A list of the most recent deficiencies for Pacific Care and Rehabilitation. 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? |
|---|---|---|---|---|
| Conduct testing and exercise requirements. | Fire Safety | 2023-05-04 | 2023-06-08 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-05-04 | 2023-06-08 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-05-04 | 2023-06-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-04 | 2023-06-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-04 | 2023-06-08 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-05-04 | 2023-06-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-05-04 | 2023-06-08 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-05-04 | 2023-06-08 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-08 | 2023-06-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-08 | 2023-06-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-05-08 | 2023-06-01 | 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 | 2023-05-08 | 2023-06-01 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-05-08 | 2023-06-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-07 | 2022-04-13 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-03-07 | 2022-04-13 | 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 | 2022-03-07 | 2022-04-13 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-03-07 | 2022-04-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-07 | 2022-04-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-07 | 2022-04-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-07 | 2022-04-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-03-07 | 2022-04-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-07 | 2022-04-13 | 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 | 2022-03-07 | 2022-04-13 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-03-07 | 2022-04-13 | 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 | 2022-03-07 | 2022-04-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-07 | 2022-04-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-07 | 2022-04-13 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2022-03-03 | 2022-03-25 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-03-03 | 2022-03-25 | 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 | 2022-03-03 | 2022-03-25 | 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 | 2022-03-03 | 2022-03-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-03-03 | 2022-03-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-03 | 2022-03-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-03-03 | 2022-03-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-03-03 | 2022-03-25 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-03-03 | 2022-03-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-03 | 2022-03-25 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2022-03-03 | 2022-03-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-03 | 2022-03-25 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2022-03-03 | 2022-03-25 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-03-03 | 2022-03-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-30 | 2021-07-20 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-08-13 | 2019-09-08 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-08-13 | 2019-09-08 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-08-13 | 2019-09-08 | 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 | 2019-08-13 | 2019-09-08 | 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 | 2019-08-13 | 2019-09-08 | N |
| Respond appropriately to all alleged violations. | Health | 2019-08-13 | 2019-09-08 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-08-13 | 2019-09-08 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-08-13 | 2019-09-08 | 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 | 2019-08-13 | 2019-09-08 | N |
| Provide activities to meet all resident's needs. | Health | 2019-08-13 | 2019-09-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-08-13 | 2019-09-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-08-13 | 2019-09-08 | 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 | 2019-08-13 | 2019-09-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-08-13 | 2019-09-08 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-08-13 | 2019-09-08 | N |
| Post nurse staffing information every day. | Health | 2019-08-13 | 2019-09-08 | 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 | 2019-08-13 | 2019-09-08 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-08-13 | 2019-09-08 | 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 | 2019-08-13 | 2019-09-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-08-13 | 2019-09-08 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2019-08-13 | 2019-09-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-08-13 | 2019-09-08 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-08-13 | 2019-09-08 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-08-13 | 2019-09-08 | N |
| Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. | Health | 2019-08-13 | 2019-09-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-08-07 | 2019-08-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-07 | 2019-08-22 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2019-08-07 | 2019-08-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-08-07 | 2019-08-22 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-08-07 | 2019-08-22 | N |
