Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pacifica Hospital Of The Valley Dp Snf during CMS and state inspections, most recent first.
A resident with a history of head trauma and a skin lesion had a dermatology appointment canceled due to staffing shortages, but the conservator was not consulted prior to the cancellation. Facility staff confirmed that the conservator, who holds exclusive authority for medical decisions, was only notified after the fact, violating the resident's rights to participate in care planning and informed consent.
A facility failed to inform a resident's family about the care plan and changes in condition, causing family anxiety due to lack of input in treatment. The resident, with a history of traumatic SDH and chronic respiratory failure, was unaware of treatment discussions. The CNO admitted to not communicating with the family, and the Social Worker confirmed the family's exclusion from IDT meetings. The facility's failure to maintain regular contact with the family and update them on significant changes led to this deficiency.
The facility failed to submit staffing information to CMS for two quarters in 2024 due to the absence of the responsible staff member and the departure of key personnel with access to the reporting portal. This resulted in incomplete staffing data for the 3rd and 4th quarters.
The facility failed to develop comprehensive care plans for three residents, leading to potential inadequate care. A resident with a stroke did not have a care plan for their RNA program, while two residents on antibiotic therapy lacked care plans to monitor adverse reactions. This failure to adhere to care planning policies could result in unaddressed complications.
The facility failed to involve residents or their representatives in IDT care conferences, affecting the development of resident-centered care plans. Additionally, a resident's care plan was not updated after the removal of an indwelling catheter, leading to inaccurate medical records and potential care issues.
The facility failed to implement necessary safety measures for three residents, leading to potential injury risks. Two residents with seizure disorders were found without required padded side rails, and a third resident had a broken wheelchair with a malfunctioning hand brake and footrest. Staff acknowledged the deficiencies, which were contrary to physician orders and care plan directives.
The facility failed to manage G-tube administration properly, leading to potential health risks. An LVN did not check a resident's stomach residual before administering medication, risking aspiration pneumonia. Another resident's feeding bottle lacked labeling, risking infection from spoiled formula. Additionally, a feeding syringe was not labeled, risking cross-contamination, and another resident's feeding formula was not labeled with the time and date, risking adverse reactions.
A facility failed to ensure physician orders were signed and dated for three residents, leading to potential delays in care. One resident with respiratory failure had unsigned orders for physical therapy and nursing assistance. Another resident with diabetes and anemia had undated medication and lab orders. A third resident had an undated lab order for iron levels. Interviews confirmed the orders were not properly documented, violating facility policy.
A resident admitted with complex medical conditions did not receive a social service assessment within the required 48 hours due to the social worker being overwhelmed with other assignments. The facility's policy mandates timely assessments to address psychosocial needs and assist with adjustment, which was not adhered to, placing the resident at risk.
The facility failed to ensure proper documentation of controlled drug administration and timely replacement of emergency kits. Two residents had discrepancies between the Controlled Drug Record and Medication Administration Records, while three residents experienced delays in e-Kit replacement after Ativan was used. Staff interviews revealed non-compliance with facility policies, potentially leading to medication errors and service delays.
The facility failed to properly label and store medications, risking the administration of expired or discontinued drugs. An open potassium chloride solution lacked an open date, and a discontinued chlorhexidine solution was stored without a physician's order. Additionally, a Vitamin A and D ointment was undated, violating facility policy on medication shelf life.
The facility failed to label food stored in its freezers with the date they were placed, as observed by a registered dietician. Unlabeled frozen pork chops and fish sticks were found, contrary to the facility's policy requiring labeling for easy identification. This practice potentially risked 17 out of 58 residents receiving food from the facility's kitchen.
The facility failed to maintain infection control practices, as observed in three separate incidents involving staff not wearing protective gowns when required. A housekeeper entered a contact isolation room without a gown and failed to perform hand hygiene. An LPN administered medication via a gastrostomy tube to a resident on enhanced barrier precautions without a gown, acknowledging the oversight. Another LPN administered enteral feeding and medication without a gown, unaware of the requirement. These lapses in PPE usage could lead to cross-contamination and infection spread.
