California Pacific Medical Ctr- Davies Campus Hosp

Based on interview and record review the facility failed to ensure as needed (PRN) psychotropic medications (a class of psychiatric drugs that helps manage severe mental health symptoms) for two out of three residents (Residents 10 and 30) were limited to 14 days and/or attending physician or prescribing practitioner documentation to support medication order extension.This failure had the potential to result in adverse consequences ranging from functional decline, hospitalization, permanent injury, or death.Findings:During a concurrent interview and record review on 1/08/2025 at 1:45 PM with Pharmacy Manager (Pharm), Resident 30's Hospital Medication Detail (undated) was reviewed. The hospital medication detail indicated, an order for Lorazepam (ATIVAN) tab 2 mg.Frequency: Bedtime PRN for Anxiety, Trouble Sleeping.Start Date/Time:01/02/26.End Date/Time: --. Pharm stated, the order was a low dose psychotropic medication, that was appropriately prescribed as needed (PRN) for anxiety and insomnia (trouble sleeping). When asked if as needed (PRN) medications required a specific…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to monitor weights according to physician orders for two (Resident 14 and Resident 16) out of 12 sampled residents.This failure may limit and/or negatively impact clinicians' treatment decisions due to unavailable information. Findings:Review of Resident 14's record titled Minimum Data Set (MDS), dated [DATE], indicated she was admitted to the Skilled Nursing Facility (SNF) on 12/19/2025 and had multiple diagnoses including malnutrition (not eating enough nutrients to maintain body functions).Review of Resident 14's record titled Manage Orders, dated 12/21/2025, indicated staff was supposed to obtain her .Weight Weekly.Review of Resident 14's record titled NUTRITIONAL ASSESSMENT, dated 12/26/2025, and authored by Registered Dietitian (RD1), indicated weight .Readings from last 10 Encounters: 12/19/25 59.8 Kg (kilogram).stated 12/17/25 59.8 kg . stated.During a concurrent interview and review of Resident 14's electronic records with the Nurse Manager (NM)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure Resident 14 (one out of 12 sample residents) was free from unnecessary medication when Remeron (a medication that treats depression and other conditions by adjusting brain chemistry to improve mood, energy, and feelings of well-being, helping to regulate mood, sleep, and appetite ) was prescribed with no identified target behaviors and no diagnosis related to depression (a serious mood disorder causing persistent sadness, loss of interest, and impacting daily life, affecting how you feel, think, and handle activities like sleeping, eating, or working). This failure may result in the use of Remeron as an unnecessary medication.Findings: Review of Resident 14's record titled Manage Orders, dated 12/21/2025, indicated Resident 14 was prescribed 15 mg (milligram) of Remeron at bedtime. Review of Resident 14's record titled Minimum Data Set (MDS), dated [DATE], indicated she was admitted to the Skilled Nursing Facility (SNF) on 12/19/2025 and had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to store food in a sanitary manner when:1.A container of soup and an opened bag of meatballs were not dated.2.Food debris, an avocado, a packet of parsley, and a packet of cilantro were found on the floor of the walk-in refrigerator and freezer.Failure to store food in a sanitary manner had the potential to subject residents to contaminated food and/or foodborne illnesses.Findings:During a concurrent observation and interview on 1/6/2026 at 10:03 AM with the Food Service Manager (FSM), these were found within the kitchen:1.A container of soup and an opened bag of meatballs were not dated.2.Food debris, an avocado, a packet of parsley, and a packet of cilantro were found on the floor of the walk-in refrigerator and freezer.During an interview, the FSM acknowledged the soup should have been dated for today and the bag of meatballs should have been dated when staff opened the bag. When the observation regarding the walk-in refrigerator and freezer were shared with the FSM, she stated staff should have been cleaning…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure two out of 12 sampled residents' (Resident 11 and 22) dignity were protected when their urinary bags were clearly visible from the hallway and were not contained in urinary bags. This failure may cause feelings of embarrassment to both Residents 11 and 22. Findings: During initial observation on 04/25/2023 at 10:00 AM, Resident 11's urinary bag was hanging by the foot of his bed and was clearly visible from the hallway. During initial observation on 04/25/2023 at 11:25 AM, Resident 22's urinary bag was hanging by the foot of her bed and was clearly visible from the hallway. During an interview on 04/28/2023 at 8:49 AM, the Charge Nurse (CN) stated the facility has privacy bags to cover up a resident's urinary bag. However, staff only put the privacy bags on when a resident goes out. Review of the facility's policy titled Policy - Indwelling Urinary Catheter Insertion, Maintenance, and Removal (Adults and Pediatrics), revised on 06/06/2022, found no information about use of privacy bags.

