Below average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Palomar Vista Healthcare Center during CMS and state inspections, most recent first.
The facility failed to confirm HH services and accurately document post-discharge arrangements before discharging three residents who required ongoing skilled care at home. One resident with a peritoneal abscess and a wound VAC was discharged with orders for RN, wound care, and PT visits, and the discharge paperwork named a specific HHA, but the referral was not sent until after discharge and was then declined, with no discharge-planning notes until days later. Another resident with impaired mobility and pneumocystosis was discharged with orders for RN and PT visits; the discharge summary listed an HHA as arranged even though acceptance was still pending, and only hours after discharge was it documented that the agency had declined, with a different HHA accepting the referral the following day. A third resident with acute cholecystitis and digestive tract ostomies had a discharge summary stating HH services were arranged, while documentation showed the referral was still pending and staff later acknowledged they never confirmed acceptance or followed up before or after discharge. Interviews with leadership and existing policy confirmed that HH referrals should have been initiated early and agencies confirmed prior to discharge, which did not occur in these cases.
Unsafe and Unhomelike Environmental Conditions: Surveyors found damaged room walls and pulled-out phone jack boxes, with residents describing the areas as depressing and not homelike. They also observed staff using an alarmed side gate and door near resident rooms at night, with repeated alarm sounds waking residents, and a portable AC in the hallway with tubing and large zip ties attached to the handrail, which the ESD said could obstruct residents and did not look homelike.
Failure to document antipsychotic side effect monitoring for two residents. One resident with MDD was receiving Rexulti, but the chart did not show monitoring for postural hypotension. Another resident with bipolar disorder was receiving Lurasidone, and the MAR required lying and sitting blood pressures each Sunday, but the sitting readings were not documented. LN, DSD, and DON all stated both readings should have been recorded.
Medication management and documentation were not completed according to professional standards for several residents. A resident receiving oral chemotherapy had personal medication from an outside source that was not properly inventoried, and staff documentation about whether and when it was available was inconsistent. Another resident on an antipsychotic lacked documentation of monitoring for postural hypotension despite a care plan calling for side effect monitoring. Two other residents had missing MAR documentation for insulin and other medications, with nurses stating doses were given but not signed at the time of administration.
Failure to follow a standardized recipe during meal prep was observed on the tray line. A cook used the wrong scoop for oregano, reused the same measuring utensils without washing between ingredients, and added an unmeasured amount of parmesan cheese to the lasagna mixture instead of following the recipe exactly. The DS stated proper portions and recipe adherence were important and that incorrect measurements could affect taste and nutritional value.
Kitchen Sanitation Deficiencies: The low-temp dishwasher was observed with a chlorine level of 10 PPM, below the facility’s stated 50-100 PPM sanitizing range, and the Cook stated he did not know the proper range. In addition, the scoop drawer was disorganized during meal prep, and the Cook, a cook resource, and the DS all touched and moved scattered scoops while searching for the correct utensil.
A resident with documented lack of decision-making capacity had multiple treatment consent forms signed only by the resident for medications including a sedative-hypnotic, an anti-anxiety medication, and other psychotropic medications. Staff interviews confirmed that a resident without capacity should not sign consent forms and that the responsible party or resident representative should sign instead, and the facility did not provide an informed consent policy.
A resident with spastic quadriplegic cerebral palsy, muscle weakness, neuromuscular bladder dysfunction, and moderate cognitive impairment was observed asking for a urinal while his call light was on the floor. CNA and LN both stated the call light should be within reach so he could make his needs known, and the DON confirmed that all residents' call lights should be within reach.
Failure to Honor Resident Choice for Bathing and Personal Items: Two residents were affected when staff did not honor a resident’s request for a shower and instead provided a sponge bath, despite staff acknowledging that a shower should have been given if requested. Another resident reported missing vitamins after staff removed them from her room; the ADM and SW stated the vitamins were taken because she was not allowed to keep them in her room, and the DON stated the MD was not notified and the resident was not evaluated for self-administration.