A facility failed to keep a call light within reach of a resident who was totally dependent on staff for all ADLs and had intact cognition. The resident's care plan required the call light to be easily accessible, but it was observed out of reach. Staff confirmed the deficiency, acknowledging it could prevent the resident from requesting assistance, contrary to facility policy.
The facility failed to follow its advance directive policies for two residents. One resident was not provided with information about their right to create an advance directive upon admission, despite having intact cognitive skills. Another resident's advance directive was not maintained in their clinical record, despite severe cognitive impairment and total dependence on staff. These deficiencies were confirmed through staff interviews and record reviews.
A resident with complex medical needs was discharged from an LTC facility without a proper care plan or discharge planning assessment. The resident, who required significant assistance and had severe cognitive impairments, did not have a discharge plan developed or documented by the social worker, who was on medical leave. The Director of Nursing confirmed the discharge planning was incomplete, as no interdisciplinary team conference was held to address the resident's needs.
A facility failed to monitor a resident for orthostatic hypotension as per physician's orders on two occasions. The resident, with a history of dysphagia, bipolar disorder, and schizophrenia, was at high risk for falls. Despite the physician's order to monitor from 7:00 a.m. to 7:00 p.m. weekly, documentation was missing for specific weeks in October and November. A nurse confirmed the importance of this monitoring to prevent falls, aligning with the facility's policy to monitor residents on certain medications for adverse effects.
The facility failed to document pain management for two residents, as pain assessments were not conducted before and after administering Norco. The MAR lacked entries for medication administration, and interviews with staff confirmed that the process of signing the MAR was not followed, leading to potential unmanaged pain.
The facility failed to act on a pharmacist's recommendations for two residents, leading to deficiencies in medication management. One resident's need for FeroSul was not reassessed, and another resident did not receive recommended blood testing for levetiracetam levels. The facility lacked a specific policy for addressing the monthly Medication Regimen Review, contributing to these deficiencies.
A facility failed to monitor a resident for side effects of Cymbalta, prescribed for depression. Despite the care plan's directive, there was no documentation of monitoring, confirmed by a nurse. The resident had a history of Guillain-Barre syndrome, diabetes, and hypertension, and required maximal assistance with ADLs. The DSD acknowledged the need for monitoring to adjust medication dosage, as per facility policy.
The facility failed to maintain safe room temperatures for 51 residents in the Sub-Acute Unit due to malfunctioning chillers and inadequate monitoring by engineering staff. Despite installing rental chillers, temperatures ranged from 77 to 82 degrees Fahrenheit, exceeding the acceptable range. Staff interviews and observations confirmed the deficiency, highlighting a lack of adherence to facility policies for temperature monitoring.
Failure to Involve Conservator in Medical Appointment Cancellation
Penalty
Summary
The facility failed to ensure that a resident's conservator was included in the decision to cancel a scheduled dermatology appointment. The resident, who was admitted for long-term care following head trauma resulting in cerebral swelling and a right temporal contusion, had a dermatology consult scheduled for a skin lesion related to dermatitis. The appointment was canceled due to a lack of available staff to accompany the resident, and the conservator was not consulted prior to this decision. Instead, the conservator was only notified after the cancellation and informed of the need to reschedule. Interviews with facility staff confirmed that there was no communication with the conservator before the appointment was canceled, despite the conservator's legal authority to make medical decisions for the resident. The facility's own admission agreement and resident rights documentation indicated that residents and their representatives have the right to participate in care planning and to be informed about medical appointments. The Director of Staff Development acknowledged that the lack of communication with the conservator before canceling the appointment was a violation of the resident's rights.
