Pacific Care Nursing Center

In the surveyor’s words

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

• Immediate jeopardy, patternF689Mar 18, 2024

  Based on observation, interview and record review, the facility failed to ensure residents with diagnoses of seizure (a sudden, uncontrolled burst of electrical activity in the brain), convulsions ( rapid, involuntary muscle contractions that cause uncontrollable shaking and limb movement ) or epilepsy (a brain condition that causes recurring seizures), and on anti-seizure medications (medications used to prevent or treat seizures or convulsions by controlling abnormal electrical activity in the brain), had seizure precautions (safety measures to prevent/lessen possible injuries during a seizure activity such as padded siderails and bed in low position), in place for three of 25 sampled residents. […]

• Actual harm, isolatedF689May 11, 2026

  Based on interview and record review, the facility failed to ensure residents, at high risk for falls and injuries, received fall prevention interventions for one of three sampled residents (Resident 1).The facility failed to:1.Ensure Certified Nursing Assistant (CNA) 1 was aware of Resident 1's high fall-risk status.2. Ensure Resident 1's physician (MD) orders dated 2/12/2026 for fall prevention devices including floor mats (cushioned pads placed on the floor besides a resident's bed to decrease the impact of a fall) and bilateral bolsters (firm, padded foam cushions placed along the sides of a bed to act as soft, safe bumpers to prevent residents from rolling out of bed) were not discontinued on 2/13/2026, despite Resident 1 continuing to be assessed as high risk for falls and… […]

• Actual harm, isolatedF684Jan 24, 2025

  Based on interview and record review, the facility failed to ensure the resident, who had a history of acute stroke ([CVA]- loss of blood flow to a part of the brain) and complained of having a slurred speech, a headache, and severe pain in left arm was timely transferred to a general acute care hospital (GACH) to prevent ischemic (a condition that occurs when blood flow to an organ, muscle group, or tissue is reduced resulting in a lack of oxygen) stroke for one of three sampled residents (Resident 1). The facility failed to: 1. Ensure Licensed Vocational Nurse (LVN unknown) assessed Resident 1 when Certified Nursing Assistant (CNA) 1, reported on 1/9/2025 at 1 p.m. […]

• Actual harm, isolatedF686Dec 2, 2024

  Based on interview and record review, the facility failed to ensure a resident, who was admitted with intact skin did not develop a pressure injury (localized damage to the skin and/or underlying tissue usually over a bony prominence) while in the facility, and a resident who was admitted with a pressure injury had measures in place to prevent the existing pressure injury from getting worse for two of two residents (Resident 2 and 12). The facility failed to: 1. Implement Resident 2's care plan, titled Alteration in Skin integrity intervention to turn and reposition the resident at least every two hours and as needed from 1/2024 to 3/2024 to prevent Resident 2 from developing the pressure injuries to the right and left lateral (to the side of, or away from, the middle of the body)… […]

• Actual harm, isolatedF686Oct 9, 2023

  Based on observation, interview and record review, the facility failed to prevent the development of an avoidable Stage IV (skin damage that extends to the muscle, tendon, or bone) pressure sore (skin injury from prolonged pressure on the skin and tissue underneath) on the sacro-coccyx (tail bone area) area for one of two sampled residents (Resident 2) by failing to: a. Ensure Resident 2 was repositioned at least every two hours, as indicated in the care plan to relieve the pressure from the sacro-coccyx area. b. […]