Pacific Care and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Pacific Care and Rehabilitation, in the surveyor’s own words.

• Actual harm, isolatedF550Mar 7, 2022

  Based on observation, interview and record review, the facility failed to ensure care and services were provided in a manner that maintained and promoted dignity when assistance was not provided in a timely manner and when staff failed to ask permission before entering resident rooms for two of two sampled residents (10 & 26) reviewed for resident rights. This failure placed residents at risk for lack of privacy, embarrassment and a diminished quality of life. This caused harm to Resident 10 when he was not assisted and he had to drive his wheelchair through the facility in soiled clothing. Findings included . <Timely Assistance> The facility's policy entitled, Resident Rights, dated 10/04/2016, documented residents have the right to a dignified existence. […]

• Actual harm, isolatedF686Mar 7, 2022

  Based on observation, interview, and record review, the facility failed to ensure adequate care and services were provided to promote wound healing when pressure reduction interventions were not implemented, antibiotic orders were not implemented and daily wound dressings were not performed for two of three sampled residents (38 & 39) reviewed for pressure ulcers. This failure placed residents at risk for wound complications, infection, delayed healing, increased pain, and a decreased quality of life. This failure caused harm to Resident 38 when interventions were not implemented and the wound became infected. Findings included . […]

• No harm, potential for more than minimal, widespreadF812Mar 7, 2022

  Based on observation and interview, the facility failed to ensure 1 of 5 staff members wore hairnets while in the kitchen, 2 of 5 staff members performed hand hygiene when entering the kitchen to obtain hot beverages, and 1 of 2 staff members observed for meal preparation touched eating surfaces of utensils and tops and inside surfaces of glasses during meal prep. These failures place residents at risk for food-borne illness and cross contamination. Findings included . On 03/03/2022 at 5:13 AM, Staff DD, Cook, was observed preparing breakfast without a hairnet on. At 5:49 AM, Staff DD place a hairnet on on their head. […]

• No harm, potential for more than minimal, widespreadF880Mar 7, 2022

  Based on observation, interview, and record review, the facility failed to ensure staff-maintained infection control practices were used to prevent the spread of infection and disease by placing a meal tray from a quarantine room onto a clean meal carts, failed to ensure hand hygiene was completed during one of two dining observations and during three of three medication administration observations, failed to disinfect shared equipment, failed to wear correct personal protective equipment (PPE) when going into a quarantine room, and failed to regularly test water for Legionella, a potentially dangerous bacteria that grows in water. […]

• No harm, potential for more than minimal, widespreadF880Jun 30, 2021

  Based on observation, interview and record review, the facility failed to maintain an infection control (ICP) program that thoroughly investigated and analyzed infection data in a timely manner, and/or identified necessary preventative measures, to prevent the spread of infections within the facility during an active outbreak of Norovirus (gastrointestinal illness). This failure placed residents, staff, and visitors at risk for infections and a diminished quality of life. Findings included . The facility Infection Control Policy, revised ,d+[DATE], showed they were intended to facilitate maintaining a safe, sanitary, and comfortable environment, and to help prevent and manage transmission of diseases and infections. […]