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Deficiency Records for Pacific Hills Manor
A list of the most recent deficiencies for Pacific Hills Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Pacific Hills Manor. 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 each resident receives an accurate assessment. | Health | 2024-06-26 | 2024-07-15 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-07-01 | 2024-07-11 | 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 | 2024-07-01 | 2024-07-11 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2024-07-01 | 2024-07-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-07-01 | 2024-07-11 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2024-07-01 | 2024-07-11 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-10 | 2024-06-05 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-04-03 | 2024-04-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-05 | 2024-02-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-23 | 2023-10-20 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-06-26 | 2023-07-24 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-11-09 | 2022-12-09 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-07 | 2022-12-07 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-01-27 | 2022-02-14 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-10-20 | 2021-11-05 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-12 | 2021-08-11 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-07-12 | 2021-08-11 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-07-12 | 2021-08-11 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-07-12 | 2021-08-11 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2021-07-12 | 2021-08-11 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2021-07-12 | 2021-08-11 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-07-12 | 2021-08-11 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-12 | 2021-08-11 | 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 | 2021-07-12 | 2021-08-11 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-07-12 | 2021-08-11 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-07-12 | 2021-08-11 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-07-12 | 2021-08-11 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-12 | 2021-08-11 | 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 | 2021-07-12 | 2021-08-11 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-07-12 | 2021-08-11 | 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 | 2021-07-12 | 2021-08-11 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-07-12 | 2021-08-11 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-07-12 | 2021-08-11 | 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 | 2021-07-12 | 2021-08-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-12 | 2021-08-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-12 | 2021-08-11 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-07-13 | 2021-07-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-07-13 | 2021-07-22 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-07-13 | 2021-07-22 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-10-16 | 2019-11-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-10-16 | 2019-11-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-10-16 | 2019-11-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-16 | 2019-11-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-10-16 | 2019-11-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-10-16 | 2019-11-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-10-16 | 2019-11-04 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-09-06 | 2019-09-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-09-06 | 2019-09-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-06 | 2019-09-30 | 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 | 2019-09-06 | 2019-09-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-06 | 2019-09-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-06 | 2019-09-30 | N |
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