Pacific Care Center

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to document the stage (classifying a pressure ulcer based on the depth and severity of tissue damage) for one (Resident #52) of three sampled residents with wounds. Staff failed to document the administration of one residents (Resident #23) medication out of three sampled residents. The facility census was 53.1. Review of the facility's Wounds policy, undated, showed all wounds must be measured and documented on weekly (skin tears, surgical, ulcers, blisters, etc ). The policy did not contain guidance on the staging of wounds.2. Review of Resident #52's Annual Minimum Date Set (MDS), a federally mandated assessment, dated 02/06/26, showed staff assessed the resident a cognitively impaired and has one or more unhealed pressure ulcer. [...]

Inspectors wroteBased on interview and record review, facility staff failed to provide the services of a Registered Nurse (RN), for at least eight consecutive hours per day, seven days a week. The facility census was 53.1. Review of the facility's policies showed staff did not provide a policy for RN coverage. Review of the facility Payroll Based Journal (PBJ), a method to collect auditable and verifiable staffing data from nursing facilities, report for Fiscal Year 2025, Quarter 4 (July 1 through September 30) showed the facility triggered for no RN hours for Saturdays and Sundays on the following: July 05, 06, 12, 13, 19, 20, 26, and 27th. August 02, 03, 09, 10, 16, 17, 23, 24, 30 and 31st . September 06, 07, and 13th. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure a medication error rate of less than five percent (%). Out of 35 opportunities observed, three errors occurred, resulting in a 8.57% error rate, which affected two residents (Resident #11 and #31) of six sampled residents. The facility census was 53. 1. Review of the facility's Medication Errors and Drug Reactions policy, undated, showed staff are directed to report all medication errors immediately to the physician, Director of Nursing (DON) and administrator. The policy did not contain a definition of a medication error. Review of the facility's Medication Administration Guidelines policy, undated, showed it is important that the residents receive their medication on a timely basis. The policy did not contain a definition of a medication error. [...]

Inspectors wroteBased on observation, interview, and record review, staff failed to ensure medications were stored in a safe and effective manner, when staff failed to ensure medications were properly labeled and contained in their original package until time of administration for three medication carts of five sampled carts. The facility census was 53.1. Review of the facility's policy, Storage of Medications, undated, showed medications must be store in the container in which they were received and no discontinued, outdated, or deteriorate drugs or biologicals may be retained for use. 2. Observation on 02/09/26 at 10:45 A.M., showed the D medication cart on the B hall contained the following: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections, when staff failed to develop and review the (IPCP), policies and procedures annually. Facility staff failed to post Enhanced Barrier Precautions (EBP) signs for one resident (Resident #26) out of six sampled residents and failed to wear Personal Protective Equipment (PPE) for one resident (Resident #52) out of three sampled residents with wounds. [...]

Inspectors wroteBased on interview and record review, facility staff failed to implement an Antibiotic Stewardship Program with antibiotic use protocols and a system to monitor and track antibiotic use within the facility. The facility census was 53.1. Review of the facility's policy titled, Antibiotic Stewardship Program (ASP), undated, showed it directed staff as follows:-Infection Preventionist (IP): This person will be the hub of the ASP. They will have the knowledge and expertise to effectively develop, implement, and monitor the ASP;-The IP/designee will be responsible to audit the clinical assessment documentation at the time of the antibiotic prescription'-The IP/designee will be responsible for auditing of the completeness of antibiotic prescribing documentation to include dose, route, state date, end date, days of therapy, and indication;-The IP/designee will track C. [...]

Inspectors wroteBased on observation, interviews and record review the facility failed to post the required Department of Health and Senior Services (DHSS) hotline information (to report allegations of abuse and neglect), or a list of names, addresses, and phone numbers of the State Survey Agency (SA) in a form and manner accessible to residents and visitors. The facility census was 53.1. Review of the facility's policies did not contain a policy for the required postings. Observation on 2/12/26 at 8:15 A.M., showed staff posted the Elder Abuse Hotline number and contact information in a manner not accessible for all residents and resident representatives. During an interview on 2/12/26 at 8:44 A.M., Resident #44 said he/she was not aware of the number being posted in the building, but he/she found it. [...]

