Pacific Post Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure the policy and procedures for resident discharge and discharge planning were followed, for one of three sampled residents (Resident 1). This failure resulted in Resident 1's discharge planning documentation to be incomplete. During a review of Resident 1's admission Record , dated 7/17/26, indicated Resident 1 was admitted to the facility on [DATE], with diagnoses including pain in left and right hips, presence of left artificial hip joint, chronic pain syndrome, lack of coordination, abnormalities of gait and mobility, asthma (chronic lung disease where your airways become inflamed, swell, and produce excess mucus), and arthritis (pain, swelling and stiffness in joints). During a review of Resident 1's History and Physical (H&P) dated 5/29/26 indicated the resident had decision making capacity. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing facility staff verify and confirmed resident's laboratory test result as reported by resident's family member (FM 1) after Resident 1 was hospitalized on [DATE] and was diagnosed with urinary tract infection (UTI - an infection in the bladder/urinary tract) and ESBL (Extended-Spectrum Beta-Lactamase - a special shield or enzyme that certain common bacteria have developed to protect themselves from common antibiotics, because the bacteria can chew up and break down the medicine, standard antibiotics don't work against them), according to facility's policy and procedure for one of four sampled residents, Resident 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to to ensure residents were treated in a manner that enhanced the resident's dignity and respect in full recognition of residents individuality during meals when:Staff placed towels on the residents chest to protect the residents clothes without obtaining consent for seven of nine sampled residents (Residents 23, 20, 36, 26, 39,14 and 43). Staff referred/called residents requiring assistance with meals feeders for for eight out of eight sampled residents (Residents 10, 13, 20, 22, 23, 26, 29, and 36). This failure had potential to negatively affect Residents 20, 20, 36, 26, 39, 14, 43, 10, 13, 20, 22, 23, 26, 29, and 36 sense of dignity and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage practices in the kitchen by failing to ensure foods with past use-by dates were not stored in the facility's food refrigerator according to the facility's policy and procedures (P&P) titled, Food Safety and Food Storage dated 11/19/2025. This failure had the potential to result in harmful bacteria growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness for all the residents who receive and consume food prepared in the facility's kitchen.

Inspectors wroteBased on interview and record review, facility failed to document an acute change of condition for one out of one sampled Resident 50 according to facility's policy and procedures (P&P) titled Documentation in the Medical Record dated, [DATE]. This deficient practice resulted in incomplete documentation of Resident 50's Healthcare Record and had the potential to cause inconsistent communication among care teams, clinical teams, resulting from inaccuracies in crucial detecting of early health changes in residents that ensure timely interventions to prevent hospitalization, and ensuring regulatory compliance and serves as an early warning system to improve patient safety and quality of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of five sampled residents (Resident 20) was free of unnecessary medication according to the facility's policy and procedure (P&P) titled Unnecessary Drugs -Without Adequate Indication for Use, reviewed 11/19/2025 by failing to adhere to Consultant Pharmacist's medication regimen review recommendation (MRR-a monthly, in-depth checkup of a patient's medicines to ensure they are safe, necessary, and effective, usually in long-term care settings) on 2/17/2026. The deficient practice resulted in the unnecessary use of medication for Resident 20.

Inspectors wroteBased on interview and record review, the facility failed to ensure that resident or their representative was notified timely in writing according to the facility's policy & procedures (P&P) titled Bed Hold Prior to Transfer with review date 11/19/2025 for two of two sampled residents, (Resident 2 and Resident 20). This deficient practice resulted in Residents 2 and 20 and/or their representative not being aware of the facility's bed hold policy upon transfer to the hospital from the facility. Findings; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of two Certified Nursing Assistant (CNA) 1 received an annual performance review according to the facility's policy and procedures (P&P) titled Evaluation Process, reviewed 11/19/2025. This deficient practice had the potential to result in facility staff that were not competent and safely providing resident care.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of five sampled residents (Resident 2) was free of unnecessary medication according to the facility policy and procedure (P&P) titled Medication Regimen Review, reviewed 11/19/2025 by failing to adhere to Consultant Pharmacist's medication regimen review recommendation (a monthly, in-depth checkup of a patient's medicines to ensure they are safe, necessary, and effective, usually in long-term care settings) on 3/20/2026. The deficient practice had the potential to result in hospitalization and possible death for Resident 2.

