Deficiency Records for Pacifica Hospital of The Valley Dp Snf
Updated as of March 01, 2024
A list of the most recent deficiencies for Pacifica Hospital of The Valley Dp Snf. 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? |
|---|---|---|---|---|
| Keep all essential equipment working safely. | Health | 2023-07-13 | 2023-08-17 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-04-20 | 2023-06-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-10 | 2023-05-18 | Y |
| 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 | 2023-01-20 | 2023-02-20 | 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 | 2023-01-20 | 2023-02-20 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-01-20 | 2023-02-20 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-01-20 | 2023-02-20 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-01-20 | 2023-02-20 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-01-20 | 2023-02-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-20 | 2023-02-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-01-20 | 2023-02-20 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-01-20 | 2023-02-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-20 | 2023-02-20 | 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 | 2023-01-20 | 2023-02-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-20 | 2023-02-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-01-20 | 2023-02-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-01-20 | 2023-02-20 | 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 | 2023-01-20 | 2023-02-20 | 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 | 2023-01-20 | 2023-02-20 | 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 | 2023-01-20 | 2023-02-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-20 | 2023-02-20 | N |
| Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. | Health | 2023-01-20 | 2023-02-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-20 | 2023-02-20 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-01-20 | 2023-02-20 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-01-20 | 2023-02-20 | N |
| Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program. | Health | 2023-01-20 | 2023-02-20 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2023-01-20 | 2023-02-20 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-01-26 | 2023-02-20 | 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 | 2023-01-26 | 2023-02-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-01-26 | 2023-02-20 | N |
| Construct fire resistant interior walls. | Fire Safety | 2023-01-26 | 2023-02-20 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2023-01-26 | 2023-02-20 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-01-26 | 2023-02-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-01-26 | 2023-02-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-01-26 | 2023-02-20 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-01-26 | 2023-02-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-26 | 2023-02-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-01-26 | 2023-02-20 | N |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2022-04-14 | 2022-05-13 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-01-28 | 2022-05-04 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-01 | 2022-04-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-10 | 2022-02-18 | Y |
| 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 | 2021-12-01 | 2021-12-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-06-04 | 2021-07-16 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-29 | 2021-07-15 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-05-13 | 2019-07-10 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-05-13 | 2019-07-10 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-05-13 | 2019-07-10 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-05-13 | 2019-07-10 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-05-13 | 2019-07-10 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-05-13 | 2019-07-10 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-05-13 | 2019-07-10 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-05-13 | 2019-07-10 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-05-13 | 2019-07-10 | N |
| Install noncombustible or limited-combustible interior walls. | Fire Safety | 2019-05-13 | 2019-07-10 | N |
| Ensure that laboratories employing quantities of flammable, combustible, or hazardous materials have fire resistant walls and automatic sprinkler system. | Fire Safety | 2019-05-13 | 2019-07-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-13 | 2019-07-10 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-05-13 | 2019-07-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-05-13 | 2019-07-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-05-13 | 2019-07-10 | N |
| Ensure medical gas and vacuum systems have documented maintenance programs. | Fire Safety | 2019-05-13 | 2019-07-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-05-13 | 2019-07-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-05-13 | 2019-07-10 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-05-15 | 2019-07-02 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-05-15 | 2019-07-02 | 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 | 2019-05-15 | 2019-07-02 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-05-15 | 2019-07-02 | N |
| Respond appropriately to all alleged violations. | Health | 2019-05-15 | 2019-07-02 | 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 | 2019-05-15 | 2019-07-02 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-05-15 | 2019-07-02 | 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 | 2019-05-15 | 2019-07-02 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-05-15 | 2019-07-02 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-05-15 | 2019-07-02 | 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 | 2019-05-15 | 2019-07-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-05-15 | 2019-07-02 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2019-05-15 | 2019-07-02 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2019-05-15 | 2019-07-02 | N |
| Post nurse staffing information every day. | Health | 2019-05-15 | 2019-07-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-05-15 | 2019-07-02 | 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 | 2019-05-15 | 2019-07-02 | 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 | 2019-05-15 | 2019-07-02 | 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 | 2019-05-15 | 2019-07-02 | 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 | 2019-05-15 | 2019-07-02 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-15 | 2019-07-02 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2019-05-15 | 2019-07-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-15 | 2019-07-02 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2018-05-14 | 2018-06-07 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2018-05-14 | 2018-06-07 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-05-14 | 2018-06-07 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-05-14 | 2018-06-07 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2018-05-14 | 2018-06-07 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-05-14 | 2018-06-07 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2018-05-14 | 2018-06-07 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2018-05-14 | 2018-06-07 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2018-05-14 | 2018-06-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-05-14 | 2018-06-07 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2018-05-12 | 2018-06-06 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-05-12 | 2018-06-06 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2018-05-12 | 2018-06-06 | N |
| Provide appropriate foot care. | Health | 2018-05-12 | 2018-06-06 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-05-12 | 2018-06-06 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2018-05-12 | 2018-06-06 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-05-12 | 2018-06-06 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-05-12 | 2018-06-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-05-12 | 2018-06-06 | N |