Inspectors wroteBased on observation, interview and record review, facility staff did not maintain a comfortable and homelike environment, when staff failed to ensure a comfortable sound level for residents when they failed to ensure the keypad for hallway C's entrance and exit door was in working order to prevent a continuous beep sound every time staff enter or exit the hall. The facility census was 53.1. Review of the facility's policies showed the facility did not provide a policy for environment.2. During an interview on 02/09/26 at 3:13 P.M., Resident #44 said the beeping noise is the broken back door that leads to the laundry room. He/She said staff start arriving at 4:00-5:00 A.M He/She said he/she is often woken up by the sound of the beeping door. [...]

Inspectors wroteBased on interview and record review, facility staff failed to obtain a contract between the facility and dialysis (the clinical purification of blood by dialysis, as a substitute for the normal function of the kidney) clinic, failed to obtain physician orders to receive dialysis, and failed to obtain physician orders to check the Artery Vein (AV) graft for one (Resident #5) out of one sampled resident who received dialysis services at a dialysis clinic. The facility census was 53.1. Review of the facility's policy titled, Dialysis, Care of a Resident Receiving, undated, showed staff were directed to: [...]

Inspectors wroteBased on interview and record review, facility staff failed to notify the State Long-Term Care Ombudsman in writing of a resident transfer to the hospital, including the reason for transfer for four residents (Resident #9, #13, #21, and #49) out of 14 sampled residents. The facility's census was 54. 1. Review of the facility's policies showed they did not contain a policy for notifying the ombudsman for transfers and discharges. 2. Review of Resident #9's medical record showed the resident transferred to the emergency room (ER) on 07/01/24 and readmitted to the facility on [DATE]. The record did not contain documentation staff notified the ombudsman of the resident's transfer. 3. Review of Resident #13's medical record showed the resident transferred to acute care on 07/23/24. The record did not contain documentaion staff notified the ombudsman of the resident's transfer. 4. [...]

Inspectors wroteBased on interview and record review, facility staff failed to inform the resident and/or resident's representative, in writing, of the facility's bed hold policy at the time of transfer for four residents (Resident #9, #13, #21, and #49) out of 14 sampled residents. The facility's census was 54. 1. Review of the facility's Bed Hold Policy Guidelines, undated, showed the facility will notify all residents, and/or their representative of the bed hold policy guidelines. This notification shall be given: upon admission to the facility, at the time of the transfer to the hospital or leave, and at the time of non-covered therapeutic leave. 2. Review of Resident #9's medical record showed the resident transferred to the emergency room (ER) on 07/01/24 and readmitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to develop and implement a comprehensive person-centered care plan for seven residents (Resident #16, #21, #25, #32, #33, #49, #50) out of 14 samples residents. The facility census was 54. 1. Review of the facility's policy titled MDS and Care Planning Guidelines dated [DATE] shows it is the policy of this facility is to use the most current Centers for Medicare & Medicaid Services (CMS) Minimum Data Set (MDS) Resident Assessment Instrument (RAI) Manual, any published interim RAI manual errata documents, and applicable federal guidelines as the authoritative guide for completion of MDS, CAAs and resident care planning. 2. Review of Resident # 16's Quarterly MDS, a federally mandated assessment tool, dated [DATE], showed staff assessed resident as: -Significantly cognitively impaired; -Received hospice. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide activities of daily living (ADLs) for eight residents (Resident #9 #21, #23, #26, #27, #33, #40 and #210) out of fourteen sampled residents when staff did not provide showers. The facility's census was 54. 1. Review of the facility's policy titled, Daily Care Needs, undated, showed before beginning care, check the resident's care plan. 2. Review of Resident # 9's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 06/20/24, showed staff assessed the resident as severely cognitively impaired, and dependent on staff for hygiene and bathing. Review of the resident's care plan, dated 06/22/24, showed: -Cognitive loss and memory issues; -Received Hospice care; -Dependent on staff for bed mobility, transfers, dressing, toileting, and hygiene; -Dependent on staff for bathing/showers. [...]