Inspectors wroteBased on observation, interview and record review, the facility failed to labeled a small zip lock bag with multiple white pills found in one of two sampled medication carts (Medication Cart 1). This failure had the potential to cause medication errors and harm to the residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft. -unit of measurement for space) per resident in multiple resident bedrooms for seven of 25 resident rooms, (Rooms 9, 11, 14 16, 26, 27, and 28). This deficient practice had the potential to result in inadequate useable living space for all the residents and working space for the health caregivers, which could affect the quality of life for the residents.

Inspectors wroteBased on interview and record review, the facility failed to provide an effective discharge for one of three sampled residents, (Resident) 1 with a safe and orderly discharge planning by failing to:1. Ensure the facility's policy and procedure (P&P), titled, Discharge Planning Process, was applied by ensuring an effective discharge planning process that addressed the discharge destination met Resident 1's health and safety needs and preferences.2. Ensure Resident 1's care plan for discharge was implemented.3. Ensure that the discharge notice is provided to the resident's representative and Ombudsman (an advocate for residents of nursing homes, board and care centers, and assisted living facilities) in a language and manner in which they can understand at least 30 days prior to discharging Resident 1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to dispose of medications in a manner that was not retrievable (able to get back,) in one of one inspected medication room (Medication room [ROOM NUMBER].) This failure had the potential to increase the opportunity for medication diversion (the transfer of a medication from a lawful to an unlawful channel of distribution or use,) and increase the risk that residents in the facility could have accidental exposure to harmful medications possibly leading to physical and psychosocial harm, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the staff followed the facility's infection control policy and procedure (P&P) by not labeling the personal hygiene belongings (two emesis basins, two toothbrushes, one toothpaste and two bottles of bath soap) in the shared bathroom for four of 14 sampled residents (Resident 25, Resident 27, Resident 28, and Resident 31). This deficient practice had the potential to result in Resident 25, Resident 27, Resident 28, and Resident 31 getting and spreading infection (the establishment of an infective agent in or on a suitable host, producing clinical signs and symptoms such as fever, redness, heat, etc.).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure to protect resident right's to be treated with respect and dignity for one of two sampled resident (Resident 390). 1. Resident 390 was not provided bathroom assistance during mealtimes, was told that she will eat after she was provided incontinence care but was not provided care timely. 2. Resident 390 was not turned and repositioned when requested. These failures of not getting timely assistance resulted in Resident 390 felt she was treated like a child, had to eat with soiled incontinence (inability to control the release of urine or stool) brief, was left uncomfortable, upset, frustrated, and helpless.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (a device used by a resident to signal his/her need for assistance from staff) was within reach for two of 25 residents (Resident 21 and 390). This failure had the potential to delay the resident's care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure to protect one of two sampled residents' (Resident 390) rights to be free from neglect (the failure of the facility, its employees, or service providers to provide goods and services to a patient that are necessary to avoid physical harm, pain, mental anguish, or emotional distress) when Certified Nurse Assistant (CNA) 3 and CNA 4 did not clean Resident 390 after she had bowel movement and did not turn and reposition Resident 390 when she requested to be repositioned. This failure resulted in Resident 390 had to eat with soiled incontinence (inability to control the release of urine or stool) brief, was left uncomfortable, felt upset, frustrated, helpless and neglected.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of five Certified Nurse Assistants (CNAs) have the competency to provide care in a respectful and timely manner. This failure resulted in Resident 390's needs not being provided care and services in a timely manner that led to feelings of frustration and disappointment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary food storage preparation practices in the kitchen when: 1. The peas and carrots were not dated, labeled in the walk-in freezer. 2. The waffles and cheese were not correctly labeled, dated and stored in the freezer. These failures had the potential to result in harmful bacterial growth and cross contamination (transfer of harmful bacteria from one place to another) that could lead to foodborne illness in 42 of 42 medically compromised residents who received food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide at least 80 square feet (sq ft-unit of measurement) per resident in three of 28 rooms (Rooms # 9, 16, and 28). This failure had the potential for residents to have inadequate space for care, privacy, and mobility.

