Pacific Palms Healthcare

In the surveyor’s words

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

• Actual harm, isolatedF689Oct 6, 2023

  Based on interview and record review, the facility failed to ensure, the resident, who was assessed as being a moderate risk for falls, did not fall for one of one sampled resident (Resident 89). The facility failed to: 1. Ensure a Certified Nurse Assistant (CNA 6) did not leave Resident 89 unsupervised when Resident 89 needed his soiled incontinence brief changed and left the resident's room to collect items for incontinence care. 2. Ensure CNA 6 followed the facility's policy and procedure (P&P) titled Answering the Call Light to summon other staff help by using the call light for assistance to get incontinence care items when CNA 6 was in the Resident 89's room. 3. […]

• Actual harm, isolatedF688Oct 28, 2022

  Based on observation, interview, and record review, the facility failed to ensure four of ten sampled residents (Resident 83, 20, 19, and 81) received appropriate services to prevent a decline in range of motion [(ROM) a full movement potential of a joint] and mobility. The facility failed to: 1. Ensure a Restorative Nursing Aide Program (RNA, nursing aide program that help residents to maintain their function and joint mobility) service was provided to Resident 83's right hand per Occupational Therapist [(OT), professional who provides services to increase and/or maintain a person's capability to participate in everyday life activities) recommendations upon discharge from therapy on 10/7/2021 and 2/2/2022. 2. […]

• Actual harm, isolatedF689Nov 4, 2021

  Based on interview and record review, the facility failed to implement the physician orders and the resident's plan of care to provide adequate supervision for one of two sampled residents (Resident 1). Resident 1, who was confused and would constantly attempt to climb out of the bed, had a physician's order for a sitter/companion to be at the bedside to prevent falls and injuries. The physician's order was not implemented on 5/10/2021 on the night shift. This deficient practice resulted in Resident 1 falling out of the bed and sustaining pain, a left wrist fracture (broken bone), requiring a transfer to a general acute care hospital (GACH), and undergoing an open reduction and internal fixation ([ORIF] a surgical repair of a broken bone) of the left wrist and requiring a four-day… […]

• No harm, potential for more than minimal, widespreadF803Oct 28, 2022

  Based on observation, interview and record review, the facility failed to follow scoop size per menu Residents, 15 Resident's on mechanical soft diet (provides foods that can be successfully and safely swallowed). This deficient practice had the potential for residents to receive the wrong caloric intake due to using the wrong scoop size, and serving the incorrect amount of food, which could result in overnutrition or undernutrition and further compromise of resident's nutritional standards. […]

• No harm, potential for more than minimal, widespreadF812Oct 28, 2022

  Based on observation, interviews, and review of facility records, the facility failed to store food in accordance with professional standards for food service safety when: The facility failed to maintain reach-in refrigerator temperature of Time/Temperature control for safety food (TCS) at or below 41 degrees Fahrenheit (F). TCS foods are foods that can support bacterial growth that can result in food borne illness unless stored, prepared, and served safely. This failure had the potential to result in harmful bacteria growth that could lead towards food borne illness for residents who receive food from the refrigerator. […]