Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Escondido Post Acute during CMS and state inspections, most recent first.
Two residents did not receive complete, person-centered care plans for identified needs and preferences. One resident, admitted with osteomyelitis and receiving IV antibiotics via PICC, had a documented history of daily marijuana use and prior rehab, frequently used the garden area, and clearly expressed dissatisfaction with gardening rules and an intent to leave AMA or transfer if guidelines were not changed; however, no care plans were developed for substance use, garden-related behavior, discharge planning, or AMA intent. Another LTC resident with a traumatic brain injury was listed as at risk for elopement and had an elopement care plan, but no care plan was created to address discharge or placement preferences, despite facility policy requiring comprehensive, person-centered care plans with measurable objectives and timetables.
A resident with a history of cerebrovascular disease was found with bruising and skin tears and reported being attacked by a staff member. The DON completed an internal abuse investigation but did not submit the required five-day summary of findings to CDPH, as mandated by facility policy.
A resident with a urinary catheter was observed with an uncovered collection bag that was visible to anyone entering the room. Staff interviews confirmed that facility policy requires dignity bags to cover catheter collection bags to maintain privacy, but this was not followed, resulting in a lack of privacy and dignity for the resident.
A resident with diabetes and a recent history of hyperglycemia had a blood sugar reading significantly above the physician-ordered threshold, but there was no documentation that the physician was notified or that new insulin orders were obtained. Nursing staff and the DON confirmed that notification and documentation were required, but no evidence of this was found.
A nurse left a cup containing 19 medications unattended on a resident's bedside table after being distracted by another resident. The resident, who was cognitively intact and had multiple diagnoses, was not informed about the medications or their purposes. Facility policy and staff interviews confirmed that medications should not be left unattended in resident rooms to ensure safety and prevent drug diversion.
A resident with moderate cognitive impairment and a history of rhabdomyolysis was found to have an over-the-counter antacid at their bedside without a care plan, physician's order, or assessment for self-administration. Staff were unaware of the medication's presence, and facility policy requiring assessment and authorization for self-administration was not followed.
The facility failed to accurately complete and issue required Medicare beneficiary notifications for two residents, leaving critical sections of the Advance Beneficiary Notices of Non-coverage blank and not obtaining signatures or issuing Notices of Medicare Non-coverage as required. The Business Office Manager acknowledged the omissions, while the DON and Administrator stated they were not involved but expected proper completion of these notifications.
A resident with intact cognition and multiple medical conditions reported being verbally abused and threatened by a former roommate, including having their belongings searched and being yelled at. The Administrator was unaware of the allegation until informed by a surveyor and did not report the incident to the state survey agency within the required timeframe, resulting in a delay that did not meet federal reporting requirements.
A resident was admitted with a negative PASRR, but later developed schizophrenia and depression and was prescribed antidepressants. Despite these significant changes, staff did not submit an updated PASRR to the state agency, and interviews revealed confusion among staff about who was responsible for this process.
A resident with multiple wounds and severe cognitive impairment did not receive wound care in accordance with physician orders. An LPN failed to apply treatments as ordered, omitted care for one wound, and used a dressing technique not specified in the orders. Facility leadership confirmed that the nurse did not follow established protocols or verify orders prior to treatment.
A nurse failed to follow infection control protocols during wound care for a resident with multiple wounds, including not changing gloves between tasks, not using a gown for Enhanced Barrier Precautions, and not sanitizing hands as required. Additionally, another resident's oxygen and nebulizer equipment were repeatedly left uncovered and not properly stored, contrary to facility policy. These deficiencies were confirmed through observations and staff interviews.
The facility did not update nurse staffing information at the beginning of each shift as required, instead posting the data once daily for all shifts. Staff interviews confirmed that the posting process did not align with policy, and the information was often outdated, potentially affecting all residents.
A facility failed to follow physician orders for a resident's positioning and use of an orthopedic device, leading to decreased range of motion and psychosocial distress. The resident's care plan did not include necessary orders, and Restorative Nursing services were not provided after physical therapy ended. Staff interviews revealed communication lapses, and the resident expressed concerns about her recovery and independence.
The facility failed to notify residents and their representatives of the bed hold policy during hospital transfers, as required by their policy. This affected four residents with various health conditions, leading to confusion and distress. Interviews revealed unclear responsibilities among staff for issuing bed hold notices, and no documentation was found in residents' records. The Administrator and DON acknowledged the oversight.