Failure to Assist With AD Formulation: A resident with no cognitive deficits and a history of MDD was not asked whether she had an AD or needed help completing one. The SSD documented use of a POLST but did not indicate that the resident was offered assistance to formulate an AD, and the DON stated a POLST is not an AD. The resident stated she would have wanted help if it had been offered.
Inaccurate MDS Coding for Hospice Status and Pressure Ulcer Admission Status: The facility failed to accurately code two residents’ MDS assessments. One resident had active hospice orders and remained on hospice, but hospice status was not coded on the quarterly MDS that was submitted to CMS. Another resident had four stage 4 pressure ulcers and one unstageable pressure ulcer present on admission, but the unstageable wound was not coded on the MDS. The MDSC and DON both confirmed the coding errors.
The facility failed to refer a resident with a new diagnosis of major depressive disorder for a new PASRR review after the resident had previously screened negative for serious mental illness. The MDSC, AD, and DON all confirmed that the PASRR on file remained the earlier screening and was not updated after the new diagnosis.
The facility failed to accurately screen two newly admitted residents for mental disorders. One resident had Huntington's disease, PTSD, and major depressive disorder, but the PASRR Level 1 screening stated no mental disorder was present and no level 2 eval was needed. Another resident had schizophrenia; although the PASRR Level 1 screening was positive and required a level 2 mental health eval, the facility did not complete the reevaluation on time and the attempted evaluation was closed after staff were unresponsive.
A resident with moderate cognitive deficits and a documented preference for Vietnamese had no person-centered care plan entry for language needs. The resident, her son, and staff all reported a language barrier, and the resident stated she did not speak English fluently, relied on her son to communicate, and had no written or visual communication aids in her room. Staff also noted the care plan did not include her language preference, despite assessments identifying Vietnamese as her primary language.
Failure to Invite Resident to Preferred Activities: A resident with MDD and intact cognition was observed lying in bed and stated she was not given an activity schedule, was not asked to join preferred social activities, and had spent the week in bed. She liked painting, drawing, manicures, BINGO, and social coffee, while an AA stated she should have been invited to activities such as BINGO because they helped keep her happy and engaged. The care plan called for inviting her to scheduled activities, and the AD and DON stated participation in activities of choice was important to her quality of life.
A resident with a history of prostate cancer and no cognitive deficits had active MD orders for enteral feeding and water flushes, but staff found the TF machine turned off with no nutrition or flushes hung on the pole. The resident stated the TF had not been given and had been off all day, and an LPN was unsure why the ordered 2:00 P.M. start had not been initiated. The RD and DON confirmed the resident did not receive the ordered feeding as scheduled, and the facility had no baseline weight taken on admission.
Failure to assess bedrail entrapment risk and obtain informed consent before installing bedrails for two residents. One resident with muscle weakness had blank safety device evaluation forms, no documented consent, and stated she did not use the bedrails and wanted them removed. Another resident with age-related physical debility had bedrails in place, but the MRD could not find a documented risk assessment. The facility also had no bedrail policy.
Failure to Account for Personal Chemotherapy Medication: A resident with breast CA and intact cognition reported missing packages of Verzenio after the med was brought from the hospital. Staff gave inconsistent accounts of how the medication was received, stored, documented, and administered, and one LPN did not complete the required inventory/account sheet for the resident’s personal medication.
An opened IV flush syringe and a green IV cap cover were left unattended on a resident’s dresser while the resident had an IV infusing in the room. The DON, who was the only RN on the floor and the IV nurse, observed the items and stated they should not have been left there. The facility policy states drugs and biologicals should not be left unsecured or unattended.
Improper Dumpster Storage and Refuse Disposal: An open dumpster outside the kitchen back exit contained garbage in clear plastic bags and scattered cardboard boxes, with a foul odor present. The DS stated the lids needed to be closed to contain the trash and prevent pests such as rats and flies from entering and potentially spreading infection. Facility policy required daily inspection of garbage and trashcans to ensure lids were closed and no debris was on the ground or surrounding area.
A resident with generalized anxiety disorder reported that vitamins in her room went missing after staff took them because she was not allowed to store them in her room. The SW did not document the incident and could not recall whether nursing was involved, and the DON confirmed there was no documentation regarding the vitamins or what was done. The facility also could not provide a documentation policy.