Inspectors wroteBased on interview and record review, the facility failed to allow and readmit one of four sampled resident (Resident 1) to return to the facility following hospitalization at General Acute Care Hospital 1 (GACH 1) on 1/6/2025 according to the facility's policy and procedure (P&P) titled, Bed Hold Notice Upon Transfer. This deficient practice resulted in Resident 1 remaining in GACH 1 and was not allowed to be readmitted timely to her original facility where she had resided.

Inspectors wroteBased on interview and record review, the facility failed to implement a comprehensive care plan that met the care/services based on the resident's individual assessed needs for one of two sampled residents (Resident 2) by failing to ensure that a comprehensive (CP) was developed after Resident 2 had a change of condition due to urinary tract infection (UTI- an infection in the bladder/urinary tract). This deficient practice had the potential to result negative impact on residents ' health and safety, as well as the quality of care and services received.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Notice of Proposed Transfer and Discharge was provided to the resident as soon as practicable for one out of the three sampled residents (Resident 1). The facility also failed to provide documented evidence that indicated that the State Long Term Care Ombudsman (public advocate) was notified that Resident 1 was transferred discharged from Skilled Nursing Facility 1 (SNF 1 - a type of inpatient facility that provides short or long-term skilled nursing care, and rehabilitation services to patients). This deficient practice denied the residents additional protections from being inappropriately discharged and caused Resident 1 to have feelings of anxiety.

Inspectors wroteBased on interview and record review, the facility failed to promote resident's rights to be given an advanced notice when the room and/or roommate changes was performed for three of three sampled residents (Resident 1, 2, 3) as indicated in the facility's policy and procedure titled, Change of Room or Roommate . This deficient practice violated the residents' right to make an informed decision regarding room/roommate changes.

Inspectors wroteBased on interview and record review, the facility failed to ensure prompt attempt was made to resolve grievances for one of four sampled residents (Resident 1). This deficient practice violated Resident 1's right to have grievances addressed.

Inspectors wroteBased on interview and record review, the facility failed to provide social services to one out of four sampled residents (Resident 1) by failing to provide necessary social services referrals. This deficient practice had the potential for delay in the delivery of care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure prompt attempt was made to resolve grievances for one of four sampled residents (Resident 1). This deficient practice violated Resident 1 ' s responsible party (R1 RP ' s) right to have grievances addressed and resolved.

Inspectors wroteBased on observation, interview, and record review, facility failed to ensure one of four sampled residents (Resident 4) was free from medication error by failing to ensure the medications were given on time as ordered by the physician. This deficient practice jeopardized Resident 4 ' s health and safety by failing to administer necessary medications in accordance with the physician order.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one of four sampled residents (Resident 1) had a change in condition (COC) assessment completed when Resident 1 ' s pressure ulcer/injury (damaged skin caused by staying in one position for too long) in the sacrococcyx (in human anatomy, is a large, triangular bone at the base of the spine) was changed from unstageable (UTD - unable to determine or unstageable pressure ulcer defined as Stage 3 or 4) to Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer. This deficient practice had the potential to result a negative impact on residents ' health and safety, as well as the quality of care and services received.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' medical records were updated to show documentation that advance directives (written statement of a person's wishes regarding medical treatment made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were discussed and written information were provided to the residents and/or responsible parties for one of five sampled residents (Residents 6, 16, 23, and 24 ). These deficient practices violated the residents' and/or the representatives' right to be fully informed of the option to formulate their advance directives and had the potential to cause conflict with the residents' wishes regarding health care.