Failure to Inform Family of Resident's Care Plan and Condition
Penalty
Summary
The facility failed to inform the family of a resident's plan of care and change of condition, leading to anxiety for the family due to their lack of input into the resident's treatment. During an observation, the resident was seen with a tracheostomy and was able to speak in short sentences. The resident mentioned that his mother visits daily, but he was unaware of the outcome of discussions regarding his treatment. The Chief Nursing Officer admitted to not having direct conversations with the resident's mother, despite the resident being a candidate for transfer to a lower level of care. The facility's Social Worker acknowledged that there was a delay in obtaining a neurosurgery consultation due to insurance issues and confirmed that the family had not been included in previous Inter-Disciplinary Team (IDT) meetings. The resident's medical records indicated a history of traumatic subdural hemorrhage and chronic respiratory failure, with a plan for transfer to a facility providing a lower level of care. However, the resident's mother was unable to care for him at home, and there was no record of communication with her regarding the resident's current medical condition. The Social Worker's job description emphasized the importance of maintaining regular contact with residents' families and updating them on significant changes or concerns. Despite this, the facility failed to include the family in the resident's care planning process, as evidenced by the lack of documentation of communication with the family and their exclusion from IDT meetings. This deficiency highlights a breakdown in communication and collaboration between the facility and the resident's family, impacting the resident's care and the family's involvement in decision-making.
Failure to Submit Staffing Data for Two Quarters
Penalty
Summary
The facility failed to electronically submit staffing information based on payroll data to the Centers for Medicare and Medicaid Services (CMS) for two fiscal quarters in 2024. Specifically, the facility did not submit the required Payroll-Based Journal Staffing Data Report (PBJ-SDR) for the 3rd quarter (April 1 to June 30) and the 4th quarter (July 1 to September 30) of 2024. This deficiency was identified during an interview and record review with the Director of Staff Development (DSD), who revealed that the individual responsible for submitting the PBJ-SDR was on medical leave. Additionally, the previous facility Administrator and Director of Nursing (DON), who had access to the reporting portal, were no longer employed by the facility, which contributed to the failure to submit the data. The facility's policy, titled PBJ Data Submission Specifications, dated April 16, 2020, mandates that staffing and census information be reported electronically to CMS through the Payroll-Based Journal system in compliance with section 6106 of the Affordable Care Act. The policy specifies that staffing information should be collected daily and submitted for each fiscal quarter no later than 45 days after the end of the reporting quarter. The failure to adhere to this policy resulted in incomplete and inaccurate direct care staffing information being unavailable to the public for the specified quarters.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to potential inadequate care. For Resident 46, who was admitted with diagnoses including stroke, tracheostomy, gastrostomy, and seizure disorder, the facility did not create a care plan addressing the Restorative Nursing Assistant (RNA) program. Despite a physician's order for passive and active assistive range of motion exercises, no person-centered interventions were developed, which could result in inadequate monitoring and care for the resident's condition. For Resident 57, who was admitted with chronic renal failure and type 2 diabetes mellitus, the facility did not develop a short-term care plan for antibiotic therapy after a change in condition due to pneumonia. The absence of a care plan meant that adverse reactions to the prescribed antibiotic, Zosyn, could go unmonitored, potentially leading to complications such as dehydration. The facility's policy required a care plan to ensure timely intervention and effective treatment evaluation, which was not followed. Similarly, Resident 55, who was in a persistent vegetative state and diagnosed with dysphagia and hypertension, did not have a care plan developed for antibiotic therapy after a change in condition due to urosepsis. The lack of a care plan for monitoring adverse reactions to Zosyn could result in unaddressed complications. The facility's failure to adhere to its care planning policy, which mandates updates upon changes in condition, contributed to these deficiencies.
