Deficiency Records for Pacific Villa, Inc
Updated as of August 01, 2024
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Deficiency Records for Pacific Villa, Inc
A list of the most recent deficiencies for Pacific Villa, Inc. 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 Villa, Inc. 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? |
---|---|---|---|---|
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-02-02 | 2024-02-20 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-01-05 | 2024-02-01 | N |
Assist a resident in gaining access to vision and hearing services. | Health | 2024-01-05 | 2024-02-01 | 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 | 2024-01-05 | 2024-02-01 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-05 | 2024-02-01 | 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 | 2024-01-05 | 2024-02-01 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-05 | 2024-02-01 | N |
Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-01-05 | 2024-02-01 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-05 | 2024-02-01 | 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 | 2024-01-05 | 2024-02-01 | N |
Ensure medication error rates are not 5 percent or greater. | Health | 2024-01-05 | 2024-02-01 | N |
Ensure that residents are free from significant medication errors. | Health | 2024-01-05 | 2024-02-01 | 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 | 2024-01-05 | 2024-02-01 | N |
Provide routine and 24-hour emergency dental care for each resident. | Health | 2024-01-05 | 2024-02-01 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-05 | 2024-02-01 | N |
Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-01-05 | 2024-02-01 | N |
Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2024-01-05 | 2024-02-01 | N |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-01-05 | 2024-02-01 | Y |
Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-01-05 | 2024-02-01 | Y |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-01-05 | 2024-02-01 | Y |
Respond appropriately to all alleged violations. | Health | 2024-01-05 | 2024-02-01 | Y |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-08 | 2024-02-01 | N |
Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-12-11 | 2024-01-17 | Y |
Honor the resident's right to choose his or her attending physician. | Health | 2023-12-11 | 2024-01-17 | Y |
Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2023-12-11 | 2024-01-17 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-12-11 | 2024-01-17 | Y |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-12-11 | 2024-01-17 | 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 | 2023-12-11 | 2024-01-17 | Y |
Provide and implement an infection prevention and control program. | Health | 2023-03-28 | 2023-05-16 | Y |
Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-02-16 | 2023-03-09 | N |
Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2023-02-16 | 2023-03-09 | N |
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-02-16 | 2023-03-09 | N |
Reasonably accommodate the needs and preferences of each resident. | Health | 2023-02-16 | 2023-03-09 | N |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-02-16 | 2023-03-09 | 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 | 2023-02-16 | 2023-03-09 | N |
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-02-16 | 2023-03-09 | N |
Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-02-16 | 2023-03-09 | N |
PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-02-16 | 2023-03-09 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-16 | 2023-03-09 | 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 | 2023-02-16 | 2023-03-09 | N |
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-02-16 | 2023-03-09 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-16 | 2023-03-09 | N |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-16 | 2023-03-09 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2023-02-16 | 2023-03-09 | 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 | 2023-02-16 | 2023-03-09 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-16 | 2023-03-09 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-16 | 2023-03-09 | 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 | 2023-02-16 | 2023-03-09 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-16 | 2023-03-09 | N |
Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2023-02-16 | 2023-03-09 | N |
Provide and implement an infection prevention and control program. | Health | 2023-02-16 | 2023-03-09 | N |
Ensure staff are vaccinated for COVID-19 | Health | 2023-02-16 | 2023-03-09 | N |
Keep all essential equipment working safely. | Health | 2023-02-16 | 2023-03-09 | N |
Install an approved automatic sprinkler system. | Fire Safety | 2023-02-14 | 2023-02-22 | N |
Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-02-14 | 2023-02-22 | N |
Have power receptacles that are properly grounded. | Fire Safety | 2023-02-14 | 2023-02-22 | N |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-28 | 2022-02-14 | Y |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-15 | 2019-12-13 | N |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-11-15 | 2019-12-13 | 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 | 2019-11-15 | 2019-12-13 | N |
Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-11-15 | 2019-12-13 | N |
Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-11-15 | 2019-12-13 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-11-15 | 2019-12-13 | 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 | 2019-11-15 | 2019-12-13 | 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 | 2019-11-15 | 2019-12-13 | N |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-11-15 | 2019-12-13 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-15 | 2019-12-13 | N |
Provide and implement an infection prevention and control program. | Health | 2019-11-15 | 2019-12-13 | N |
Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2019-11-14 | 2019-12-05 | N |
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