Inspectors wroteBased on observation, interview, and record review facility staff failed to complete bed rail assessments and obtain consent for the use of bed rails for three (Resident #21, #33, and #49) of 14 sampled residents. The facility census was 54. 1. Review of the facility's policy titled Bed Rails, undated showed staff were directed to: -Complete bed rail observation; -Obtain consent for the bed rails; -Provide education to the resident/legal representative on the benefits and risk of bed rail use; -Develop a care plan for bed rail use; -Staff will conduct regular inspections of all bedframes, mattresses, and bed rails to identify areas of possible entrapment. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure four nurse aides ((NA) NA R, NA K, NA Q, and NA S) out of six sampled NA's, completed the nurse aid training program within four months of their employment in the facility. The facility census was 54. 1. Review of the facility's policy's showed the facility did not provide a policy for the completion of the nurse aide training program. Review of the Facility Assessment Tool, dated July 2024, showed staff documented all NA's must be certified within 120 days. 2. Review of NA R's personnel file showed a hire date of 10/10/23. The file did not contain documentation NA R completed the nurse aide training program. Review of NA K's personnel file showed a hire date of 10/24/23. The file did not contain documentation NA R completed the nurse aide training program. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to reconcile narcotics at the change of shift when the medication cart changed from one staff member to another. The facility census was 54. 1. Review of the facility's policy titled Narcotic Count, undated, showed one Registered Nurse (RN), Licensed Practical Nurse (LPN), or Certified Medication Technician (CMT) going off duty and one RN, LPN, CMT coming on duty must count and justify accuracy of narcotics supply for each resident at the change of shift. Narcotic records are to be retained for at least one year. After the supply is counted and justified, the nurse/CMT records the date and his/her signature verifying the count is correct. 2. Review of the facility's staffing report showed: -Day shift charge nurse worked 7:00 A.M. to 7:00 P.M.; -Night shift charge nurse worked 7:00 P.M. to 7:00 A.M.; [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to help prevent the development and transmission of infections when staff failed to perform hand hygiene in a manner to reduce the spread of infection for for three residents (Resident #14, #24, and #35) out of 14 sampled residents. The facility census was 54. Review of the Centers for Disease control and Prevention CDC Hand Hygiene in Healthcare Settings guidelines, last reviewed 01/10/20, showed the guidance directs healthcare personnel to follow the following recommendations: -Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indication: -Immediately before touching a patient; -Before performing an aseptic task (e.g. placing an indwelling device) or handling medical devices; [...]

Inspectors wroteBased on observation, interview, and record review facility staff failed to conduct regular inspections of bed rails as a part of regular maintenance program for four residents (Resident #21, #25, #33, and #49) of 14 residents' sampled to identify areas of possible entrapment. The facility census was 54. 1. Review of the facility's policy titled Bed Rails, undated, showed staff will conduct regular inspections of all bedframes, mattresses, and bed rails to identify areas of possible entrapment. Review of the United States Food and Drug Administration (FDA) document entitled, Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment, dated March 10, 2006, showed 413 people died as a result of entrapment events in the United States. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to properly contain waste and refuse to prevent the harboring and/or feeding of rodents and pests when the facility failed ensure outdoor waste containers remained covered when not in actual use. The facility census was 54. 1. Review of 2022 United States Food and Drug Administration Food Code, subsection 5-501.113 (Covering Receptacles), showed receptacles and waste handling units for refuse, recyclables, and returnables shall be kept covered with tight-fitting lids or doors if kept outside the food establishment. Observation on 07/23/24 at 12:45 P.M., showed the outside dumpster, which contained waste, uncovered and it did not contain lids or doors to cover the waste. [...]

