Pacific Care Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF919Apr 19, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Feb 10, 2023

  Based 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to ensure the ice bin drained through an air gap and to properly store open food to prevent cross contamination and outdated usage.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. […]

• No harm, potential for more than minimal, patternF658Feb 12, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF727Feb 12, 2026

  Based 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 . […]

• No harm, potential for more than minimal, patternF759Feb 12, 2026

  Based 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. […]