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Deficiency Records for Pacific Heights Transitional Care Center

A list of the most recent deficiencies for Pacific Heights Transitional Care 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 Pacific Heights Transitional Care 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?
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2024-08-29 2024-09-26 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 2024-08-29 2024-09-26 N
Ensure each resident receives an accurate assessment. Health 2024-08-29 2024-09-26 N
PASARR screening for Mental disorders or Intellectual Disabilities Health 2024-08-29 2024-09-26 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2024-08-29 2024-09-26 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 2024-08-29 2024-09-26 N
Post nurse staffing information every day. Health 2024-08-29 2024-09-26 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2024-08-29 2024-09-26 N
Ensure each resident?s drug regimen must be free from unnecessary drugs. Health 2024-08-29 2024-09-26 N
Provide timely, quality laboratory services/tests to meet the needs of residents. Health 2024-08-29 2024-09-26 N
Provide and implement an infection prevention and control program. Health 2024-08-29 2024-09-26 N
Conduct testing and exercise requirements. Fire Safety 2024-09-05 2024-09-24 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2024-09-05 2024-09-24 N
Have properly located and lighted "Exit" signs. Fire Safety 2024-09-05 2024-09-24 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2024-09-05 2024-09-24 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2024-09-05 2024-09-24 N
Install corridor and hallway doors that block smoke. Fire Safety 2024-09-05 2024-09-24 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2024-09-05 2024-09-24 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2024-09-05 2024-09-24 N
Meet requirements for the use of electrical equipment. Fire Safety 2024-09-05 2024-09-24 N
Ensure proper usage of power strips and extension cords. Fire Safety 2024-09-05 2024-09-24 N
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Health 2023-09-12 2023-10-03 Y
Provide and implement an infection prevention and control program. Health 2023-07-20 2023-08-18 N
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Health 2023-07-03 2023-08-04 Y
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-06-02 2023-08-04 Y
Reasonably accommodate the needs and preferences of each resident. Health 2023-03-30 2023-04-07 Y
Keep all essential equipment working safely. Health 2023-03-30 2023-04-07 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2023-02-10 2023-04-07 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-02-10 2023-04-07 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-01-18 2023-02-06 Y
Ensure that residents are fully informed and understand their health status, care and treatments. Health 2022-07-19 2022-08-14 Y
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2022-04-20 2022-06-23 Y
Provide and implement an infection prevention and control program. Health 2022-02-01 2022-02-22 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2021-04-28 2021-06-11 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2021-04-28 2021-06-11 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 2021-04-28 2021-06-11 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 2021-04-28 2021-06-11 N
Ensure medication error rates are not 5 percent or greater. Health 2021-04-28 2021-06-11 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 2021-04-28 2021-06-11 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2021-04-28 2021-06-11 N
Provide and implement an infection prevention and control program. Health 2021-04-28 2021-06-11 N
Implement emergency and standby power systems. Fire Safety 2021-05-05 2021-05-27 N
Use approved construction type or materials. Fire Safety 2021-05-05 2021-05-27 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2021-05-05 2021-05-27 N
Install corridor and hallway doors that block smoke. Fire Safety 2021-05-05 2021-05-27 N
Install properly constructed and protected linen or trash chutes. Fire Safety 2021-05-05 2021-05-27 N
Ensure proper usage of power strips and extension cords. Fire Safety 2021-05-05 2021-05-27 N
Allow residents to self-administer drugs if determined clinically appropriate. Health 2020-02-06 2020-04-16 N
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Health 2020-02-06 2020-04-16 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2020-02-06 2020-04-16 N
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Health 2020-02-06 2020-04-16 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2020-02-06 2020-04-16 N
Provide appropriate foot care. Health 2020-02-06 2020-04-16 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 2020-02-06 2020-04-16 N
Provide safe, appropriate pain management for a resident who requires such services. Health 2020-02-06 2020-04-16 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 2020-02-06 2020-04-16 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 2020-02-06 2020-04-16 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2020-02-06 2020-04-16 N
Address patient/client population and determine types of services needed. Fire Safety 2020-03-03 2020-04-15 N
Address subsistence needs for staff and patients. Fire Safety 2020-03-03 2020-04-15 N
Establish procedures for tracking staff and patients during an emergency. Fire Safety 2020-03-03 2020-04-15 N
Establish policies and procedures including evacuation. Fire Safety 2020-03-03 2020-04-15 N
List the names and contact information of those in the facility. Fire Safety 2020-03-03 2020-04-15 N
Provide primary/alternate means for communication. Fire Safety 2020-03-03 2020-04-15 N
Provide a means of sharing information on occupancy/needs. Fire Safety 2020-03-03 2020-04-15 N
Provide family notifications of emergency plan. Fire Safety 2020-03-03 2020-04-15 N
Conduct testing and exercise requirements. Fire Safety 2020-03-03 2020-04-15 N
Implement emergency and standby power systems. Fire Safety 2020-03-03 2020-04-15 N
Use approved construction type or materials. Fire Safety 2020-03-03 2020-04-15 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 2020-03-03 2020-04-15 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2020-03-03 2020-04-15 N
Have properly located and lighted "Exit" signs. Fire Safety 2020-03-03 2020-04-15 N
Provide properly protected cooking facilities. Fire Safety 2020-03-03 2020-04-15 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2020-03-03 2020-04-15 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2020-03-03 2020-04-15 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2020-03-03 2020-04-15 N
Install corridor and hallway doors that block smoke. Fire Safety 2020-03-03 2020-04-15 N
Install properly constructed and protected linen or trash chutes. Fire Safety 2020-03-03 2020-04-15 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2020-03-03 2020-04-15 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2020-03-03 2020-04-15 N
Meet requirements for the use of electrical equipment. Fire Safety 2020-03-03 2020-04-15 N
Have proper medical gas storage and administration areas. Fire Safety 2020-03-03 2020-04-15 N

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