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Deficiency Records for Foothill Regional Medical Center D/p Snf
A list of the most recent deficiencies for Foothill Regional Medical Center D/p Snf. 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 Foothill Regional Medical Center D/p Snf. 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 that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2024-02-29 | 2024-03-29 | 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 | 2024-02-29 | 2024-03-29 | 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 | 2024-02-29 | 2024-03-29 | 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 | 2024-02-29 | 2024-03-29 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-02-29 | 2024-03-29 | 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 | 2024-02-29 | 2024-03-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-29 | 2024-03-29 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-02-29 | 2024-03-29 | 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 | 2024-02-29 | 2024-03-29 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-02-29 | 2024-03-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-29 | 2024-03-28 | 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 | 2024-02-29 | 2024-03-22 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2024-03-05 | 2024-03-20 | N |
| Ensure gas and vacuum systems are inspected and tested as part of a maintenance program. | Fire Safety | 2024-03-05 | 2024-03-20 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-03-05 | 2024-03-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-29 | 2024-03-18 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-02-29 | 2024-03-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-02 | 2024-02-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-02-02 | 2024-02-26 | 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 | 2023-12-08 | 2023-12-08 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2023-12-08 | 2023-12-08 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2023-08-22 | 2023-09-25 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-08-22 | 2023-09-25 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-08-22 | 2023-09-25 | Y |
| 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 | 2023-08-22 | 2023-08-23 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-22 | 2023-08-23 | 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 | 2023-08-22 | 2023-08-23 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-07-05 | 2023-07-25 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-31 | 2023-06-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-05-31 | 2023-06-15 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-16 | 2023-04-07 | Y |
| 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 | 2023-02-10 | 2023-03-10 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-01-30 | 2023-03-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-01-30 | 2023-03-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-30 | 2023-03-01 | 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 | 2023-01-30 | 2023-03-01 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-30 | 2023-03-01 | 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 | 2023-01-30 | 2023-03-01 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-01-30 | 2023-03-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-30 | 2023-03-01 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-01-30 | 2023-03-01 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-01-31 | 2023-02-21 | N |
| Use approved construction type or materials. | Fire Safety | 2023-01-31 | 2023-02-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-01-31 | 2023-02-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-01-31 | 2023-02-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-01-31 | 2023-02-21 | 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 | 2023-02-08 | 2023-02-15 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-08 | 2023-02-15 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-10 | 2022-12-10 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-10 | 2022-12-10 | Y |
| 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 | 2022-11-10 | 2022-12-10 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-10 | 2022-12-10 | Y |
| Provide activities to meet all resident's needs. | Health | 2022-10-31 | 2022-11-30 | Y |
| 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 | 2022-10-31 | 2022-11-30 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-10-25 | 2022-11-24 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-10-15 | 2022-11-13 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-15 | 2022-11-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-15 | 2022-11-13 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-10-15 | 2022-11-13 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-08-24 | 2022-09-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-24 | 2022-09-16 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-08-20 | 2019-09-16 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-08-20 | 2019-09-16 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-08-20 | 2019-09-16 | N |
| Implement emergency and standby power systems. | Fire Safety | 2019-08-20 | 2019-09-16 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-08-20 | 2019-09-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-20 | 2019-09-16 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-20 | 2019-09-16 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-08-20 | 2019-09-16 | N |
| Respond appropriately to all alleged violations. | Health | 2019-07-22 | 2019-08-23 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2019-07-22 | 2019-08-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-07-22 | 2019-08-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-07-22 | 2019-08-23 | 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 | 2019-07-22 | 2019-08-23 | 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 | 2019-07-22 | 2019-08-23 | 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 | 2019-07-22 | 2019-08-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-07-22 | 2019-08-23 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-07-22 | 2019-08-23 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-22 | 2019-08-23 | N |
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