ElderGrade

Inspection citations at Pacific Care Nursing Center

70 citations on record, 4 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2026 5 1
2025 20 0
2024 32 1
2023 5 1
2021 8 1
D May 11, 2026 Tag F0726 Complaint investigation Corrected Jun 2026

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

No actual harm, potential for more than minimal harm

D May 11, 2026 Tag F0684 Complaint investigation Corrected Jun 2026

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

G May 11, 2026 Tag F0689 Complaint investigation Corrected Jun 2026

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Actual harm to a resident

D February 4, 2026 Tag F0880 Complaint investigation Corrected Feb 2026

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

D February 4, 2026 Tag F0686 Complaint investigation Corrected Feb 2026

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

No actual harm, potential for more than minimal harm

E August 21, 2025 Tag F0565 Complaint investigation Corrected Sep 2025

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

No actual harm, potential for more than minimal harm

D July 18, 2025 Tag F0887 Corrected Aug 2025

Infection Control Deficiencies

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

No actual harm, potential for more than minimal harm

D July 18, 2025 Tag F0881 Corrected Aug 2025

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

No actual harm, potential for more than minimal harm

D July 18, 2025 Tag F0867 Corrected Aug 2025

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

No actual harm, potential for more than minimal harm

D July 18, 2025 Tag F0759 Corrected Aug 2025

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

No actual harm, potential for more than minimal harm

D July 18, 2025 Tag F0730 Corrected Aug 2025

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

No actual harm, potential for more than minimal harm

D July 18, 2025 Tag F0690 Corrected Aug 2025

Quality of Life and Care Deficiencies

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

No actual harm, potential for more than minimal harm

D July 18, 2025 Tag F0689 Corrected Aug 2025

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, potential for more than minimal harm

D July 18, 2025 Tag F0688 Corrected Aug 2025

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

No actual harm, potential for more than minimal harm

D July 18, 2025 Tag F0676 Corrected Aug 2025

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

No actual harm, potential for more than minimal harm

D July 18, 2025 Tag F0658 Corrected Aug 2025

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

No actual harm, potential for more than minimal harm

D July 18, 2025 Tag F0604 Corrected Aug 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

No actual harm, potential for more than minimal harm

E July 18, 2025 Tag F0880 Corrected Aug 2025

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

E July 18, 2025 Tag F0761 Corrected Aug 2025

Pharmacy Service Deficiencies

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.

No actual harm, potential for more than minimal harm

E July 18, 2025 Tag F0755 Corrected Aug 2025

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

No actual harm, potential for more than minimal harm

E July 18, 2025 Tag F0697 Corrected Aug 2025

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

No actual harm, potential for more than minimal harm

E July 18, 2025 Tag F0693 Corrected Aug 2025

Quality of Life and Care Deficiencies

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.

No actual harm, potential for more than minimal harm

D March 6, 2025 Tag F0600 Complaint investigation Corrected Mar 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

No actual harm, potential for more than minimal harm

D February 28, 2025 Tag F0609 Complaint investigation Corrected Mar 2025

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

No actual harm, potential for more than minimal harm

D January 24, 2025 Tag F0684 Complaint investigation Corrected Feb 2025

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

No actual harm, potential for more than minimal harm

D December 11, 2024 Tag F0656 Complaint investigation Corrected Dec 2024

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

No actual harm, potential for more than minimal harm

D December 11, 2024 Tag F0600 Complaint investigation Corrected Dec 2024

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

No actual harm, potential for more than minimal harm

D December 3, 2024 Tag F0550 Complaint investigation Corrected Dec 2024

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

No actual harm, potential for more than minimal harm

E December 3, 2024 Tag F0880 Complaint investigation Corrected Dec 2024

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

D December 2, 2024 Tag F0842 Complaint investigation Corrected Dec 2024

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

No actual harm, potential for more than minimal harm

E December 2, 2024 Tag F0825 Complaint investigation Corrected Dec 2024

Quality of Life and Care Deficiencies

Provide or get specialized rehabilitative services as required for a resident.

No actual harm, potential for more than minimal harm

G December 2, 2024 Tag F0686 Complaint investigation Corrected Dec 2024

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Actual harm to a resident

D September 30, 2024 Tag F0610 Complaint investigation Corrected Oct 2024

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

No actual harm, potential for more than minimal harm

E September 30, 2024 Tag F0880 Complaint investigation Corrected Oct 2024

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

E September 30, 2024 Tag F0609 Complaint investigation Corrected Oct 2024

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

No actual harm, potential for more than minimal harm

D September 19, 2024 Tag F0626 Complaint investigation Corrected Oct 2024

Resident Rights Deficiencies

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

No actual harm, potential for more than minimal harm

D July 25, 2024 Tag F0761 Corrected Aug 2024

Pharmacy Service Deficiencies

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.

No actual harm, potential for more than minimal harm

D July 25, 2024 Tag F0759 Corrected Aug 2024

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

No actual harm, potential for more than minimal harm

D July 25, 2024 Tag F0755 Corrected Aug 2024

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

No actual harm, potential for more than minimal harm

D July 25, 2024 Tag F0698 Corrected Aug 2024

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.