Failure to Involve Residents in Care Planning and Update Care Plans
Penalty
Summary
The facility failed to ensure that the Interdisciplinary Team (IDT) invited residents or their representatives to participate in care conferences for three out of five sampled residents. This lack of involvement was observed in residents who were in a persistent vegetative state and totally dependent on staff for self-care. The facility's policy encourages the participation of residents or their representatives in IDT meetings to ensure the care plan is resident-centered. However, the facility did not extend invitations to the representatives of these residents during several IDT meetings, potentially leading to care plans that were not tailored to the residents' needs. Additionally, the facility failed to update and revise a resident's care plan after the removal of an indwelling catheter. The resident, who had a history of hemorrhagic stroke and recurrent urinary tract infections, had their catheter removed, but the care plan was not revised to reflect this change. The care plan continued to include interventions related to the catheter, which was no longer applicable. This oversight was acknowledged by the MDS Nurse and the Director of Nursing, who stated that care plans should be updated immediately after such changes to ensure accurate medical records and appropriate care. The facility's policy on care planning requires that a coordinated and comprehensive written plan be developed based on the resident assessment instrument and updated upon any change of condition. However, the failure to revise the care plan after the catheter removal indicates a lapse in adhering to this policy. The Director of Nursing emphasized the importance of having care plans that reflect the current condition of residents to provide appropriate care and services.
Failure to Implement Safety Measures for Residents
Penalty
Summary
The facility failed to implement necessary accident risk and hazard interventions for three residents, leading to potential injury risks. Resident 30, who has a seizure disorder, was observed without the required padding on the bed side rails, despite physician orders and care plan interventions specifying the need for such precautions. The Licensed Vocational Nurse confirmed the absence of padding and acknowledged the risk of injury during a seizure. Similarly, Resident 34, also diagnosed with a seizure disorder, was found without padded side rails, contrary to physician orders and care plan directives. The Director of Nursing confirmed that the staff did not implement the required seizure precautions, which could result in injuries during seizure activity. Resident 18 experienced issues with a broken wheelchair, which had a malfunctioning hand brake and footrest. Despite the resident's intact cognitive skills and ability to voice concerns, the wheelchair remained unrepaired for two weeks, with the resident resorting to using a rubber band to hold the hand brake in place. The Registered Nurse acknowledged awareness of the broken wheelchair components and admitted to not following up on the repair status. The Director of Nursing confirmed that staff failed to ensure the wheelchair was functioning properly, posing a risk of falls and injuries. The facility's policies and procedures for seizure precautions and safety precautions were not adhered to, as evidenced by the lack of padded side rails for Residents 30 and 34 and the unresolved issues with Resident 18's wheelchair. These deficiencies highlight the facility's failure to provide a safe environment and adequate supervision to prevent accidents, as required by their own guidelines.
Deficiencies in G-Tube Management and Labeling
Penalty
Summary
The facility failed to properly manage the administration of medications and feeding through gastrostomy tubes for several residents, leading to potential health risks. In one instance, a Licensed Vocational Nurse (LVN) did not check the residual volume in the stomach of a resident in a persistent vegetative state before administering Tramadol via a G-tube. This oversight could have increased the risk of aspiration pneumonia, as the medication might have been delivered into the lungs if the tube was improperly placed. Another deficiency was observed with a resident whose G-tube feeding bottle was not labeled with the date and time it was started. This lack of labeling made it impossible to determine if the feeding formula had been used for more than 24 hours, posing a risk of infection from spoiled formula. The facility's policy requires that feeding bottles be labeled to ensure they are changed within the safe time frame. Additionally, the facility did not label a feeding syringe with the resident's name and the date it was last changed, which could lead to cross-contamination and increased risk of healthcare-acquired infections. Furthermore, another resident's feeding formula was not labeled with the time, date, and initials of the nurse who initiated it, potentially allowing the formula to exceed its safe hang-time, which could cause adverse reactions. These deficiencies highlight lapses in following established protocols for enteral feeding management.
Physician Orders Not Properly Signed and Dated
Penalty
Summary
The facility failed to ensure that physicians signed and dated all orders in the physical or electronic records during visits for three residents. Resident 4, who was admitted with respiratory failure and had severe cognitive impairment, had several telephone orders related to physical therapy and nursing assistance that were not signed, dated, or timed by a physician. These orders included evaluations and exercises for maintaining the resident's functioning, as well as the application of supportive devices. Resident 13, who was cognitively intact and had diagnoses of diabetes mellitus and anemia, had multiple medication and laboratory orders that lacked dates and times. These orders included medications for weight loss and allergies, as well as laboratory tests and imaging studies. Similarly, Resident 51, who was severely cognitively impaired and dependent on staff for daily activities, had an order for laboratory tests related to iron levels that was not dated or timed. Interviews with the Director of Staff Development and the Director of Nurses confirmed that the orders were not properly signed, dated, or timed, which is against the facility's policy. The facility's policy requires that all medication orders be clear, complete, and signed by a licensed physician, with telephone orders countersigned within five days. The lack of proper documentation could lead to delays in the residents' care plans.