Inspectors wroteBased on interview and record review, the facility failed to implement its protocol for Antibiotic Stewardship (the effort to measure and improve how antibiotics are prescribed by clinicians and used by patients) for four (4) of four (4) sampled residents (Resident 3, 14, 20 and 21). This deficient practice had the potential for Resident 3, 14, 20 and 21, to develop antibiotic resistance (not effective to treat infection) from unnecessary or inappropriate antibiotic use.

Inspectors wroteBased on interview and record review, the facility failed to ensure Pneumonia (lung infection) vaccines were offered and/or re-offered to four (4) of six (6) sampled residents (Resident 3, 21, 26 and 28) per facility policy. This deficient practice had the potential to place residents at a higher risk of acquiring and transmitting pneumonia infection to other residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure that COVID-19 (a viral infection, highly contagious, that easily transmits from person to person, causing respiratory problems and may cause death) vaccine was offered/ re-offered to the residents and/or the vaccine was administered with consent for four of six sampled residents (Resident 3, 21, 26 and 28) according to the facility's policy. This deficient practice placed Resident 3, 21, 26 and 28 at risk for COVID-19 infection.

Inspectors wroteBased on observation, interview and record review, facility failed to ensure that one of ten sampled residents (Resident 33) was assessed for medication self-administration. This deficient practice had the potential to cause over medication or harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment entries in the Minimum Data Set (MDS- an assessment and care screening tool) related to smoking status was accurately documented to reflect the resident's smoking status for one of three sampled residents (Resident 34). This deficient practice had the potential to negatively affect Resident 34's plan of care and delivery of necessary care and services.

Inspectors wroteBased on interview and record review the facility failed to ensure one out of ten sampled residents (Resident 16's) medical records had accurately documented assessment and treatment reflective of the resident's skin condition. This deficient practice resulted in Resident 16's medical records being inaccurate and missing vital information of treatment and services needed to care for three left anterior (front of the body[bicep]) upper arm lacerations (cuts) measuring approximately 0.1 centimeters (cm -unit of measure) by 0.2 cm each.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow through with the Preadmission Screening and Resident Review (PASARR- a federally required screening to help identify individuals with possible serious mental illnesses requiring a specialized follow up evaluation) recommendation to obtain a PASRR level II (assessment that determines if resident's mental condition could be met in the nursing facility or if the individual requires specialized services) evaluation for one of three sampled residents (Resident 6). This deficient practice had the potential to result in inappropriate placement and unidentified specialized services for Resident 6.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide skin, wound, and pressure ulcer (injuries to the skin and underlying tissue, primarily caused by prolonged pressure on the skin) care consistent with professional standards of practice and facility policy and procedure, for one out of ten sampled residents (Resident 16) by failing to ensure the resident's low air loss mattress (LAL -a pressure relieving mattress for the management of pressure ulcers) was set at the appropriate level per the manufacture's guidance. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure to follow the physical therapy discharge instruction to place one of two sampled resident (Resident 26) on Restorative Nurse Program ([RNP] a formal, planned, and organized program of care which is intended to restore a lost ability or maintain a potentially deteriorating function) to maintain current level of functionality (CLOF). This failure had the potential to result in a decline in Resident 26's functional ability.

Inspectors wroteBased to observation, interview, and record review the facility failed to ensure one out of 4 sampled Certified Nursing Assistants (CNA1) caring for facility residents had active and unexpired professional certification as per facility policy. CNA1 certification expired on [DATE]. This deficient practice had the potential for all 37 facility residents not to receive the appropriate treatment, care, and services.

Inspectors wroteBased on interviews and records review, the facility failed to ensure that the physician order for as needed anti-psychotic drugs (any medication capable of affecting the mind, emotions, and behavior) was not renewed unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of medication use for one of three sampled resident (Resident 10). This deficient practice had the potential for Resident 10 to experience a decline in quality of life and functional capacity resulted from side effect and adverse consequence due to unnecessary psychotropic drugs use.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide at least 80 square feet (sq. ft. -unit of measure) per resident in multiple resident rooms for the three of the 25 resident rooms. Those three rooms consisted of two beds each. This deficient practice had the potential to result in inadequate useable living space for the residents and working space for the health caregivers.