020-10-06 | 2020-11-10 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-10-06 | 2020-11-10 | 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 | 2020-10-06 | 2020-11-10 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-10-06 | 2020-11-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-10-06 | 2020-11-10 | 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 | 2020-10-06 | 2020-11-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-10-06 | 2020-11-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-10-06 | 2020-11-10 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2020-10-06 | 2020-11-10 | 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 | 2020-10-06 | 2020-11-10 | 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 | 2020-10-06 | 2020-11-10 | 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 | 2020-10-06 | 2020-11-10 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-10-06 | 2020-11-10 | 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 | 2020-10-06 | 2020-11-10 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-10-06 | 2020-11-10 | 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 | 2020-10-06 | 2020-11-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-10-06 | 2020-11-10 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2020-10-06 | 2020-11-10 | N |
| Implement a program that monitors antibiotic use. | Health | 2020-10-06 | 2020-11-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-10-06 | 2020-11-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-10-06 | 2020-11-10 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-10-06 | 2020-11-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2020-10-06 | 2020-11-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-03-08 | 2019-05-03 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2019-03-08 | 2019-04-16 | N |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2019-03-08 | 2019-04-16 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-03-08 | 2019-04-16 | 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 | 2019-03-08 | 2019-04-16 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-03-08 | 2019-04-16 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-03-08 | 2019-04-16 | N |
| Respond appropriately to all alleged violations. | Health | 2019-03-08 | 2019-04-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-03-08 | 2019-04-16 | 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 | 2019-03-08 | 2019-04-16 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-03-08 | 2019-04-16 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-03-08 | 2019-04-16 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-03-08 | 2019-04-16 | 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 | 2019-03-08 | 2019-04-16 | 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 | 2019-03-08 | 2019-04-16 | 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 | 2019-03-08 | 2019-04-16 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-03-08 | 2019-04-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-08 | 2019-04-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-08 | 2019-04-16 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-03-08 | 2019-04-16 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-03-08 | 2019-04-16 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-03-08 | 2019-04-16 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-03-08 | 2019-04-16 | N |