Failure to Conduct Timely Social Service Assessment
Penalty
Summary
The facility failed to implement its policy and procedure for conducting a social service assessment within 48 hours of admission for a resident. The resident, who was admitted with complex medical conditions including stroke, tracheostomy, gastrostomy, and seizure disorder, did not receive a timely social service assessment. Despite having intact cognitive skills and being dependent on staff for various daily activities, the resident reported not having seen a social worker since admission. The social worker confirmed that no assessment was conducted due to being overwhelmed with other assignments. The facility's policy requires social workers to meet with residents within 24 hours of admission and complete an initial assessment within 48 hours. This assessment is crucial for gathering psychosocial information pertinent to the resident's adjustment and well-being. The Director of Nursing acknowledged the lapse, emphasizing the importance of timely assessments to address psychosocial concerns and assist with the resident's adjustment to the facility. The failure to conduct the assessment as per policy placed the resident at risk of not receiving appropriate social services to meet their needs.
Medication Administration and e-Kit Replacement Deficiencies
Penalty
Summary
The facility failed to ensure that the Controlled Drug Record (CDR) coincided with the Medication Administration Records (MAR) for two residents, which could lead to medication errors or drug diversion. Resident 6, who was severely impaired in cognition and dependent on staff for daily activities, had discrepancies in the administration of Norco and lorazepam. The CDR indicated that these medications were removed on specific dates, but there were no corresponding entries in the MAR. Similarly, Resident 42, who was cognitively intact but required assistance with daily activities, had a discrepancy with the administration of Norco. The CDR showed that Norco was removed, but the MAR did not reflect this administration. The facility also failed to replace the refrigerator emergency kit (e-Kit) within 72 hours after medications were removed for three residents. Resident 4, who was severely impaired in cognition and had a diagnosis of seizures, received Ativan from the e-Kit, but the kit was not replaced in a timely manner. Resident 27, also severely impaired in cognition and with a seizure diagnosis, had a similar issue with the e-Kit not being replaced after Ativan was administered. Additionally, Resident 14, who had a seizure disorder and was totally dependent on staff, had an e-Kit opened for Ativan, but the replacement process was not followed, and the log for usage was missing. Interviews with staff, including the Director of Staff Development (DSD) and the Director of Nursing (DON), revealed that the process for documenting medication administration and replacing the e-Kit was not followed. The facility's policies and procedures required immediate documentation on the MAR after administering controlled drugs and prompt replacement of the e-Kit within 72 hours. However, these protocols were not adhered to, leading to potential delays in pharmaceutical services and inadequate documentation of medication administration.
Medication Labeling and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, leading to potential risks of administering expired or discontinued drugs. In one instance, an open potassium chloride solution used for a resident with severe cognitive impairment and total dependency on staff was found without an open date, making it difficult to determine its beyond use date. This oversight was confirmed by a registered nurse during an observation of the medication cart. Another deficiency involved the storage of an open and discontinued chlorhexidine solution in the medication cart for a resident who had no physician's order for this medication. The solution was not labeled with an open date, and the Director of Staff Development acknowledged that medications without orders should be removed promptly to prevent medication errors. The facility's policy mandates the removal of outdated or discontinued medications, which was not adhered to in this case. Additionally, a container of Vitamin A and D ointment was found in a medication cart without an open date. The Director of Staff Development confirmed that all opened medications should be dated to track their shelf life. The facility's policy requires that floor stock medications not be maintained beyond the manufacturer's expiration date or 180 days after opening, which was not followed in this instance.