A resident with dementia and cancer was found in an undignified state, with food on her face and an improperly fitting gown and brief. Staff provided care without adequate communication, despite the resident's deafness, and used an extra-large brief that could cause discomfort.
A resident's painting was lost due to improper storage of belongings after the resident was transferred to a hospital. The facility's staff, including the Director of Social Services and Central Supply Person, were unclear about the designated storage area for discharged residents' belongings, leading to the painting being left outside and discarded due to rain damage. This incident highlights a failure to adhere to the facility's policies on personal property and lost and found.
A resident with epilepsy and severe cognitive impairment experienced increased fall risk due to the facility's failure to implement fall prevention interventions. The resident's care plan required a functional fall alarm, assistance with transfers, and scheduled toileting, but these measures were not consistently followed, leading to the resident self-transferring and attempting to move independently.
A resident with severe cognitive impairment and physical instability experienced multiple falls due to the facility's failure to implement preventive interventions, such as maintaining a functioning fall alarm and providing necessary assistance during transfers. Additionally, the resident was at risk of elopement due to inadequate monitoring and improper use of a wander guard device, despite a history of wandering and injury. The facility's documentation and monitoring practices for residents at risk of elopement were found to be incomplete and inconsistent.
A resident admitted with multiple medical conditions, including a fall, pain, UTI, anticoagulant therapy, and high risk for skin injuries, did not have person-centered care plans developed. Despite high fall risk and constant pain, no care plans were documented for fall prevention or pain management. Antibiotic and anticoagulant therapies also lacked care plans. Interviews with staff confirmed the absence of necessary care plans, which are required by facility policy to ensure consistent and effective care.
A resident was discharged from a facility without a documented skin assessment, despite being on anticoagulant therapy and having surgical wounds. Staff interviews revealed that the discharge was rushed, preventing a thorough examination. The lack of documentation led to the family being unaware of the resident's bruises and injuries, which were later discovered through photographs.
Failure to Develop Person-Centered Care Plans for Substance Use, Garden Behavior, AMA Intent, and Placement Preferences
Penalty
Summary
The deficiency involves the facility’s failure to develop comprehensive, person-centered care plans with measurable objectives and timetables for identified resident needs and preferences. For Resident 1, who was admitted with osteomyelitis of the left ankle and foot and had a PICC line for IV antibiotics, the record showed a documented history of daily marijuana use and prior drug rehabilitation, as noted in a hospital consultation and a behavior progress note. Despite this information and the DON’s acknowledgment that there was no care plan addressing illicit drug use, the facility did not create a care plan to address Resident 1’s substance use history, including safety interventions to prevent use, overdose, or access to illicit substances. The report also describes that Resident 1 frequently used the facility’s garden area, with nursing staff reporting that this was part of his usual routine and that he engaged in replanting activities. A progress note by the ADON documented a meeting with Resident 1 about gardening activities, during which he was educated on facility guidelines and safety protocols, expressed dissatisfaction with those guidelines, and stated a preference to garden without limitations. He further expressed an intent to leave the facility AMA or transfer elsewhere if the guidelines were not modified, stating the facility had until the next day or he would leave AMA. The ADON later confirmed that, despite these behaviors and expressed intent, there were no care plans addressing Resident 1’s behavior in the garden, his discharge planning, or his stated intent to leave AMA. For Resident 3, who was admitted with a traumatic brain injury and identified on the facility’s Wanderguard list as being at risk for elopement, the DON confirmed that there was an existing care plan addressing elopement risk. However, the DON also stated that there was no care plan regarding discharge or placement preference for this long-term care resident. The DON acknowledged that residents should have discharge planning care plans to reflect proper placement according to their preferences. The facility’s own policy on comprehensive, person-centered care plans requires development and implementation of care plans with measurable objectives and timetables to meet residents’ physical, psychological, and functional needs, but this was not done for the identified areas for Residents 1 and 3.
