Inspection visit
Health inspection
8 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 8 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0658
Ensure services provided by the nursing facility meet professional standards of quality.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure the blood pressure was obtained prior
to administering the blood pressure medication according to the physician's order, for one of five residents
observed during the medication administration (Resident 45).
Residents Affected - Few
This failure had the potential for Resident 45 to experience low blood pressure.
Findings:
On February 9, 2022, at 8:03 a.m., during the medication administration observation with Licensed
Vocational Nurse (LVN) 1. LVN 1 was observed to prepare Clonidine (medication to treat high blood
pressure) for Resident 45. The bubble pack was labeled, Clonidine 0.1 mg (milligrams) 1 (one) tablet by
mouth twice a day for Hypertension (high blood pressure) hold for sbp (systolic blood pressure - pressure
exerted against blood vessels when the heart pumps the blood to the rest of the body) < (less than) 120.
LVN 1 was observed not to have taken the blood pressure before administering Clonidine to Resident 45.
During a concurrent interview with LVN 1, he stated he did not obtain Resident 45's blood pressure prior to
administering Resident 45's blood pressure medication.
On February 9, 2022, at 11:56 a.m., an interview was conducted with the Infection Preventionist (IP) and
the Director of Nursing (DON). They stated the resident's blood pressure should be obtained prior to
administering the blood pressure medications according to the physician's order.
On February 9, 2022, Resident 45's record was reviewed. Resident 45 was admitted to the facility on
[DATE], with diagnoses which included hypertension.
The Medication Administration Record (MAR), for February 2022, included a physician's order, dated
January 29, 2021, which indicated, .cloNIDine HCl Tablet Give 0.1 mg by mouth two times a day for
Hypertension hold for sbp <120 .
The facility's policy and procedure titled, Hypertension - Clinical Protocol Policy and Procedure, revised
2017, was reviewed. The policy indicated, .It is the policy of this facility to monitor the administration of
blood pressure medication .The nurse shall assess and document in EMR (electronic medical record) prior
to administration of antihypertensive medication, the residents blood pressure .If blood pressure .are
outside of physician specified parameters medication shall be held .
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 12
Event ID:
055361
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055361
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/11/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vista Pacifica Convalescent Hospital
3662 Pacific Avenue
Jurupa Valley, CA 92509
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
Based on observation, interview, and record review, the facility failed to ensure expired wound care
medications and supplies were not readily available for use.
This failure had the potential for the residents to receive wound care medications and supplies with
decreased efficacy.
Findings:
On February 9, 2022, at 10:16 a.m., a medication storage area inspection was conducted with the Infection
Preventionist (IP). The following wound care medications and supplies were observed expired and readily
available for use:
- 25 packs of a Puracol Microscaffold Collagen Wound Dressing (medicated dressing applied to treat
wounds) with an expiration date of June 2021;
- One packet of AD (Vitamin A and D) Skin Protectant Ointment with an expiration date of March 2021;
- One package of Kerra Max Care Super-absorbent dressing (a non adhesive dressing to cover wounds)
with an expiration date of December 2020;
- One packet of Triple Helix Collagen Powder Wound Dressing (medicated dressing applied to treat
wounds) with an expiration date of August 2020; and
- Two packets of Hydrogel absorbent sheet wound dressing (medicated dressing applied to treat wounds)
with an expiration date of October 25, 2020.
On February 9, 2022, at 10:46 a.m., an interview was conducted with the IP. She stated she reviewed the
medication storage in January 2022 and restocked it last week. She stated it is the responsibility of each
staff member to ensure the medication supplies they are using have not expired.
On February 9, 2022, at 11:55 a.m., an interview was conducted with the Director of Nursing (DON). She
stated the medication storage area should not have expired medications and supplies readily available for
use.
The facility's policy and procedure titled, Storage of Medications, revised 2017, was reviewed. The policy
indicated, .The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals. All such
drugs shall be returned to the dispensing pharmacy or destroyed .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055361
If continuation sheet
Page 2 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055361
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/11/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vista Pacifica Convalescent Hospital
3662 Pacific Avenue
Jurupa Valley, CA 92509
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0803
Level of Harm - Minimal harm
or potential for actual harm
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.
Based on observation, interview, and record review, the facility failed to ensure the menu was followed, for
two of 44 residents observed during meal observation (Residents 8 and 41).