Improper Food Storage Practices in Facility Freezers
Penalty
Summary
The facility failed to ensure proper food storage practices by not labeling food stored in the facility's freezers with the date they were placed in the freezer. This deficiency was observed during a survey when a registered dietician found an unlabeled plastic bag containing five individually sealed frozen pork chops in Freezer 1 and an unlabeled bag of frozen fish sticks in Freezer 2. Both the registered dietician and the dietary supervisor confirmed that all food items in the freezer are required to be labeled with the date they were placed in the freezer. The facility's policy and procedure for Food and Nutrition Services, last reviewed in March 2021, also indicated that frozen foods should be labeled with the name of the item and date of delivery for easy identification. This practice had the potential to place 17 out of 58 residents who receive food from the facility's kitchen at risk for foodborne illnesses.
Infection Control Lapses in PPE Usage
Penalty
Summary
The facility failed to maintain proper infection control practices in several instances, leading to potential cross-contamination and infection spread. In one case, a housekeeper entered a resident's room, which was under contact isolation due to Carbapenem-resistant Enterobacterales (CRE) and Extended-Spectrum Beta-Lactamases (ESBL) in the urine, without donning a gown. After collecting trash, the housekeeper exited the room, removed gloves, and failed to perform hand hygiene. This was observed by a Licensed Vocational Nurse (LVN), who confirmed that all staff entering such rooms are required to wear gloves and gowns and perform hand hygiene to prevent infection spread. In another instance, a Licensed Vocational Nurse (LVN) administered medication via a gastrostomy tube to a resident on enhanced barrier precautions without wearing a protective gown. The LVN acknowledged the oversight and recognized that wearing a gown is necessary to prevent cross-contamination, as staff clothing can become contaminated when caring for multiple residents. The facility's policy requires staff to don personal protective equipment, including gowns, during high-contact resident care activities. A third incident involved another LVN who administered enteral feeding and medication via a gastrostomy tube to a resident on enhanced barrier precautions without wearing a gown. The LVN was unaware of the requirement to wear a gown during such procedures. The Director of Staff Development and the Infection Preventionist confirmed that the facility's policies mandate the use of gowns and gloves during high-contact activities to prevent the spread of multidrug-resistant organisms. These deficiencies highlight lapses in adherence to infection control protocols, potentially compromising resident and staff safety.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the call light was within reach of Resident 11, who was totally dependent on staff for all activities of daily living and had intact cognition. Resident 11 was admitted with diagnoses including Guillain-Barre syndrome, diabetes mellitus type 2, and hypertension. The resident's care plan specifically indicated that the call light should be placed within easy reach at the bedside. However, during an observation, it was noted that the adaptive call light was positioned on the left side of the head of the bed, out of reach for the resident, who could only move his head. Interviews with Registered Nurse 3 and the Director of Staff Development confirmed that the call light was not within reach, which contradicted the facility's policy and procedure. The policy required that call cords be placed within the resident's reach at all times. The staff acknowledged that the deficient practice could prevent the resident from requesting assistance and potentially lead to falls. The facility's policy emphasized the importance of ensuring that call lights are always accessible to residents.
Failure to Follow Advance Directive Policies
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding advance directives for two residents, Resident 46 and Resident 35. For Resident 46, the facility did not provide written information about the right to refuse or accept medical or surgical treatments and to formulate an advance directive upon admission. This was confirmed during interviews with Registered Nurse 1 and Social Worker 1, who acknowledged that the Advance Directive Acknowledgment form was not completed for Resident 46 upon admission, which is a violation of the resident's right to be informed about advance directives. Resident 46 was admitted with several medical conditions, including a stroke, tracheostomy, gastrostomy, and seizure disorder. Despite having intact cognitive skills for daily decision-making, the facility did not ensure that Resident 46 was informed about the option to create an advance directive, as required by the facility's policy. The policy mandates that residents be provided with written information about their rights concerning medical treatment and advance directives upon admission. For Resident 35, the facility failed to maintain a current copy of the resident's advance directives in the clinical record. Although the Advance Directive acknowledgment form indicated that Resident 35 had an advance directive, it was not present in the resident's chart. This oversight was confirmed by Social Worker 1 and the Director of Staff Development, who both stated that a copy of the advance directive should have been kept in the resident's chart to ensure the resident's wishes would be carried out. Resident 35 had severe cognitive impairment and was totally dependent on staff for all activities of daily living, making it crucial for the facility to have the advance directive readily available to guide care decisions.
