California Pacific Medical CTR- Davies Campus Hosp

In the surveyor’s words

From the most serious findings on record at California Pacific Medical CTR- Davies Campus Hosp, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF880Jan 21, 2022

  Based on observations, interviews, and record reviews, the facility failed to implement its infection control program in accordance with internal policies and procedures, nationally recognized infection control guidelines and regulations when: 1. COVID-19 (a highly contagious respiratory disease) response testing was not implemented to identify and mitigate possible active transmission of infection. 2a. Respirator was not properly worn by staff. A respirator is a device worn over the nose and mouth to protect the wearer from inhaling dangerous particles. b. Extended use respirator mask and reusable eye protection were not properly stored. Eye protection such as goggles and face shield, provides barrier to infectious material from entering the eyes. c. […]

• No harm, potential for more than minimal, patternF885Jan 21, 2022

  Based on interview and record review, the facility failed to demonstrate how it communicated to residents and their responsible parties the newly confirmed COVID-19 infections along with the mitigating actions in a timely manner for all residents admitted in the facility. Failure to communicate newly confirmed COVID-19 infections and what mitigating actions are being implemented by the facility may contribute anxiety associated with the COVID-19 pandemic. Findings: During an interview with the Infection Preventionist (IP) on 1/14/22, at 11:31 AM, the IP stated resident's families were not notified of every single confirmed case(s) of COVID-19 infection. […]

• No harm, potential for more than minimal, isolatedF605Jan 9, 2026

  Based on interview and record review the facility failed to ensure as needed (PRN) psychotropic medications (a class of psychiatric drugs that helps manage severe mental health symptoms) for two out of three residents (Residents 10 and 30) were limited to 14 days and/or attending physician or prescribing practitioner documentation to support medication order extension.This failure had the potential to result in adverse consequences ranging from functional decline, hospitalization, permanent injury, or death.Findings:During a concurrent interview and record review on 1/08/2025 at 1:45 PM with Pharmacy Manager (Pharm), Resident 30's Hospital Medication Detail (undated) was reviewed. […]

• No harm, potential for more than minimal, isolatedF692Jan 9, 2026

  Based on interview and record review, the facility failed to monitor weights according to physician orders for two (Resident 14 and Resident 16) out of 12 sampled residents.This failure may limit and/or negatively impact clinicians' treatment decisions due to unavailable information. Findings:Review of Resident 14's record titled Minimum Data Set (MDS), dated [DATE], indicated she was admitted to the Skilled Nursing Facility (SNF) on 12/19/2025 and had multiple diagnoses including malnutrition (not eating enough nutrients to maintain body functions).Review of Resident 14's record titled Manage Orders, dated 12/21/2025, indicated staff was supposed to obtain her .Weight Weekly.Review of Resident 14's record titled NUTRITIONAL ASSESSMENT, dated 12/26/2025, and authored by Registered… […]

• No harm, potential for more than minimal, isolatedF757Jan 9, 2026

  Based on interview and record review, the facility failed to ensure Resident 14 (one out of 12 sample residents) was free from unnecessary medication when Remeron (a medication that treats depression and other conditions by adjusting brain chemistry to improve mood, energy, and feelings of well-being, helping to regulate mood, sleep, and appetite ) was prescribed with no identified target behaviors and no diagnosis related to depression (a serious mood disorder causing persistent sadness, loss of interest, and impacting daily life, affecting how you feel, think, and handle activities like sleeping, eating, or working). […]