Failure to Submit Required Abuse Investigation Summary to State Agency
Penalty
Summary
The facility failed to submit a five-day summary of investigation to the California Department of Public Health (CDPH) following an abuse allegation involving a resident. The resident, who had a history of cerebrovascular disease, was observed with a dark purple discoloration on the left forearm and bandages on both hands. The resident reported being attacked by a staff member, which resulted in bruises and skin tears. The resident's son also reported these injuries and requested clarification on their cause. Interviews with staff, including the DON and a licensed nurse, revealed uncertainty about how the injuries occurred. Despite completing an internal investigation into the alleged abuse, the DON acknowledged that the required five-day written summary of the investigation was not submitted to CDPH. The facility's policy mandates that all reports of resident abuse, including injuries of unknown origin, be reported to local, state, and federal agencies, with a written report of findings provided within five working days. This omission constituted a failure to comply with both regulatory requirements and the facility's own policy.
Failure to Provide Privacy and Dignity for Resident with Urinary Catheter
Penalty
Summary
A deficiency was identified when a resident with a history of a displaced left hip fracture and diabetes mellitus was observed with an uncovered urinary catheter collection bag. The resident had a physician's order for an external condom catheter due to urinary retention. During an observation, the urinary collection bag was found to be uncovered and visible to anyone entering the room, containing approximately 200 cc of yellow urine. Certified nursing assistant 1 (CNA 1) confirmed that the collection bag was not covered and acknowledged that it should have been, stating that a dignity bag is used to provide privacy and promote dignity for the resident. Further interviews with the Director of Staff Development (DSD) and the Director of Nursing (DON) confirmed that facility policy requires all urinary catheter collection bags to be covered with dignity bags, regardless of the resident's alertness, to maintain privacy and dignity. The facility's policy on dignity, dated 2001, also states that staff are to promote, maintain, and protect privacy. The failure to cover the urinary catheter collection bag resulted in a lack of privacy and dignity for the resident.
Failure to Notify Physician of Out-of-Range Blood Sugar Levels
Penalty
Summary
The facility failed to notify the physician when a resident's blood sugar level exceeded the parameters set by the physician. The resident, who had a history of diabetes mellitus and a recent diagnosis of hyperglycemia following a hospital visit, had a blood sugar reading of 343, which was above the physician-ordered threshold of 250. There was no documentation in the nursing progress notes that the physician was notified of this elevated blood sugar level, nor that any new orders for insulin were obtained. The resident's care plan specifically required that blood glucose levels outside of set parameters be reported to the physician. Interviews with nursing staff and the Director of Nursing confirmed that it was the responsibility of licensed nurses to notify the physician and document any response or new orders when blood sugar levels were out of range. The Director of Nursing was unable to find any evidence that the physician had been notified regarding the abnormal blood sugar level. Additionally, the facility was unable to provide a policy specifically related to hyperglycemia management.
Medications Left Unattended at Bedside
Penalty
Summary
A licensed nurse left a cup containing 19 medications unattended on a resident's bedside table. The resident, who had diagnoses including atrial fibrillation and urinary tract infection and was assessed as cognitively intact, reported that the nurse left the medications while the resident was still asleep and did not provide information about what the medications were or their purposes. The medications included several with specific administration instructions, such as checking the apical pulse, not crushing or chewing, and taking with food or water. The nurse stated she was distracted by another resident and left the medications at the bedside. Facility policy requires that medications are not to be left unattended in resident rooms to ensure safety and prevent drug diversion. Both the nurse and the Director of Nursing confirmed that leaving medications unattended is against facility policy. The observation and interviews confirmed that the medications were left in the resident's room without supervision, in violation of the facility's medication storage and administration protocols.
Failure to Assess and Authorize Resident Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident's ability to self-administer medication, as required by facility policy, for one resident with a history of rhabdomyolysis and moderate cognitive impairment. The resident was admitted with a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment, and there was no care plan or physician's order in place for self-administration of medication or for keeping medication at the bedside. Despite this, a bottle of Tums, an over-the-counter antacid, was repeatedly observed on the resident's bedside table over several days. The resident reported that staff were aware of the medication and that a family member had provided it, and stated a desire to self-administer the medication as needed. Staff interviews revealed that neither the assigned CNA nor the LVN were aware of the medication at the bedside prior to the surveyor's observation, and both confirmed that no residents on the unit had orders to self-administer medications. The LVN acknowledged responsibility for conducting self-administration assessments and removed the medication upon discovery. The DON confirmed that an assessment and physician's order are required before a resident may self-administer medication or keep it at the bedside, and stated that no such orders were in place for any residents, including for over-the-counter medications. The administrator also stated that medication should not be left at the resident's bedside and expected staff to remove any such medications.