Failure in Discharge Planning for a Resident with Complex Needs
Penalty
Summary
The facility failed to adhere to its discharge planning policy and procedure for a resident, identified as Resident 60, who was discharged without a proper care plan or discharge planning assessment. The resident, who had significant medical needs including a tracheostomy, gastrostomy, and seizure disorder, was admitted to the facility with severely impaired cognitive skills and was dependent on staff for various daily activities. Despite these needs, the facility did not develop a care plan addressing the resident's discharge plan or initiate a discharge planning assessment prior to the resident's discharge. The review of the resident's records revealed that the interdisciplinary team (IDT) conference notes lacked documentation for psychosocial and discharge planning sections. The social worker, who was responsible for the discharge planning, was on medical leave during the last IDT conference and did not document any discharge planning notes or develop a care plan for the resident's discharge. The social worker acknowledged the oversight and stated that it was important to comply with the facility's discharge policy by documenting all necessary discharge information and conducting required assessments. The Director of Nursing confirmed that the discharge planning for Resident 60 was incomplete, as there was no care plan developed for the resident's discharge needs, and no IDT conference was held to discuss these needs. The facility's policy required the social worker to document the level of care required for discharge within seven days of admission and to update it as needed. However, this was not done, and the discharge planning assessment was not initiated, leading to a lack of provision of necessary discharge care and services for the resident.
Failure to Monitor Orthostatic Hypotension
Penalty
Summary
The facility failed to adhere to a physician's order by not monitoring a resident for orthostatic hypotension on two specific dates, 10/23/2024 and 11/27/2024. This oversight involved a resident who had been admitted to the facility on 8/17/2021 and had a history of dysphagia, bipolar disorder, and schizophrenia. The resident's Minimum Data Set (MDS) indicated intact cognitive skills for daily decision-making and a requirement for supervision in certain activities. The resident was also identified as high risk for falls according to a Fall Risk Assessment. The physician's order, dated 2/3/2023, required monitoring for orthostatic hypotension from 7:00 a.m. to 7:00 p.m. weekly, which was not documented in the Medication Administration Records (MAR) for the specified weeks in October and November 2024. During an interview, a registered nurse confirmed the importance of monitoring for orthostatic hypotension, especially for residents on medications like Zoloft, to prevent potential falls and injuries. The facility's policy emphasized monitoring residents on certain medications for adverse effects, but this was not followed in the case of the resident in question.
Failure to Document Pain Management for Two Residents
Penalty
Summary
The facility failed to ensure proper pain management for two residents, Resident 6 and Resident 42, by not assessing their pain before and after administering pain medication. Resident 6, who was severely impaired in cognition and dependent on staff for daily activities, had orders for Norco to be administered via G-Tube for severe pain. However, the Medication Administration Record (MAR) did not reflect the administration of Norco on several dates, and there was no documentation of pain assessment for those times. Similarly, Resident 42, who was cognitively intact and required assistance with daily activities, had orders for Norco to be administered orally for severe pain. The Controlled Drug Record (CDR) indicated that Norco was removed from the blister pack, but the MAR did not show any record of administration or pain assessment on the specified date. Interviews with the Director of Staff Development (DSD) and the Director of Nurses (DON) confirmed that the process of signing the MAR after administering medication was not followed, which is crucial for assessing the effectiveness of pain relief. The facility's policies and procedures for controlled drug management and medication administration were not adhered to, as the licensed nurses failed to document the administration of pain medication on the MAR. This lack of documentation meant that there was no assessment or reassessment of the residents' pain levels, potentially leaving their pain unmanaged. The DON stated that the absence of documentation on the MAR indicated that pain was not assessed, which could result in the residents' pain not being relieved.
