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Deficiency Records for Laguna Hills Health and Rehabilitation Center
A list of the most recent deficiencies for Laguna Hills Health and Rehabilitation Center. 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 Laguna Hills Health and Rehabilitation 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? |
|---|---|---|---|---|
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-09-25 | 2024-09-26 | 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 | 2024-08-27 | 2024-09-20 | Y |
| 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 | 2024-08-27 | 2024-09-20 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-08-27 | 2024-09-20 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-08-19 | 2024-09-19 | Y |
| Provide activities to meet all resident's needs. | Health | 2024-08-19 | 2024-09-19 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-08-19 | 2024-09-19 | 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 | 2024-08-19 | 2024-09-19 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-08-19 | 2024-09-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-08-19 | 2024-09-19 | 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 | 2024-08-19 | 2024-09-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-08-19 | 2024-09-19 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-08-19 | 2024-09-19 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2024-08-19 | 2024-09-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-08-19 | 2024-09-19 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-08-19 | 2024-09-19 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-08-19 | 2024-09-19 | 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 | 2024-08-19 | 2024-09-19 | 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 | 2024-08-19 | 2024-09-19 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-08-19 | 2024-09-19 | 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 | 2024-08-19 | 2024-09-19 | 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 | 2024-08-19 | 2024-09-19 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2024-08-19 | 2024-09-19 | 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 | 2024-08-19 | 2024-09-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-08-19 | 2024-09-19 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2024-08-19 | 2024-09-19 | 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 | 2024-08-19 | 2024-09-19 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-08-19 | 2024-09-19 | N |
| Keep all essential equipment working safely. | Health | 2024-08-19 | 2024-09-19 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-08-19 | 2024-09-19 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-08-19 | 2024-09-19 | Y |
| 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 | 2024-08-19 | 2024-09-19 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-08-19 | 2024-09-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-19 | 2024-09-19 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-08-19 | 2024-09-19 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-08-19 | 2024-09-19 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-08-19 | 2024-09-19 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-08-19 | 2024-09-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-08-21 | 2024-09-04 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-08-21 | 2024-09-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-08-21 | 2024-09-04 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2024-08-21 | 2024-09-04 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-08-21 | 2024-09-04 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-07-01 | 2024-07-02 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-07-01 | 2024-07-02 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-05-08 | 2024-05-10 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2024-05-08 | 2024-05-10 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-02-13 | 2024-02-29 | 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 | 2024-02-13 | 2024-02-15 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-02 | 2024-01-10 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-11-03 | 2023-11-17 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-11-03 | 2023-11-17 | Y |
| Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death. | Health | 2023-10-05 | 2023-10-05 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-10-05 | 2023-10-05 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-13 | 2023-10-03 | 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 | 2023-09-13 | 2023-10-03 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-09-13 | 2023-10-03 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-09-13 | 2023-10-03 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-09-13 | 2023-10-03 | 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 | 2023-09-13 | 2023-10-02 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-09-13 | 2023-10-02 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-09-13 | 2023-10-02 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-09-13 | 2023-10-01 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-09-13 | 2023-09-28 | 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 | 2023-09-13 | 2023-09-26 | 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 | 2023-09-13 | 2023-09-25 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-09-11 | 2023-09-25 | N |
| Use approved construction type or materials. | Fire Safety | 2023-09-11 | 2023-09-25 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-09-11 | 2023-09-25 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2023-09-11 | 2023-09-25 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-11 | 2023-09-25 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-09-11 | 2023-09-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-11 | 2023-09-25 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-09-11 | 2023-09-25 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-11 | 2023-09-25 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-09-13 | 2023-09-20 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-09-13 | 2023-09-20 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-09-13 | 2023-09-20 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-09-13 | 2023-09-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-13 | 2023-09-20 | 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 | 2023-09-13 | 2023-09-20 | N |
| Provide activities to meet all resident's needs. | Health | 2023-09-13 | 2023-09-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-13 | 2023-09-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-13 | 2023-09-20 | 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 | 2023-09-13 | 2023-09-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-09-13 | 2023-09-20 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-13 | 2023-09-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-13 | 2023-09-20 | N |
| Keep all essential equipment working safely. | Health | 2023-09-13 | 2023-09-20 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-09-13 | 2023-09-20 | Y |
| 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 | 2023-09-13 | 2023-09-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-09-13 | 2023-09-13 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-09-13 | 2023-09-13 | 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 | 2023-09-13 | 2023-09-13 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2023-09-13 | 2023-09-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-13 | 2023-09-13 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-09-13 | 2023-09-13 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2023-09-13 | 2023-09-13 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-09-13 | 2023-09-13 | 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 | 2023-09-13 | 2023-09-13 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-09-13 | 2023-09-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-08-10 | 2023-09-01 | Y |
| 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 | 2023-08-10 | 2023-09-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-10 | 2023-09-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-02 | 2023-08-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-02 | 2023-08-21 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-08-02 | 2023-08-21 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-02 | 2023-08-21 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-02 | 2023-08-21 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-31 | 2023-06-26 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-02 | 2023-05-31 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-02 | 2023-05-31 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-02 | 2023-05-31 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-04-14 | 2023-05-05 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-14 | 2023-05-05 | Y |
| 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 | 2023-04-14 | 2023-05-05 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-04-13 | 2023-05-02 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-04-13 | 2023-05-02 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-03-14 | 2023-03-29 | 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 | 2023-03-14 | 2023-03-29 | Y |
| 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 | 2023-03-14 | 2023-03-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-14 | 2023-03-29 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-11-22 | 2022-12-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-13 | 2022-09-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-17 | 2022-09-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-22 | 2021-12-11 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-11-22 | 2021-12-11 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-11-10 | 2021-11-26 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-06-22 | 2021-07-15 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2021-06-22 | 2021-07-15 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-06-22 | 2021-07-15 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2021-06-22 | 2021-07-15 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2021-06-22 | 2021-07-15 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2021-06-22 | 2021-07-15 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-06-22 | 2021-07-15 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-06-22 | 2021-07-15 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-06-22 | 2021-07-15 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-06-22 | 2021-07-15 | N |
| Use approved construction type or materials. | Fire Safety | 2021-06-22 | 2021-07-15 | 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 | 2021-06-22 | 2021-07-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-06-22 | 2021-07-15 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-06-22 | 2021-07-15 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2021-06-22 | 2021-07-15 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-06-22 | 2021-07-15 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-06-22 | 2021-07-15 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-06-22 | 2021-07-15 | 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 | 2021-06-11 | 2021-07-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-06-11 | 2021-07-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-11 | 2021-07-09 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-06-11 | 2021-07-09 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-06-11 | 2021-07-09 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-06-11 | 2021-07-09 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-06-11 | 2021-07-09 | 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 | 2021-06-11 | 2021-07-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-06-11 | 2021-07-09 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-06-11 | 2021-07-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-06-11 | 2021-07-09 | N |
| Keep all essential equipment working safely. | Health | 2021-06-11 | 2021-07-09 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-06-11 | 2021-07-09 | N |
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