Pacifica Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Pacifica Nursing and Rehabilitation Center, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Nov 22, 2024

  Based on observation, interview, and record review, the facility failed to ensure safe operations when swirl bowls were stored wet. Findings: According to the 2022 Federal Food Code, equipment and utensils are to be air dried. During a concurrent observation and concurrent interview on 11/20/24 at 1:15 p.m., in the kitchen, with Dietary Aide (DA) 1, clear bowls were placed on a tray stacked within one another that were wet on the inside. DA 1 stated tableware (term for all the dishes, utensils used for eating and serving food) were dried before stacking. During a concurrent observation and concurrent interview on 11/20/24 at 1:18 p.m., with the Director of Food and Nutrition Services (DFNS), showed clear bowls placed on a tray stacked within one another that were wet on the inside. […]

• No harm, potential for more than minimal, patternF658Nov 22, 2024

  Based on observation, interview, and record review, the facility failed to ensure that licensed staff initialed and dated lidocaine patches (pain medication delivered through the skin from applying patches) after applying the patches to affected areas on two out of two residents (Resident 5 and Resident 15). This failure has the potential for residents to not receive the full therapeutic effects of the pain medication. Findings: During a concurrent observation and record review on 11/18/24 at 9:30 a.m. on the second floor, second team at resident 15's bedside, the resident did not want to sit up. The resident was asked to roll over onto his left side with LVN2's (licensed vocational nurse) help which he did. The resident's affected area was his lower back. […]

• No harm, potential for more than minimal, patternF880Aug 24, 2023

  Based on observation, interview, and record review, the facility failed to implement their infection prevention and control program when: 1. Housekeeping Staff (HKS) 1 did not remove gown and gloves, (types of personal protective equipment (PPE), worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) before exiting a resident's room, in the facility's COVID-19 (Coronavirus disease 2019, a respiratory infectious disease) unit (a designated area or floor for residents who were confirmed positive for COVID-19). 2. HKS 1 wore an N95 respirator (a respiratory protective device designed to filter airborne particles) with the lower strap hanging loose below the chin, in the facility's designated COVID-19 unit. 3. […]

• No harm, potential for more than minimal, isolatedF661Nov 22, 2024

  Based on interview and record review, the facility failed to ensure resident's discharge summary (provides necessary information to continuing care providers pertaining to the course of treatment while the resident was in the facility and the resident's plans for care after discharge) included an accurate recapitulation of stay (a concise summary of the resident's stay and course of treatment in the facility) and reconciliation of medications (a process of comparing pre-discharge medications to post-discharge medications by creating an accurate list of both prescription and over the counter medications that includes the drug name, dosage, frequency, route, and indication for use) for one of three sampled residents (Resident 1). […]

• No harm, potential for more than minimal, isolatedF641Jun 4, 2024

  Based on interview and record review, the facility failed to ensure the assessment of one of 5 sampled residents (Resident 1) accurately reflected the resident's redness on his right chest on 9/8/23, 9/9/23, 9/10/23, 9/12/23, 9/13/23, 9/14/23, 9/15/23, 9/17/23, and 9/19/23. This deficient practice had the potential to result in Resident 1 not receiving appropriate treatments and services. Findings: Review of Resident 1's clinical record indicated, Resident 1 was admitted on [DATE] (Saturday) for rehab after his hospital stay from 8/12/23 to 8/26/23 due to his fall. […]