Incomplete Beneficiary Notifications for Medicare Coverage
Penalty
Summary
The facility failed to ensure that beneficiary notifications regarding Medicare coverage and potential liability for non-covered services were completed accurately for two of three sampled residents. For one resident with moderate cognitive impairment and a diagnosis of metabolic encephalopathy, the Advance Beneficiary Notice of Non-coverage (ABN) was incomplete, with critical sections such as the reason Medicare may not pay and the options for the resident left blank. The ABN was also not signed or dated, and a Notice of Medicare Non-coverage (NOMNC) was not issued. The Business Office Manager acknowledged these omissions, stating that the form was not filled out completely and that the resident's representative was not contacted for a signature. Similarly, for another resident with intact cognition and a history of a left tibia fracture, the ABN was also incomplete, with the section for the reason Medicare may not pay and the options section left blank. The Business Office Manager admitted that the form was not filled out correctly and that a NOMNC was not issued due to a lack of communication. Both the Director of Nursing and the Administrator stated they were not involved in the beneficiary notification process but expected the notifications to be completed accurately and within the required timeframe.
Failure to Timely Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to timely report an allegation of verbal abuse involving a resident with intact cognition and a history of muscle weakness, need for assistance with personal care, and hypertension. The resident reported that their former roommate had threatened, yelled, cursed, and accused them of theft, as well as rummaged through their belongings. The resident stated they were scared of their former roommate, who was subsequently moved to another unit. The facility's policy requires that all allegations of abuse be investigated and reported within federally mandated timeframes. Despite the resident's disclosure of verbal abuse, the Administrator was not aware of the allegation until informed by a surveyor. The Administrator acknowledged the requirement to report such allegations within two hours but did not notify the state survey agency until the following day, well beyond the required timeframe. The Director of Nursing was informed of the allegation later that same day, and both the Administrator and DON confirmed the delayed reporting. The deficiency was identified due to the failure to report the abuse allegation promptly as required by policy and regulation.
Failure to Update PASRR After Significant Change in Resident's Mental Health Status
Penalty
Summary
The facility failed to submit a new Preadmission Screening and Resident Review (PASRR) to the state agency after a significant change in status for a resident. The resident was originally admitted with a negative Level I PASRR, indicating no mental illness such as schizophrenia or depression. However, subsequent medical records showed that the resident was later diagnosed with unspecified schizophrenia and depression, and was prescribed antidepressant medications for these conditions. Despite these new diagnoses, the PASRR on file was not updated or resubmitted to the state agency for review. Interviews with facility staff revealed confusion and lack of clarity regarding responsibility for reviewing and updating PASRRs when a resident's condition changes. The Administrator, Admissions Director, Director of Social Services, MDS Coordinator, and DON each provided differing accounts of who was responsible for submitting updated PASRR information. The MDS Coordinator confirmed that the addition of new psychiatric diagnoses should have triggered a new PASRR submission, but acknowledged that the facility had not designated anyone to review PASRRs for accuracy. The facility's policy required that a new PASRR be submitted if a possible serious mental disorder or intellectual disability arises after admission. Despite this policy, the resident's PASRR remained outdated, and staff failed to identify and act on the significant change in the resident's mental health status. The deficiency was identified through record review and staff interviews, which confirmed that the required process was not followed.
Failure to Follow Physician Orders for Pressure Ulcer Care
Penalty
Summary
The facility failed to provide necessary treatments and services consistent with professional standards of practice during wound care for a resident with multiple pressure ulcers and wounds. The resident, who had severe cognitive impairment and required extensive to total assistance with activities of daily living, had a medical history including type 2 diabetes mellitus, cellulitis, and pressure-induced deep tissue injuries (DTIs) on both heels. Physician orders were in place for specific wound care treatments for the resident's left heel, right heel, right medial second toe, and right third toe tip, including the use of topical Lidocaine, normal saline cleansing, skin prep, Hydrofera Blue, and foam dressings, with instructions to reassess and notify the physician if changes occurred. During an observed wound care session, the nurse did not follow the physician's orders as written. The nurse applied Lidocaine only to the right second toe, despite orders to use it on all wounds, and did not address the wound on the right third toe at all. Additionally, the nurse placed a single foam dressing over all the toes on the right foot, which was not in accordance with the specific wound care orders and could result in the toes being pressed together. The nurse also admitted to not verifying the physician's orders prior to gathering supplies and acknowledged not following the orders exactly as written. Interviews with facility leadership confirmed that the nurse's actions did not align with facility policy or physician orders. The Director of Nursing and the Administrator both stated that the expectation was for nurses to verify and follow physician orders precisely and to prepare supplies accordingly. The failure to follow wound care orders and policies was identified as a deficiency during the survey.
