Federal Nursing-Home Survey Record
TRABUCO HILLS POST ACUTE
Does TRABUCO HILLS POST ACUTE have a federal violation or abuse history?
According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), TRABUCO HILLS POST ACUTE (CCN 555308), in LAKE FOREST, CA, has federal inspection findings on its record.
In its current inspection cycle, CMS cited the facility for 41 deficiencies; the most serious carries scope/severity E on CMS's A–L scale — CMS's "potential for harm" tier, below actual harm. The most recent federal survey on file is dated 2024-10-11. Citations from earlier inspection cycles appear in the dated timeline below as historical findings, not current ones. This page restates the federal record as published by CMS and draws no conclusion of its own. Federal nursing-home surveys are conducted on a recurring cycle by state survey agencies acting on CMS's behalf, and the figures on this page are compiled from CMS's published provider data, as on file with CMS; the federal record may understate what actually occurred, and inspection findings are point-in-time survey results, not a determination that any specific resident was harmed.
The Federal Record
The most recent federal inspection on file records no actual-harm or immediate-jeopardy citations for this facility.
Below is this facility's federal survey record as on file with CMS.
Scope & Severity — current cycle
Overall CMS star rating: this facility vs the CMS-published state average
This facility: 2 · CMS state average: 3.2
Deficiency timeline — full federal history
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Keep residents' personal and medical records private and confidential.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide timely, quality laboratory services/tests to meet the needs of residents.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Allow residents to self-administer drugs if determined clinically appropriate.
Provide and implement an infection prevention and control program.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame.
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Provide safe and appropriate respiratory care for a resident when needed.
Implement a program that monitors antibiotic use.
Allow residents to self-administer drugs if determined clinically appropriate.
Reasonably accommodate the needs and preferences of each resident.
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Keep residents' personal and medical records private and confidential.
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Ensure medication error rates are not 5 percent or greater.
Provide activities to meet all resident's needs.
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Keep all essential equipment working safely.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Assist a resident in gaining access to vision and hearing services.
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Provide bedrooms that don't allow residents to see each other when privacy is needed.
19 citations from earlier inspection cycles — historical, not current (expand)
Provide or get specialized rehabilitative services as required for a resident.
Provide or get specialized rehabilitative services as required for a resident.
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide safe and appropriate respiratory care for a resident when needed.
Provide and implement an infection prevention and control program.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Reasonably accommodate the needs and preferences of each resident.
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Have a policy regarding use and storage of foods brought to residents by family and other visitors.
Document what happened
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