Residents Affected - Few
This failure had the potential for Residents 8 and 41 to not receive the prescribed diet which could
compromise their overall medical condition.
Findings:
1. During lunch observation on February 7, 2022, at 12:09 p.m., Resident 8 was observed to have the
following food items on his lunch meal tray:
- One sandwich of peanut butter and jelly (PBJ);
- One small cup of apple sauce;
- One (4 oz [ounce - unit of measurement]) cup of canned fruit;
- Two 4 oz carton of milk; and
- One cup of ice cream.
A review for the facility's planned menu, titled, Week 3 - Winter Cycle Menu, indicated the following food
items was to be served on February 7, 2022, during lunch:
- Three beans salad;
- Turkey and cheese sandwich;
- Tomato slice; and
- Ice cream.
In a concurrent interview with the Director of Nursing (DON), she verified Resident 8 received one PBJ
sandwich.
On February 8, 2022, Resident 8's record was reviewed. Resident 8 was admitted to the facility with
diagnoses which included end stage renal disease (kidney disease). The physician's order, dated May 10,
2021, indicated, .Renal diet Regular texture, Served double protein lunch and dinner .
On February 8, 2022, a review of the Week 3 Winter Alternate Menu, indicated, .Lunch .Peanut Butter and
Jelly Sandwich, Starch, Veggies, Dessert as per menu .THIS MENU CAN NOT BE USED FOR .RENAL
(kidney) DIETS .
On February 10, 2022, at 10:31 a.m., the Director of Nursing (DON) was interviewed. The DON stated
Resident 8 should have not received a PBJ sandwich according to the alternate menu and the physician's
order.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055361
If continuation sheet
Page 3 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055361
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/11/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vista Pacifica Convalescent Hospital
3662 Pacific Avenue
Jurupa Valley, CA 92509
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0803
2. During lunch observation on February 8, 2022, at 12:20 p.m., Resident 41 was observed to have the
following food items on her lunch meal tray:
Level of Harm - Minimal harm
or potential for actual harm
- Roast pork with gravy;
Residents Affected - Few
- One small cup of noodles or pasta;
- One small cup of carrots;
- One small cup of canned fruit ; and
- One 4 oz carton of low fat milk.
Resident 41's diet card indicated, .Diabetic, Mechanical, Low Potassium .
In a concurrent interview with the Director of Nursing (DON), she verified Resident 41 received a low
potassium diet.
On February 8, 2022, Resident 41's record was reviewed. The physician's order, dated November 5, 2021,
indicated, CCHO (Consistent Carbohydrate) diet Mechanical Soft diet texture .avoid high potassium foods .
A review for the facility's planned menu titled, Week 3 - Winter Cycle Menu, indicated the following food
items was to be served during lunch on February 8, 2022 for CCHO diet:
- Roast pork with gravy;
- Mashed potatoes;
- Seasoned broccoli;
- Dinner roll with margarine;
- Diet chocolate delight; and
- Low fat milk.
On February 8, 2022, at 3:35 p.m., the Dietary Service Supervisor (DSS) was interviewed. The DSS stated
Resident 41 was served a low potassium diet. The DSS stated the physician's diet order should have been
written correctly on the diet card of Resident 41.
On February 10, 2022, at 1:40 p.m., the DON was interviewed. The DON stated the diet order was not
followed for Resident 41 according tot the physician's order.
The facility policy and procedure titled, Menu Planning, dated 2019, was reviewed. The policy indicated,
.Nutritional needs of individuals will be provided in accordance with the established national standards
adjusted to age, gender, activity level and disability, through nourishing, well-balanced diets, unless
contraindicated by medical needs .Regular and therapeutic menus will be written to provide a variety of
foods served on different days of the week .in adequate amounts at each meal to
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055361
If continuation sheet
Page 4 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055361
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/11/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vista Pacifica Convalescent Hospital
3662 Pacific Avenue
Jurupa Valley, CA 92509
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0803
satisfy recommended daily allowances .
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055361
If continuation sheet
Page 5 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055361
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/11/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vista Pacifica Convalescent Hospital
3662 Pacific Avenue
Jurupa Valley, CA 92509
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0806
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure each resident receives and the facility provides food that accommodates resident allergies,
intolerances, and preferences, as well as appealing options.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure a variety of food substitutes and meal
alternatives were offered, for five of 44 residents (Residents 8, 39, 10, 44, and 48) who received food from
the facility kitchen.