Infection Control Failures During Wound Care and Respiratory Equipment Storage
Penalty
Summary
The facility failed to implement proper infection control practices during wound care for a resident with multiple wounds and failed to ensure correct storage of respiratory equipment for another resident. During a wound care observation, a nurse did not follow established protocols, including not donning a gown for Enhanced Barrier Precautions (EBP), not placing a barrier under wound care supplies, and not changing gloves or sanitizing hands between clean and dirty tasks. The nurse also used scissors from her pocket without cleaning them between uses and did not sanitize her hands until the end of the procedure. These actions were inconsistent with facility policies that require hand hygiene, use of PPE, and prevention of cross-contamination during wound care. The resident involved in the wound care deficiency had a history of type 2 diabetes, cellulitis, pressure-induced deep tissue injuries, and required extensive assistance with activities of daily living due to severe cognitive impairment. The nurse performed wound care on multiple sites without changing gloves between tasks or wounds, handled clean and dirty items with the same gloves, and failed to use a clean field for supplies. The nurse also did not follow EBP requirements for gown use and did not ensure that EBP signage and supplies were present outside the resident's room after a room change. For another resident with chronic obstructive pulmonary disease and acute respiratory distress syndrome, the facility did not ensure that oxygen cannulas and nebulizer equipment were stored in accordance with infection control policies. The oxygen tubing and nebulizer mask were repeatedly observed uncovered and not bagged when not in use, being left on the bed rail or bedside dresser. The resident confirmed that no covering was provided for the oxygen tubing, and staff interviews verified that the equipment was not stored as required by policy.
Failure to Post Nurse Staffing Information Per Shift
Penalty
Summary
The facility failed to post nurse staffing information at the beginning of each shift as required by its own policy and federal regulations. Observations over several days revealed that the posted nurse staffing data was not updated for each shift, but instead was posted once daily, often reflecting outdated information. For example, on multiple occasions, the posted staffing information was dated for previous days, and staff confirmed that the data was posted in the morning for the entire day rather than prior to each shift. The staffing information was located at the receptionist desk in the lobby, but did not meet the requirement to be updated within two hours of the beginning of each shift. Interviews with facility staff, including the Admissions Assistant, Certified Nursing Assistant, Director of Staff Development, Director of Nursing, and the Administrator, confirmed that the practice was to post staffing data once daily, not per shift. The Director of Staff Development stated that the posting was preprogrammed in the software for a 24-hour period and was unaware of the requirement to update it for each shift. The Director of Nursing and Administrator both acknowledged that the posting should be updated prior to each shift, but this was not the practice observed during the survey. This deficiency had the potential to affect all residents in the facility.