Inspectors wroteBased on record review and interview, facility staff failed to prevent the misappropriation of funds for one resident (Resident #1) out of four sampled residents, when Housekeeper A stole the Resident #1's wallet and used his/her debit card without the resident's consent consent. The facility census was 54. 1. Review of the facility's Abuse, Neglect, Exploitation or Mistreatment Policy and Procedure, undated, showed it is the right of residents to be free from abuse, neglect, exploitation or mistreatment, misappropriation of resident property, corporal punishment, and involuntary seclusion. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure the wireless call light system was fully operational twenty-four hours per day, seven days a week when direct care staff failed to carry and utilize the wireless nurse call pagers at all times. This failure had the potential to affect 56 residents who resided in the facility. The facility census was 56 residents. 1. Review of the facility's Call Light, answering policy, undated, showed some residents may not be able to use their call light. Be sure to check these residents frequently and answer the resident's call as soon as possible. The policy did not contain direction on when to obtain pagers, what to do if the pager did not work, and how to utilize the pager. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to revise a comprehensive person-centered care plan for four (Resident #2, #13, #14, and #18) out of six sampled residents who had a fall. The facility census was 56. 1. Review of the facility's Care Plan Comprehensive policy, undated, showed: -Assessment of each resident is ongoing process and the care plan will be revised as changes occur in the resident's condition; -The interdisciplinary team (IDT) is responsible for the periodic review and updating of care plans when a significant change has occurred or when changes occur that impact the resident's care. 2. Review of Resident #2's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 3/11/24 showed staff assessed the resident as: -Cognitively impaired; -History of falls one month prior to admission; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure one resdident (Resident #3) of three sampled dependent residents received the necessary services to remain clean and dry, when staff failed to provide timely toileting assistance and incontinence care. The facility census was 56. 1. Review of the facility's Perineal Care policy, undated, showed: -The purpose is to cleanse the perinium and prevent infection and odor; -Use a wet lightly soaped washed cloth to wash from front to back; -Rinse and pat dry; -The policy did not contain direction on when/how often to provide perineal care. 2. Review of Resident #3's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 3/11/24 showed staff assessed the resident as: -Cognitively impaired; -Did not have behaviors or rejection of care; -Functional impairment on one side; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide safe transfers with a mechanical lift for one resident (Residents #3) of two sampled residents in a manner to prevent accidents. The facility census was 56. 1. Review of the facility's Hydraulic Lift policy, undated, showed to follow manufacturer's instructions when using any type of hydraulic lift: . Review of the hydraulic lift manual, dated September 2023, showed: -Residents should be able to bear some weight, have upper body strength and able to follow simple commands; -For safety of resident, securely fasten the safety strap around the residents torso, secure the buckle and pull the strap to tighten; -Position the resident's arms on the outside of the harness and have them place their hands on the paddle handles; [...]

Inspectors wroteBased on observation, interviews, and record review, the facility staff failed to ensure the ice bin drained through an air gap and to properly store open food to prevent cross contamination and outdated usage. This had the potential to affect all facility residents. The census was 57. 1. Review of the facility's Monthly Preventative Maintenance Checklist, undated, showed staff are instructed to inspect the ice machine to ensure there is at least a two inch air gap above the floor drain. Observation on 2/8/23 at 1:57 P.M., showed the ice machine, located in the kitchen storage room off the utility hallway, contained two drains which did not drain through an air gap. Further observation showed a clear plastic tube connected the ice storage bin drain to the floor drain, and the inside of the plastic tubing contained an accumulation of a black substance. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain the dignity of three residents (Residents #14, #16, and #30), when staff failed to cover two residents' (Resident #14 and Resident #30) catheter (a tube inserted into the bladder) drainage bags, and failed to notify Resident #16 prior to elevating the back of a reclining chair. The facility census was 57. Review of the facility's Resident Rights document, undated, showed residents have the right to be treated with consideration, respect and dignity. Review showed it did not indicate or provide direction on how to maintain or provide resident dignity. 1. Review of Resident #14's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/28/22, showed staff assessed the resident as: -Severe Cognitive Impairment; -Required limited assistance from one staff member for transfers; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide a comfortable and homelike environment, when staff failed to ensure resident rooms were clean, and maintained. Further, facility staff failed to ensure a comfortable water temperature in resident rooms. The facility census was 57. Review of the policies provided by the facility showed they did not contain a policy for environmental concerns. 1. Observation on 2/7/23 at 3:04 P.M., showed Resident #8's room had gouges in the wall, toilet paper and black marks on the floor, and the paper towel dispenser did not work. Observation on 2/9/23 at 3:27 P.M. showed Resident #8's room had gouges in the wall, black marks on the floor, and the paper towel dispenser did not work. During an interview on 2/9/23 at 3:27 P.M., Resident #8 said the paper towel dispenser doesn't work, and hasn't worked for a while. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to develop and implement a comprehensive person-centered care plan for five sampled residents (Residents #14, #33, #38, #46 and #57). The facility census was 57. Review of the facility's Care Plan, Comprehensive Policy, undated, showed: -An individualized comprehensive care plan that includes measurable goals and time frames will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being; -The comprehensive care plan will be based on thorough assessments that includes, but is not limited to, the Minimum Data Set (MDS) a federally mandated assessment completed by facility staff; -Assessment of each resident is ongoing process and the care plan will be revised as changes occur in the resident's condition; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed ensure four dependent residents (Resident #31, #33, #38 and #57) received the necessary services to maintain good grooming and personal hygiene when staff failed to maintain the residents' facial hair and nails. The facility census was 57. Review of the facility's Nails, Care of (Fingers and Toes) policy, undated, showed the purpose is to provide cleanliness, comfort, and prevent the spread of disease. Review showed it did not contain direction for staff on when to provide nail care. Review of the facility's Shaving the Resident policy, undated, showed the purpose is to remove facial hair and improve the resident's appearance and morale. Review showed it did not contain direction for staff on when to provide facial shaving. 1. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide safe transfers with a mechanical lift for two residents (Residents #16 and #38) and failed to propel two residents (Resident #14 and #57) in wheelchairs in a manner to prevent accidents. The facility census was 57. 1. Review of the EZ Way Smart Lift safety guide, undated, showed: -Patient falls from lifts may cause injuries, including head trauma, fractures and death; -Move lift base legs near or around the resident's device; -Base legs are usually more stable in the full open position; -Clear a path for the lift; -Ensure there is space for lift to pivot and move freely to receiving area; -Do no leave the resident unattended while in the lift; -Never keep resident suspended in sling for more than a few minutes. Review of the facility's Wheelchair policy, undated, showed: [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment when staff failed to use hand hygiene during resident care and change gloves during care for four residents (Resident #31, #14, #16, and #57) during perineal care for two residents (Resident #16 and #38) and wound care for one resident (Resident #30). Additionally, facility staff failed to decrease the risk of infection for one resident (Resident #37) when staff failed to ensure sanitary conditions for catheter tubing, failed to sanitize or clean a mechanical lift (mechanical device used to lift and transfer residents) after use for one resident (Resident #36), and failed to sanitize or clean a pulse oximeter (device used to measure oxygen levels) between two residents (Resident #48 and #5). [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to provide appropriate treatment and services to prevent further decrease in range of motion (ROM- movement of a joint), for one resident (Resident #30), who had a contracture (shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) to the left wrist. The facility census was 57. 1. Review of the facility's Range of Motion (ROM) Policy, undated, showed: -ROM is used to improve or maintain joint mobility and muscle strength; -Assistive devices may be used; -When resident's activity level or joint function is at risk of or decreased, ROM should be started as soon as possible; -Joints may begin to stiffen within 24 hours of disuse. [...]