A CNA provided mouth care to a resident on EBP without wearing a gown, despite the resident having prostate cancer, a G-tube, and a history of MDRO. The CNA used gloves and hand hygiene but did not use the required gown during direct contact care. Another CNA, the IPN, and the DON all stated gown and gloves were expected for this type of care.
Two residents in a facility were using a bathroom without safety rails, which are crucial for safe toilet transfers. One resident required substantial assistance due to conditions like malignant neoplasm and chronic respiratory failure, while the other needed supervision due to gait abnormalities and a history of falls. The absence of safety rails was confirmed by staff and the facility's administrator, who stated they were removed for wall repairs and not replaced, despite the facility's policy requiring them.
A resident with hemiplegia and hemiparesis experienced ongoing diarrhea and developed purple, swollen feet, but the facility failed to create a care plan addressing these issues. Despite documentation of the resident's symptoms, no care plan was developed, leading to delayed care and decreased physical well-being. The facility's policy required comprehensive care plans, which were not implemented in this case.
A resident with hemiplegia and hemiparesis experienced continued diarrhea and skin breakdown due to the facility's failure to administer prescribed diarrhea medication. Despite having an order for Loperamide HCL, it was only given once, and the stool softener was not consistently held. The facility's policy required adherence to physician orders, which was not followed, putting the resident at risk for fluid deficit and dehydration.
A resident with hemiplegia and hemiparesis developed a deep tissue injury due to inadequate care and monitoring of a rash and diarrhea episodes. The facility failed to reposition the resident every two hours and did not document or follow up on the resident's skin condition, leading to the development of a pressure ulcer.
The facility failed to provide RN coverage for eight consecutive hours daily, leading to inconsistent care oversight. Payroll data showed low weekend staffing and a 1-star quality rating. Interviews revealed challenges in maintaining RN staffing, with the DON occasionally assisting on the floor. The facility lacked a staffing policy, contributing to the deficiency.
The facility failed to ensure a sanitary kitchen environment, with unlabeled food items and staff personal items improperly stored in the refrigerator. Additionally, a coil above the food shelf was covered in debris, posing a contamination risk. These issues violated FDA Food Code requirements and increased the risk of foodborne illness.
A resident with neuromuscular dysfunction of the bladder experienced delays in incontinent care, leading to feelings of upset and neglect. The resident reported waiting for hours to be changed, as CNAs were occupied with other tasks. The DON acknowledged the discomfort and potential skin issues resulting from such neglect.
A facility failed to complete the PASRR II evaluation for a resident with schizoaffective disorder, despite a positive Level I screening. The resident, who had been in and out of the facility since 2021, was observed experiencing visual hallucinations. Interviews with staff revealed confusion and lack of responsibility regarding the PASRR process, with no assigned personnel to review and follow up on screenings. The facility's policy required proper PASRR screening, but it was not followed, risking the resident's access to necessary mental health care.
Two residents in the facility did not have appropriate care plans developed to address their specific medical needs. One resident, with obstructive sleep apnea, lacked a care plan for CPAP use, while another, receiving IV antibiotics through a PICC line, had no care plan for its management. These deficiencies were identified through observations, interviews, and record reviews, highlighting a failure to meet the residents' care requirements.
A resident with obstructive sleep apnea reported that their CPAP machine was not working well and had requested a replacement since admission. Observations revealed the CPAP mask and tubing were held together with tape, indicating a need for replacement. A licensed nurse confirmed the machine needed replacement, and the Director of Nursing expected checks before use. However, the facility's policy lacked guidance on checking the machine's function.
A resident with end-stage renal disease did not receive consistent dialysis access site care as required. The resident, who had mild cognitive impairment, was observed with an intact dressing on the dialysis site, which he often removed himself. Facility staff interviews revealed that the dressing should be removed three hours post-dialysis to prevent infection and allow for assessment, as per physician's orders. The facility's policy required licensed nurses to provide vascular access site care, but this was not consistently followed.
The facility failed to follow infection control practices for three residents, leading to potential contamination of medical equipment. A resident's CPAP mask was left exposed, another's IV tubing and PICC line dressing were undated, and a third resident's CPAP mask was improperly stored. The facility's policies lacked guidance on proper storage and labeling, contributing to these deficiencies.
