Deficiency Records for The Pillars of North County Health and Rehab Center
Updated as of July 01, 2023
This is not the most recent data for The Pillars of North County Health and Rehab Center. For the most recent information, click here.
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? |
---|---|---|---|---|
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 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 |
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 |
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 |
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 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 |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-10-06 | 2020-11-10 | Y |
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 | Y |
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 | Y |
Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-10-06 | 2020-11-10 | Y |
Ensure medication error rates are not 5 percent or greater. | Health | 2020-10-06 | 2020-11-10 | Y |
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 |
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-02-09 | 2018-03-22 | N |
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-02-09 | 2018-03-22 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-02-09 | 2018-03-22 | N |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-02-09 | 2018-03-22 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2018-02-09 | 2018-03-22 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-02-09 | 2018-03-22 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2018-02-09 | 2018-03-22 | N |
Ensure medication error rates are not 5 percent or greater. | Health | 2018-02-09 | 2018-03-22 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-02-09 | 2018-03-22 | N |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-02-09 | 2018-03-22 | N |
Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2018-02-09 | 2018-03-22 | N |
To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-02-09 | 2018-03-22 | N |