A list of the most recent deficiencies for Trabuco Hills Post Acute. 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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-27 | 2023-05-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-06 | 2023-05-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-04-04 | 2023-04-14 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-02-15 | 2023-03-08 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-15 | 2023-03-08 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-11-17 | 2022-11-30 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-11-15 | 2022-11-23 | Y |
| 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 | 2022-09-29 | 2022-11-10 | Y |
| 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 | 2022-07-27 | 2022-08-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-29 | 2022-07-29 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-29 | 2022-07-29 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-04-08 | 2022-05-08 | 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 | 2022-04-08 | 2022-05-08 | 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 | 2022-04-08 | 2022-05-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-08 | 2022-05-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-08 | 2022-05-08 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-04-08 | 2022-05-08 | 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 | 2022-04-08 | 2022-05-08 | 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 | 2022-04-08 | 2022-05-08 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-04-08 | 2022-05-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-08 | 2022-05-08 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2022-04-08 | 2022-05-08 | N |
| Dispose of garbage and refuse properly. | Health | 2022-04-08 | 2022-05-08 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-08 | 2022-05-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-08 | 2022-05-08 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-04-11 | 2022-05-03 | N |
| Use approved construction type or materials. | Fire Safety | 2022-04-11 | 2022-05-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-04-11 | 2022-05-03 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-04-11 | 2022-05-03 | 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 | 2022-04-11 | 2022-05-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-04-11 | 2022-05-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-11 | 2022-05-03 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-04-11 | 2022-05-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-04-11 | 2022-05-03 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2022-04-11 | 2022-05-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-11 | 2022-05-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-04-11 | 2022-05-03 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-04-11 | 2022-05-03 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-12-15 | 2022-01-31 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-15 | 2022-01-31 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-12-15 | 2022-01-31 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-07 | 2021-12-16 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2021-07-28 | 2021-08-27 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-07-21 | 2021-08-20 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-03-10 | 2021-04-09 | Y |
| 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 | 2021-03-10 | 2021-04-09 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2021-03-10 | 2021-04-09 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-03-10 | 2021-04-09 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-06-13 | 2019-07-01 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-06-13 | 2019-07-01 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2019-06-13 | 2019-07-01 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-06-13 | 2019-07-01 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-06-13 | 2019-07-01 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-06-13 | 2019-07-01 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-06-13 | 2019-07-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-13 | 2019-07-01 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-06-13 | 2019-07-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-06-13 | 2019-07-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-06-13 | 2019-07-01 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-04-29 | 2019-05-22 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-04-29 | 2019-05-22 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-04-29 | 2019-05-22 | 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 | 2019-04-29 | 2019-05-22 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-04-29 | 2019-05-22 | 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 | 2019-04-29 | 2019-05-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-04-29 | 2019-05-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-29 | 2019-05-22 | 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 | 2019-04-29 | 2019-05-22 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-04-29 | 2019-05-22 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-04-29 | 2019-05-22 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-04-29 | 2019-05-22 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2019-04-29 | 2019-05-22 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-04-29 | 2019-05-22 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-04-29 | 2019-05-22 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-04-29 | 2019-05-22 | 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 | 2019-04-29 | 2019-05-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-29 | 2019-05-22 | N |
| Dispose of garbage and refuse properly. | Health | 2019-04-29 | 2019-05-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-04-29 | 2019-05-22 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-04-29 | 2019-05-22 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-05-18 | 2018-09-09 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-05-18 | 2018-09-09 | 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 | 2018-05-18 | 2018-09-09 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2018-05-18 | 2018-09-09 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2018-05-18 | 2018-09-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-05-18 | 2018-09-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-05-18 | 2018-09-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-05-18 | 2018-08-27 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2018-05-18 | 2018-08-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-05-18 | 2018-08-27 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2018-05-18 | 2018-08-27 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-05-18 | 2018-08-27 | 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 | 2018-05-18 | 2018-08-27 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2018-05-18 | 2018-08-27 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2018-05-18 | 2018-08-27 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2018-05-18 | 2018-08-27 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2018-05-18 | 2018-08-27 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-05-18 | 2018-08-27 | N |
| Keep all essential equipment working safely. | Health | 2018-05-18 | 2018-08-27 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2018-05-18 | 2018-08-27 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-07-12 | 2018-07-30 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-07-12 | 2018-07-30 | N |
| Develop a communication plan. | Fire Safety | 2018-07-12 | 2018-07-30 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-07-12 | 2018-07-30 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-07-12 | 2018-07-30 | 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 | 2018-07-12 | 2018-07-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2018-07-12 | 2018-07-30 | 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 | 2018-07-12 | 2018-07-30 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2018-07-12 | 2018-07-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-07-12 | 2018-07-30 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2018-05-18 | 2018-07-12 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-05-18 | 2018-07-12 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2018-05-18 | 2018-07-12 | 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 | 2018-05-18 | 2018-07-12 | N |
| Respond appropriately to all alleged violations. | Health | 2018-05-18 | 2018-07-12 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-05-18 | 2018-07-12 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-05-18 | 2018-07-12 | 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 | 2018-05-18 | 2018-07-12 | N |
| Provide activities to meet all resident's needs. | Health | 2018-05-18 | 2018-07-12 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-05-18 | 2018-07-12 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2018-05-18 | 2018-07-12 | 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 | 2018-05-18 | 2018-07-12 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-05-18 | 2018-07-12 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-05-18 | 2018-07-12 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2018-05-18 | 2018-07-12 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2018-05-18 | 2018-07-12 | 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 | 2018-05-18 | 2018-07-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-05-18 | 2018-07-12 | N |