This failure had the potential for Residents 8, 10, 39, 44, and 48's dietary intake to be inadequate by not
making reasonable effort of adjusting resident's food plan and preference.
Findings:
1. On February 7, 2022, at 12:09 p.m., Resident 8 was observed eating one peanut butter and jelly
sandwich, one cup of apple sauce, one cup of canned fruit and two cartons of four-ounce [oz - unit of
measurement]) milk.
In a concurrent interview with Resident 8, he stated he had peanut butter and jelly sandwich as substitute
for lunch as there was no other choices the facility offered as meal alternative. Resident 8 stated the facility
only offered sandwiches and there were no variety of choices for meal substitutes or alternatives.
On February 8, 2022, Resident 8's record was reviewed. Resident 8 was admitted to the facility on [DATE],
with diagnoses which included end stage renal disease (the kidneys no longer able to filter blood and make
urine)
The Minimum Data Set, dated November 2, 2021, indicated Resident 8 had a BIMS (Brief Interview for
Mental Status - an assessment for cognitive status) score of 12 (cognitively intact).
2. On February 7, 2022, at 12:25 p.m., Resident 39 was observed eating one peanut butter and jelly
sandwich, tomato slice, three beans salad, ice cream and two cartons of four oz milk.
In a concurrent interview with Resident 39, he stated he did not request a peanut butter and jelly sandwich
for lunch. Resident 39 stated, I don't like peanut butter and jelly sandwich, it's mushy and it's too sweet.
Resident 39 further stated the facility did not offer a variety of food substitutes.
Resident 39's record was reviewed. Resident 39 was admitted to the facility on [DATE], with diagnoses
which included hypertension (high blood pressure).
The MDS, dated January 5, 2022, indicated Resident 39 had a BIMS score of 13 (cognitively intact).
3. During Resident Council Meeting conducted on February 8, 2022, at 9:55 a.m., four residents (Residents
10, 39, 44, and 48), they stated there were one or two choices the facility would offer for meal alternative, if
they did not like the food served, or they have food allergies, or if on a diabetic (abnormal blood sugar) diet.
They stated they wanted more variety of meal substitutes.
On February 8, 2022, a review of the facility's document titled, Week 3 Winter Alternate Menu, for lunch and
dinner, indicated the facility would offer one choice of sandwich, or fruit plate with
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055361
If continuation sheet
Page 6 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055361
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/11/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vista Pacifica Convalescent Hospital
3662 Pacific Avenue
Jurupa Valley, CA 92509
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0806
cottage cheese for lunch or dinner as a meal substitute.
Level of Harm - Minimal harm
or potential for actual harm
On February 8, 2022, at 2:30 p.m., the Dietary Service Supervisor (DSS) was interviewed. He stated he
was not aware multiple residents did not like the food alternatives or meal substitutes.
Residents Affected - Some
The facility policy and procedure titled, Menu Planning, dated 2019, was reviewed. The policy indicated,
Nutritional needs of individuals will be provided in accordance with the established national standards
adjusted to age, gender, activity level and disability, through nourishing, well-balanced diets, unless
contraindicated by medical needs .Menus will include at least three meals daily at regular times comparable
to the normal mealtimes in the community or in accordance with the individual's needs and preference .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055361
If continuation sheet
Page 7 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055361
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/11/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vista Pacifica Convalescent Hospital
3662 Pacific Avenue
Jurupa Valley, CA 92509
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview, and record review, the facility failed to ensure food safety requirements for
food storage and preparation were followed when multiple food items stored in the refrigerator and freezer
were not labeled with opened dates or use-by dates.
This failure had the potential to place the residents of the facility at risk for food-borne illnesses in a
medically vulnerable resident population of 44 residents who consumed food in the facility.
Findings:
On February 7, 2022, at 8:50 a.m., during the initial kitchen tour with the Dietary Service Supervisor (DSS),
the following food items were observed inside the facility refrigerator and freezer undated and with no
use-by-date:
- Two peanut butter and jelly (PBJ) sandwiches; One PBJ sandwich was observed to be stained with liquid;
- Six small cups of fruit;
- Nine eight ounces (oz - unit of measurement) of protein shakes;
- One four oz cranberry juice;
- One large container of mixed vegetables; and
- Two large containers of pre-mixed peanut butter and jelly.
In a concurrent interview with the DSS, he stated the food items in the refrigerator and freezer were not
labeled with the date they were prepared or with a use-by date. He stated the food items should have been
labeled with appropriately with the date it was prepared or with the use-by date.