Based on interview, and record review, the facility failed to send a copy of the written notice to a representative of the Office of the State Long-Term Care Ombudsman after the facility-initiated discharge for Resident 20. This failure had the potential not to provide added protection to residents from being inappropriately discharged , provide residents with access to an advocate who can inform them of their options and rights, and to ensure that the Ombudsman is aware of facility practices and activities related to transfers and discharges. Findings: Review of Resident 20's Discharge Summary, dated 4/24/23, indicated, he was admitted in the facility on 2/8/23, then discharged on 4/24/23 with discharge diagnoses including heart failure (a condition that develops when your heart does not pump enough blood for your body's needs), acute renal failure (a condition in which the kidneys suddenly cannot filter waste from the blood), and diabetes mellitus (a disease of inadequate control of blood sugar). Review of Resident 20's Care Team Note, dated 4/24/23, indicated, . Left unit via…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to measure pressure injuries for 1 of 12 sampled residents (Resident 8) upon admission and on a regular basis. This failure to measure Resident 8's pressure injuries on his left and right heels upon admission and on a regular basis did not ensure the facility was objectively monitoring these pressure injuries over time (102 days). Findings: Review of Resident 8's medical record titled MINIMUM DATA SET (MDS, a standardized resident assessment tool), dated 03/29/2023, indicated he was admitted to the facility on [DATE]. He was totally dependent on two staff for bed mobility, and he was totally dependent on one staff for: dressing, toilet use, and personal hygiene. His MDS indicated he was admitted with unhealed pressure injuries. During an interview and concurrent record review on 04/27/2023 at 10:45 AM, RN 2 (Registered Nurse) stated Resident 8 was originally admitted to the hospital's emergency room with two pressure injuries back in 01/02/2023. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure safe and sanitary conditions were met for food storage when nine expired nutrition supplements were found in the kitchen storage room. This failure had the potential to put residents at risk for foodborne illnesses. Findings: During a concurrent observation and interview on 4/25/23, at 11:20 AM, with Registered Dietitian (RD), there were nine items of nutrition supplements labeled, Katefarms Peptide 1.5 cal/mL plain in the kitchen storage room, with marks indicating Best if used by: [DATE]. When asked if these nine items were expired, RD stated, Expired. Yes, correct. During an interview on 4/25/23, at 11:24 AM, with Food and Nutrition Manager (FNM) who was witnessing this incident stated, Yes, I agree . when asked if these nine items were expired. During an interview on 4/25/23, at 11:33 AM, with Nursing Operations Manager (NOM) who was also witnessing this incident acknowledged, these nine items were expired. Review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure a refuse (solid waste not carried by water through the sewage system) container had a lid and refuse were disposed in a proper manner. This failure had the potential to promote development and spread of communicable diseases and infections that could jeopardize the health of the residents in the facility. Findings: During a concurrent observation and interview on 4/26/23, at 8:53 AM, with food service supervisor (FSS), outside of the facility building far enough from the kitchen, there was a green plastic garbage container full of trash. There was no lid attached to the garbage container. There were also several very tiny flies flying around the garbage container. FSS stated, It should be shut when asked about the policy of the garbage container. When asked if he could see the tiny flies around the garbage container, FSS stated, Yes. Observation of another metal garbage container nearby indicated, it was closed but a garbage bag with dark brownish wet material inside was protruding outside the closed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, a nurse failed to follow facility policy regarding disinfecting a shared device after medication administration. Failure to disinfect a shared device did not ensure other residents were protected from infection. Findings: Review of Resident 12's medical records titled INFECTIOUS DISEASES FOLLOW UP PROGRESS NOTE, dated 04/17/2023, indicated he has a history of infections with MDRO (multi drug resistant organism) and was currently on three antibiotics to treat a bacterial infection. Review of the front page of Resident 12's electronic medical record with RN 2 on 04/28/2023 at 11:49 AM indicated Resident 12 was on contact precaution. Review of the facility's policy titled Policy - Infection Control Strategies- Guidelines for Use of Transmission Based Precautions: Airborne, Droplet, Contact Precautions, and Enhanced Contact Precautions, revised on 01/20/2022, indicated .Contact, or touch, is the most common and most significant mode of transmission of infectious agents. Contact transmission can occur by directly touching the patient,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.