The facility failed to assess a resident's ability to self-administer medications, leading to a potential risk of over or under medication. The resident, with hemiplegia and hemiparesis, self-administered antibiotics and an ointment without any assessment or supervision from the nursing staff. The facility's policy for self-administration of medications was not followed.
Failure to Confirm Home Health Services Prior to Discharge
Penalty
Summary
The deficiency involves the facility’s failure to ensure that home health (HH) services were confirmed and accurately reflected in discharge documentation prior to residents’ discharge. For Resident 1, who was admitted with a peritoneal abscess and required surgical wound dressing changes, there was an order for discharge with HH services for RN visits, wound care, and PT. The discharge summary and post-discharge plan of care identified a specific home health agency as arranged, and the resident was discharged with a wound VAC in place. However, the referral to that agency was not faxed until approximately 29 minutes after the resident had already left the facility, and the agency did not accept the referral. There were no progress notes documenting discharge planning prior to the social services assistant’s (SSA) notes four days after discharge. The resident later reported to a GACH that no nurse had come to his home and that he did not know how to care for his wound VAC. For Resident 2, admitted with difficulty walking and pneumocystosis, an order was written for discharge to home with HH services for RN and PT visits. A discharge progress note documented that a referral had been sent to a home health agency and was pending review and acceptance, yet the discharge summary and post-discharge plan of care stated that this same agency had been arranged to provide services. The resident was discharged home, and more than three hours after discharge, a discharge planning note documented that the agency did not accept the referral. Over 24 hours after discharge, the SSA documented that a different home health agency confirmed acceptance of the referral. The SSA later stated that the day she documented the acceptance was the day the second agency confirmed, which was the day after the resident’s discharge. For Resident 3, admitted with acute cholecystitis and artificial openings of the digestive tract, the discharge summary stated that HH services had been arranged with a specific home health agency. A discharge planning note documented that a referral had been made to that agency and was pending review and acceptance. The social services staff stated she sent the referral but did not hear back from the agency regarding acceptance and did not have a chance to follow up on the referral before or after the resident’s discharge. In interviews, the administrator stated that referrals to HH agencies should have been initiated as soon as the facility became aware of a resident’s discharge date, and the DON in training stated that HH agencies should have been confirmed prior to residents’ discharges. The facility’s own policy required that discharge needs be identified on admission and that a discharge plan be developed and implemented in a timely manner to effectively transition residents to post-discharge care.
Unsafe and Unhomelike Environmental Conditions
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for seven of 21 sampled residents. Surveyors observed multiple areas of physical damage in resident rooms, including phone jack boxes pulled out of walls and still connected to phone wiring, damaged walls with scraped paint and exposed drywall, and broken plaster near a sliding glass door. Residents 43, 85, and 8 each described the damaged walls as not homelike or depressing and stated they wanted the repairs completed. The Environmental Service Director confirmed the damaged phone jack boxes could be a tripping hazard, the wall damage was not homelike, and the broken wall by the sliding door could let in pests. The survey also found that night staff were entering and exiting through an alarmed side gate and door near Resident 69 and Resident 79’s room. Resident 69 stated he had trouble sleeping because staff came and went all night, the door slammed, and the gate alarm sounded repeatedly when the code was entered incorrectly. Resident 79 stated the gate alarm woke him from sleep often. The Environmental Service Director tested both the side door alarm and the gate alarm and stated the sounds were harsh, not homelike, and could wake residents from sleep. Surveyors additionally observed a portable air conditioner placed in the hallway near rooms 31, 32, and 33. The unit occupied part of the hallway, and approximately 12 feet of tubing was secured to the resident handrail with large zip ties. A gap was noted at the connection points where hand entrapment could occur, and one zip tie extended upward about a foot. The Environmental Service Director stated residents could get caught on the zip ties, the tubing could obstruct residents who have trouble walking, and the setup did not look homelike. The Administrator stated the facility should be homelike, safe, and in good repair.