Inspectors wroteBased on interview and record review, facility staff failed to implement their Grievance Protocol for missing items, and failed to maintain evidence demonstrating the results of all grievances for a period of no less than three years. The facility census was 57. 1. Review of the facility's Grievance Protocol, undated, showed: -The purpose of the Grievance/Complaint Report and Grievance Log is to provide a written record of each resident and family concern and to ensure proper follow-up through the appropriate discipline; -The Social Service Director (SSD) is responsible for the program, although the Administrator is ultimately responsible for the proper implementation of the program; -Any member of the Social Services staff can complete the Grievance Complaint Report. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure the admission Policy did not require the resident and/or responsible party to waive facility liability for loss or damage to personal belongings for four residents (Residents #12, #33, #37 and #38). This had the potential to affect all residents. The census was 57. 1. Review of the facility's Ancillary Services Policy, undated, showed: -All apparel and personal care items should be marked with the resident's name; -To ensure the safety of our residents, certain items cannot be kept at the bedside or brought in for use. They are: medications including over the counter (OTC), medicated ointments, all aerosol spray cans, any products labeled Harmful if swallowed or Keep out of the reach of children i.e., nail polish remover, valuables-credit cards, jewelry, checkbooks, and cash. We cannot be responsible for those items; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to post the required nurse staffing information, which included the facility census, and the actual hours worked, by both licensed and unlicensed nursing staff directly responsible for resident care, per shift, and on a daily basis. Additionally, facility staff failed to keep the required daily staffing records for eighteen months. The facility census was 57. Review of the policies provided by the facility showed they did not contain a policy for the nurse staff posting. 1. Observation on 2/07/23 at 11:58 A.M., showed staff displayed the daily nurse staff posting on a dry erase board at the entrance to the dining room. Further observation, showed it did not have Certified Medication Technicians (CMTs) listed or their actual hours worked. [...]