Failure to Follow Physician Orders and Provide Restorative Care
Penalty
Summary
The facility failed to provide appropriate care for a resident to maintain and improve range of motion (ROM) and mobility, as ordered by the physician. The resident, who was admitted for physical therapy following surgery, had specific physician orders for positioning and the use of an orthopedic device, which were not followed. The resident's care plan did not include the physician's orders for turning every two hours, keeping the left hip in a neutral position, and using the PRAFO brace. Observations revealed that the resident's legs were not positioned as ordered, and the brace was not used correctly, leading to the resident's distress and fear of not regaining independence. The facility also failed to provide continued care with Restorative Nursing services after the resident was discharged from physical therapy. The resident was supposed to transition to a Restorative Nursing Program (RNA) to maintain ROM, but this was not implemented. Interviews with staff indicated a lack of communication and follow-up regarding the resident's care needs, including the absence of RNA services and the failure to notify the physician about the ill-fitting brace and the discontinuation of physical therapy services. The resident expressed concerns about the lack of proper post-operative care and the impact on her recovery and independence. The physician confirmed that the resident's leg should have been kept in a neutral position and that skilled physical therapy services were necessary to prevent contractures and maintain mobility. The facility's failure to adhere to the care plan and physician orders resulted in the resident's decreased ROM and psychosocial distress.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility failed to notify residents and their representatives of the bed hold policy during transfers to hospitals or therapeutic leaves, as required by their policy. This deficiency was identified for four residents who were transferred to hospitals due to various health conditions, including osteomyelitis, diabetes, dementia, and chronic kidney disease. The facility's policy mandates that residents or their representatives receive written information about bed hold policies at least twice: during admission and at the time of transfer, or within 24 hours if the transfer is an emergency. However, the facility did not provide the second notification at the time of emergency transfers, leading to confusion and distress among residents and their families. Interviews with nursing staff revealed a lack of clarity regarding who is responsible for issuing bed hold notices during emergency transfers. One nurse was unsure of the process, while another mentioned that either the medication nurse or the supervisor nurse could notify the family. Despite the facility's policy requiring a phone review and documentation of bed hold notices, no such forms were found in the residents' records. The Administrator and Director of Nursing acknowledged the oversight and confirmed that the second notification was not given as required by their policy.
Failure to Provide Dignified Care to Resident
Penalty
Summary
The facility failed to treat a resident with dignity and respect, as observed during a survey. The resident, who has dementia and stomach cancer, was found in a state that could cause embarrassment. She was sitting in bed with oatmeal on her face and bedding, wearing an unsnapped hospital gown that exposed her upper body, and a bath blanket that inadequately covered her lower body. This situation was observed during a visit by a Licensed Vocational Nurse (LN) and a Certified Nursing Assistant (CNA), who later provided care without engaging the resident in conversation, except for a brief instruction. The resident's breakfast tray was still in front of her, although breakfast is typically served between 7:15 and 7:45 A.M., indicating a delay in care. Additionally, the staff used an extra-large brief for the resident, which was too large and could potentially cause discomfort or skin issues. The LN acknowledged that the resident is deaf and cannot hear verbal communication, yet there was minimal effort to communicate with her during care. The use of an improperly sized brief and the lack of communication contributed to the deficiency in providing dignified care.
Failure to Protect Resident's Property from Loss and Damage
Penalty
Summary
The facility failed to protect a resident's property from loss and damage, resulting in the loss of a painting. The resident, who had been admitted with osteomyelitis and type 2 diabetes, was transferred to an Acute Care Hospital due to respiratory issues. During the resident's absence, their belongings, including a painting, were improperly stored outside on a back patio, exposed to rain, and subsequently discarded due to damage. The Central Supply Person confirmed that the belongings were initially left outside and later moved to a covered storage area, but the painting was already damaged and discarded. Interviews with various staff members, including the Director of Social Services, Central Supply Person, and Licensed Nurses, revealed a lack of clarity and consistency regarding the storage of discharged residents' belongings. The Director of Social Services was unsure of the current storage location due to a facility remodel, and other staff members were uncertain about the designated storage area for resident belongings. The facility's policies on personal property and lost and found were reviewed, indicating that resident belongings should be treated with respect and stored securely, but these procedures were not followed in this instance.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement interventions to prevent falls for a resident who was at risk due to a history of falls and medical conditions, including epilepsy and severe cognitive impairment. The resident was admitted with a diagnosis of epilepsy, unsteadiness, and a severely impaired mental status, as indicated by a BIMS score of 6. Despite these conditions, the facility did not ensure that the fall alarm on the resident's bed was functional, as it was found to have a dead battery. Additionally, the resident was observed self-transferring without assistance, which was not in line with the care plan that required one-person assistance for transfers and ambulation. The care plan for the resident, initiated in July, included keeping the bed in a low position and providing verbal reminders to ask for assistance. However, these interventions were not consistently implemented, as the bed was observed in a standard position, and the resident was not regularly reminded to ask for help. Staff interviews revealed that the resident frequently attempted to transfer independently and was not provided with scheduled toileting assistance, despite being incontinent and having a history of falls. The lack of adherence to the care plan and the absence of scheduled interventions increased the risk of falls for the resident.