Failure to Act on Pharmacist Recommendations for Medication Review
Penalty
Summary
The facility failed to act upon the consultant pharmacist's recommendations for two residents, leading to deficiencies in medication management. For Resident 17, who was admitted with respiratory failure and was cognitively intact, the facility did not reassess the need for the medication FeroSul, which had been prescribed since admission. Despite the consultant pharmacist's recommendation to reassess the necessity of this medication, there was no documentation indicating that the physician had been contacted to address this concern. Similarly, for Resident 35, who had severe cognitive impairment and was dependent on staff for all activities of daily living, the facility did not follow the consultant pharmacist's recommendation to order blood testing for levetiracetam, a medication used to treat seizures. The recommendation was made to ensure the medication levels were within a safe range, but no Keppra level test was conducted. This oversight was acknowledged by the nursing staff, who recognized the increased risk of medication side effects due to the lack of monitoring. The facility's policies and procedures for medication administration and pharmaceutical services were reviewed, highlighting the requirement for medications to be administered according to physician orders and for any concerns about medication orders to be clarified with the pharmacy. However, the facility lacked a specific policy for addressing the monthly Medication Regimen Review (MRR) and the timeframe for addressing issues raised in the report, contributing to the deficiencies observed.
Failure to Monitor Side Effects of Cymbalta
Penalty
Summary
The facility failed to monitor a resident for side effects associated with the use of Cymbalta, a medication prescribed for depression. The resident, who had a history of Guillain-Barre syndrome, diabetes mellitus type 2, and hypertension, was admitted to the facility with intact cognition but required maximal assistance with activities of daily living. Despite the care plan's directive to monitor for adverse side effects every shift, there was no documentation indicating that the licensed nurses were performing this monitoring. During an interview, a registered nurse confirmed the administration of Cymbalta to the resident over several consecutive days but could not provide evidence of side effect monitoring. The Director of Staff Development acknowledged the necessity of monitoring for adverse side effects to inform the physician and adjust the medication dosage if needed. The facility's policy on psychoactive drug monitoring also required documentation of monitoring for adverse consequences, which was not adhered to in this case.
Failure to Maintain Safe Room Temperatures in Sub-Acute Unit
Penalty
Summary
The facility failed to maintain acceptable room temperatures ranging from 71 to 81 degrees Fahrenheit for 51 residents in the Sub-Acute Unit. This deficiency was identified through observations, interviews, and record reviews. The facility's chillers, which are essential for the air conditioning system, were not functioning properly, and the temporary rental chillers installed as replacements were also not working correctly. The engineering staff did not monitor or record the room temperatures as required by the facility's policies, leading to unsafe conditions for the residents. Interviews with various staff members, including the Chief Nursing Officer, House Supervisor, and engineering staff, revealed that the chillers had malfunctioned, and the rental chillers were installed incorrectly by the vendor. Despite the installation of rental chillers, the engineering staff failed to verify the room temperatures, and no temperature logs were maintained. Observations confirmed that the room temperatures ranged from 77 to 82 degrees Fahrenheit, exceeding the acceptable range and creating a hot environment in the Sub-Acute Unit. The facility's policies and procedures required daily monitoring and documentation of room temperatures, but these were not followed. The engineering department was expected to have a contingency plan for air conditioning failures, but this was not effectively implemented. The lack of proper monitoring and maintenance of the air conditioning system placed the residents at risk, as confirmed by staff interviews and temperature readings.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 3,542 citations issued within 25 miles in the last 12 months — including the 22 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sun Valley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| All Saints Healthcare Subacute | 2.3 mi | — | 36 | 1 |
| Totally Kids Specialty Healthcare - Sun Valley | 2.3 mi | — | 23 | 0 |
| Villa Scalabrini Special Care | 2.4 mi | — | 10 | 0 |
| Panorama Gardens Nursing And Rehabilitation Center | 2.9 mi | — | 1 | 0 |
| Country Manor Healthcare | 3 mi | — | 26 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.