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Deficiency Records for Pacific Post Acute
A list of the most recent deficiencies for Pacific Post Acute. 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 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? |
|---|---|---|---|---|
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2024-06-03 | 2024-06-24 | 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 | 2024-06-03 | 2024-06-24 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2024-06-03 | 2024-06-24 | 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 | 2024-04-03 | 2024-04-25 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-02-26 | 2024-03-20 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-02-26 | 2024-03-20 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-01-09 | 2024-01-26 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-01-09 | 2024-01-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-09 | 2024-01-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-09 | 2024-01-26 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-01-05 | 2024-01-25 | 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 | 2024-01-05 | 2024-01-25 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-01-05 | 2024-01-25 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-01-05 | 2024-01-25 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-01-05 | 2024-01-25 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-05 | 2024-01-25 | 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 | 2024-01-25 | N |
| Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. | Health | 2024-01-05 | 2024-01-25 | 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 | 2024-01-25 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-01-05 | 2024-01-25 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-01-05 | 2024-01-25 | N |
| 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 | 2024-01-05 | 2024-01-25 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2024-01-05 | 2024-01-25 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-10 | 2023-09-01 | Y |
| Post nurse staffing information every day. | Health | 2023-08-10 | 2023-09-01 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-05-16 | 2023-06-05 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-05-05 | 2023-05-27 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-19 | 2023-04-30 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-02-24 | 2023-03-13 | Y |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-12-19 | 2022-05-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-24 | 2022-04-06 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-12-19 | 2022-01-18 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-12-19 | 2022-01-18 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2021-12-19 | 2022-01-18 | 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 | 2021-12-19 | 2022-01-18 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-12-19 | 2022-01-18 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-12-19 | 2022-01-18 | N |
| Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. | Health | 2021-12-19 | 2022-01-18 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-12-19 | 2022-01-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-19 | 2022-01-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-19 | 2022-01-18 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2021-12-19 | 2022-01-18 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-12-19 | 2022-01-18 | N |
| Post nurse staffing information every day. | Health | 2021-12-19 | 2022-01-18 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-19 | 2022-01-18 | 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 | 2021-12-19 | 2022-01-18 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-12-19 | 2022-01-18 | 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 | 2021-12-19 | 2022-01-18 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-12-19 | 2022-01-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-19 | 2022-01-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-19 | 2022-01-18 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-12-19 | 2022-01-18 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-12-19 | 2022-01-18 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-12-19 | 2022-01-18 | N |
| 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 | 2021-12-19 | 2022-01-18 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-12-20 | 2022-01-18 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-12-20 | 2022-01-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-12-20 | 2022-01-18 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-12-20 | 2022-01-18 | N |
| Have exits that are accessible at all times. | Fire Safety | 2019-10-08 | 2019-11-14 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2019-10-08 | 2019-11-14 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-10-08 | 2019-11-14 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2019-10-08 | 2019-11-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-10-08 | 2019-11-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-08 | 2019-11-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-10-08 | 2019-11-14 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-10-08 | 2019-11-14 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2019-10-04 | 2019-11-05 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2019-10-04 | 2019-11-05 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2019-10-04 | 2019-11-05 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2019-10-04 | 2019-11-05 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-10-04 | 2019-11-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-04 | 2019-11-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-04 | 2019-11-05 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-10-04 | 2019-11-05 | 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 | 2019-10-04 | 2019-11-05 | 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 | 2019-10-04 | 2019-11-05 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-10-04 | 2019-11-05 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2019-10-04 | 2019-11-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-10-04 | 2019-10-05 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-10-04 | Not Fixed | N |
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