Failure to Prevent Falls and Elopement Risks
Penalty
Summary
The facility failed to implement interventions to prevent falls for a resident who was at high risk due to severe cognitive impairment and physical instability. The resident, who had a history of epilepsy, unsteadiness, and severe cognitive impairment as indicated by a BIMS score of 6, experienced multiple falls, including one that resulted in hospitalization. Observations revealed that the fall alarm on the resident's bed was not functioning due to a dead battery, and the resident was observed self-transferring without assistance, contrary to the care plan that required staff assistance for transfers and ambulation. Additionally, the facility did not adhere to its elopement policy for the same resident, who was at risk of wandering due to confusion and a history of elopement. The resident was observed without a functioning wander guard device on the wheelchair he was using, despite the care plan requiring such a device to prevent unsupervised exits. The resident had previously eloped from the facility, resulting in a fall and injury, yet the wander guard was not properly transferred to the resident's active wheelchair. The facility's documentation and monitoring practices for residents at risk of elopement were also found to be inadequate. The elopement binders, which were supposed to track the whereabouts of high-risk residents, were incomplete and not consistently updated. Interviews with staff revealed a lack of adherence to the expected monitoring and documentation procedures, further compromising the safety of residents at risk of elopement.
Failure to Develop Person-Centered Care Plans
Penalty
Summary
The facility failed to develop person-centered care plans for a resident, identified as Resident 1, who was admitted with multiple medical conditions including a fall resulting in a fracture, pain, a urinary tract infection (UTI), anticoagulant therapy, and a high risk for skin injuries. Despite these conditions, there was no documented evidence of care plans being developed or implemented to address these specific needs. This lack of care planning meant that Resident 1's care was not being provided consistently, and potential problem areas were not identified. Resident 1's clinical records revealed several deficiencies. The Fall Risk Assessment indicated a high risk for falls, yet no care plan was developed for future fall prevention. The resident was experiencing constant pain, as noted in the Minimum Data Set (MDS), but there was no care plan to manage this pain. Additionally, although the resident was on antibiotics for a UTI, there was no care plan for managing the infection or the antibiotic therapy. Similarly, despite being on anticoagulant therapy for deep vein thrombosis, no care plan was in place to manage this treatment. Interviews with facility staff, including the Treatment Nurse, Licensed Nurse 2, and the Assistant Director of Nursing, confirmed the absence of necessary care plans. The staff acknowledged that care plans should have been developed to ensure consistent care and to address the resident's risks and actual problems. The facility's policy on baseline care plans, which requires the inclusion of instructions for effective, person-centered care, was not followed, leading to the identified deficiencies.
Failure to Document Skin Assessment at Discharge
Penalty
Summary
The facility failed to perform and document a comprehensive skin assessment for a resident prior to discharge, which is a standard practice to ensure quality care. The resident, who was admitted with a fall resulting in fractures and was on anticoagulant therapy, was discharged without a documented skin assessment. This oversight led to the family being unaware of the bruises and skin injuries present on the resident's body, which were later revealed through photographs provided by a complainant. Interviews with facility staff revealed that the Treatment Nurse regularly checked the resident's surgical wound but did not perform a full skin assessment due to the resident's early discharge. The Licensed Nurse responsible for the discharge admitted to not conducting a head-to-toe examination due to being rushed, which is contrary to the nursing standard of practice. The Assistant Director of Nursing confirmed that the discharge summary lacked documentation of the resident's skin condition, which should have included any bruises or injuries. The Director of Staff Services and other staff members acknowledged the importance of skin assessments at discharge to inform families about potential skin issues and necessary care. The failure to document the resident's skin condition upon discharge was attributed to incomplete documentation by a registry agency CNA and the rushed discharge process, which did not allow for a thorough assessment as required by the facility's standards.
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 403 citations issued within 25 miles in the last 12 months — including the 3 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 Escondido
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Palomar Vista Healthcare Center | 0.7 mi | ★★★★★ | 32 | 0 |
| Palomar Heights Post Acute | 1.2 mi | ★★★★★ | 5 | 0 |
| Valley Vista Post Acute | 1.4 mi | ★★★★★ | 24 | 0 |
| Redwood Terrace Health Center | 1.7 mi | ★★★★★ | 0 | 0 |
| Meadowbrook Village Christian Retirement Community | 1.8 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Escondido Post Acute.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.