The facility's policy and procedure titled, Food Storage, dated 2008, was reviewed. The policy indicated,
.Refrigeration .All foods should be covered, labeled and dated .Frozen Foods .Foods should be covered,
labeled, and dated .
According to the Food Code, published by the United States Food & Drug Administration, dated 2017,
.refrigerated, READY-TO-EAT, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and held
in a FOOD ESTABLISHMENT for more than 24 hours shall be clearly marked to indicate the date or day by
which the FOOD shall be consumed on the PREMISES .refrigerated, READY-TO-EAT,
TIME/TEMPERATURE CONTROL FOR SAFETY FOOD prepared and PACKAGED by a FOOD
PROCESSING PLANT shall be clearly marked, at the time the original container is opened in a FOOD
ESTABLISHMENT and if the FOOD is held for more than 24 hours, to indicate the date or day by which the
FOOD shall be consumed on the PREMISES .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055361
If continuation sheet
Page 8 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055361
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/11/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vista Pacifica Convalescent Hospital
3662 Pacific Avenue
Jurupa Valley, CA 92509
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0814
Dispose of garbage and refuse properly.
Level of Harm - Minimal harm
or potential for actual harm
Based on observation, interview, and record review, the facility failed to ensure a clean environement for the
residents and visitors was provided when the dumpster was observed overflowing and was not securely
closed with the dumpster lids.
Residents Affected - Many
This failure had the potential to attract pests, insects, and vermin which could create an unsanitary
environment for vulnerable residents residing in the facility.
Findings:
On February 8, 2022, at 2:30 p.m., four dumpsters were observed outside the facility. One dumpster was
observed to be open with garbage overflowing over the top and the dumpster lid was not completely closed.
On February 8, 2022, at 2:33 p.m., an interview was conducted with the Dietary Services Supervisor
(DSS). The DSS verified the dumpster was overflowing with trash and not completely closed. He stated the
dumpster lid should be completely closed.
The facility's policy and procedure titled, Waste Disposal, dated 2019, was reviewed. The policy indicated,
.Prior to disposal, all waste shall be kept in leak-proof, non-absorbent, fireproof container, that are kept
covered when not in use .
According to Federal Food Code 2017, published by the United States Food & Drug Administration, .Proper
storage and disposal of garbage and refuse are necessary to minimize the development of odors, prevent
such waste from becoming an attractant and harborage or breeding place for insects and rodents, and
prevent the soiling of food preparation and food service areas .Outside receptacles must be constructed
with tight-fitting lids or covers to prevent scattering of the garbage or refuse by birds, the breeding of flies,
or the entry of rodents .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055361
If continuation sheet
Page 9 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055361
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/11/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vista Pacifica Convalescent Hospital
3662 Pacific Avenue
Jurupa Valley, CA 92509
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure proper infection control were
implemented when the facility staff did not wear the proper PPE (Personal Protective Equipment - mask,
gown, gloves, face shield or goggles) while inside the PUI (Person Under Investigation - a resident
suspected of having or exposed to COVID-19 [coronavirus-an illness caused by a virus that can spread
from person to person]) room when:
Residents Affected - Some
1. One Certified Nursing Assistant (CNA) was observed not wearing gloves while feeding Resident 11; and
2. One housekeeper (HSKP) was observed not wearing gloves or a gown while cleaning the PUI room.
This failure had the potential to result in the transmission of infection to an already vulnerable population of
residents and staff in the facility.
Findings:
1. On February 7, 2022, at 12:24 p.m., CNA 1 was observed feeding Resident 11 inside room [ROOM
NUMBER] (PUI room). CNA 1 was observed not wearing gloves while feeding Resident 11.
In a concurrent interview with CNA 1, he stated he should be wearing gloves while feeding Resident 11.
2. On February 8, 2022, at 9:58 a.m., the HSKP was observed cleaning room [ROOM NUMBER] (PUI
room). The HSKP was observed not wearing an isolation gown and gloves while cleaning the PUI room.
In a concurrent interview with the HSKP, she was not aware she had to wear an isolation gown and gloves
while cleaning a PUI room.
On February 9, 2022, at 11:56 a.m., an interview was conducted with the Infection Preventionist (IP) and
the Director of Nursing (DON). They stated proper infection control prevention measures should be
implemented.
The facility's policy and procedure, titled, Covid-19 Mitigation Plan, revised August 9, 2021, was reviewed.
The policy indicated, .Personal Protective Equipment (PPE) .Staff have been trained on selecting, donning
and doffing appropriate PPE and demonstrate competency of such skills during resident care .Signs are
posted immediately outside of resident rooms indicating appropriate infection control and prevention
precautions and required PPE in accordance with CDPH (California Department of Public Health) guidance
.All staff will wear recommended PPE while in the building per current CDPH (California Department of
Public Health) PPE guidance .
According to the web article titled, Interim Infection Prevention and Control Recommendations for
Healthcare Personnel during the Coronavirus Disease (COVID - 19) Pandemic, published by the Centers
for Disease Control and Prevention (CDC), dated February 2, 2022, .If SARS-CoV-2 infection is not
suspected in a patient presenting for care (based on symptoms and exposure history), HCP (Healthcare
Personnel) should follow Standard Precautions (and Transmission-Based Precautions if required based on
the suspected diagnosis) .
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055361
If continuation sheet
Page 10 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055361
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/11/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vista Pacifica Convalescent Hospital
3662 Pacific Avenue
Jurupa Valley, CA 92509
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
According to the web article titled, Isolation Precautions, published by the Centers for Disease Control and
Prevention (CDC), dated July 22, 2019, .Wear gloves when it can be reasonably anticipated that contact
with blood or other potentially infectious materials, mucous membranes .Wear gloves with fit and durability
appropriate to the task .Wear disposable medical examination gloves for providing direct patient care .Wear
a gown .to protect the skin and prevent soiling or contamination of clothing during procedures and
patient-care activities when contact with blood, bloody fluids, secretions, or excretions is anticipated .
Event ID:
Facility ID:
055361
If continuation sheet
Page 11 of 12
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055361
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/11/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Vista Pacifica Convalescent Hospital
3662 Pacific Avenue
Jurupa Valley, CA 92509
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0912
Level of Harm - Potential for
minimal harm
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single
resident rooms.
Based on observation, interview, and record review, the facility failed to ensure the required 80 square feet
(sq ft) per resident was met for six of 25 resident bedrooms (Rooms 1, 9, 11, 12, 14, and 26).
Residents Affected - Some
This failure had the potential to negatively affect the quality of life of the residents.
Findings:
On February 7, 2022, at 9:02 a.m., the Administrator (ADM) was interviewed regarding the room sizes for
resident Rooms 1, 9, 11, 12, 14, and 26. He stated the rooms did not meet the space requirement of at
least 80 square feet per resident in the above listed bedrooms.
Rooms 1, 9, 11, 12, 14, and 26 had been set up as two-bed bedrooms.
The facility document titled, Client Accommodations Analysis, dated February 10, 2021, was provided by
the Director of Nursing (DON). The document indicated the rooms set up as two-bed bedrooms measured
143 square feet or 71.5 square feet per resident (143/2 = 71.5).
During the survey dates of February 7, 8, 9, 10, and 11, the above listed rooms were observed at different
times of the day. All care and services provided to the residents residing in the listed rooms were able to be
conducted without restrictions. Residents who were able to be interviewed stated they were comfortable in
the space provided. Health record reviews did not indicate the health and safety of the residents residing in
these rooms were compromised, based on the room measurements.
The facility requested a continued waiver for Rooms 1, 9, 11, 12, 14, and 26. Approval of the waiver is
recommended. Granting this waiver will not adversely affect the residents' health and safety and is in
accordance with the special needs of the residents.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055361
If continuation sheet
Page 12 of 12
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
8 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F658 - Comprehensive Care Plans
Ensure services provided by the nursing facility meet professional standards of quality.
F803 - Menus and nutritional adequacy
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.
F806 - Food and drink
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F912 - Measure at least 80 square feet per resident in multiple resident
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
F761 - Labeling of Drugs and Biologicals
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.
F814 - Food Safety Requirements
Dispose of garbage and refuse properly.
FAQ · About this visit
Common questions about this visit
What happened during the February 11, 2022 survey of VISTA PACIFICA CONVALESCENT HOSPITAL?
This was a inspection survey of VISTA PACIFICA CONVALESCENT HOSPITAL on February 11, 2022. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at VISTA PACIFICA CONVALESCENT HOSPITAL on February 11, 2022?
Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure services provided by the nursing facility meet professional standards of quality."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.