Failure to Document Antipsychotic Side Effect Monitoring
Penalty
Summary
The facility failed to ensure that residents receiving antipsychotic medications were monitored for side effects, including postural hypotension, for two sampled residents. Resident 42 was admitted with a history of Major Depressive Disorder and was receiving Rexulti 2 mg daily for depression. During record review and interviews, LN 1 stated that antipsychotic side effect monitoring for Resident 42 included sedation, dry mouth, constipation, slurred vision, EPS, weight gain, edema, and postural hypotension, but there was no documentation in the clinical chart showing that postural hypotension was being monitored. LN 1 also stated that the resident could experience syncope, dizziness, headaches, and injury from falls related to adverse side effects of the medication. Resident 28 was admitted with bipolar disorder and had an order for Lurasidone on the MAR for August 2025. The MAR included an order to monitor for side effects of Lurasidone, including postural hypotension, and to check blood pressure every Sunday while lying down and while sitting. Review of the MAR showed that the sitting blood pressure was not documented for any Sunday in the month. LN 11 stated that both blood pressure readings should have been entered if they were taken, and if the second reading was not documented, there was no evidence it occurred. The DSD and DON 2 also stated that both lying and sitting blood pressures should have been documented on the MAR.
Medication accounting, side effect monitoring, and MAR documentation failures
Penalty
Summary
The facility failed to ensure services met professional standards for four sampled residents related to medication management and documentation. For one resident admitted with joint replacement surgery, muscle weakness, recurrent left hip dislocation, breast cancer, and major depressive disorder, the record showed an order for Verzenio oral chemotherapy. The resident stated she believed multiple packages of the medication had been brought from the hospital, but the facility did not accurately account for the personal medication received from an outside pharmacy or hospital source. The Admissions Director stated she brought the resident’s medications from the hospital to the facility, and the nurse stated he kept one box of chemotherapy pills and gave the other medications to the resident’s boyfriend, but no inventory sheet was made to reflect the amount received as required by facility policy. The same resident’s medication record also showed inconsistent administration documentation. The eMAR indicated the chemotherapy medication was documented as given on a date after the facility had already recorded it as not available for several days, and staff interviews showed confusion about whether the medication was in the cart, whether an account sheet existed, and whether the medication had been received from the boyfriend or the hospital. The DON stated the nurse should have notified the physician when the medication was about to expire, should have completed an inventory sheet upon receipt, and should have documented accurately in the MAR and progress note. For another resident with major depressive disorder receiving an antipsychotic medication, the chart and staff interview showed that monitoring for side effects did not include documentation of postural hypotension, even though the care plan called for monitoring and reporting side effects and adverse reactions of psychoactive medications. The nurse identified expected side effects such as sedation, dry mouth, constipation, slurred vision, EPS, weight gain, edema, and postural hypotension, but stated there was no documentation supporting that postural hypotension was being monitored. The DON stated the expectation was that staff monitor this side effect closely. Two additional residents had missing medication administration documentation. One resident with diabetes had orders for Humulin insulin with meals, but the MAR did not show administration for several scheduled doses, and there were no progress notes to explain the missing doses. Two nurses stated they had given doses but did not sign the MAR at the time of administration or forgot to sign after giving the insulin. Another resident with late syphilitic neuropathy had MAR entries showing several medications were not given, and the nurse stated she had not documented the medications she had given and planned to enter them later. The DON stated documentation was expected at the time medication was given, and the facility policy stated medications were to be accurately prepared, administered, and documented as ordered.
Failure to Follow Standardized Recipe During Meal Preparation
Penalty
Summary
The facility failed to follow standardized recipes during meal preparation on the tray line. During observation of lunch preparation, the cook had already measured the turkey and onions for Zesty Lasagna, then used a green scoop equivalent to 1/3 cup for dried oregano even though the recipe called for 3/8 cup and the cook stated the ivory scoop for that amount could not be found. The cook then used the same tablespoon and teaspoon without washing in between for thyme, cayenne, and garlic powder, and mixed the dried ingredients together, including the oregano measured with the wrong scoop. The cook also prepared the cheese mixture by combining cottage cheese, mozzarella cheese, and an unmeasured amount of parmesan cheese with pasteurized eggs. The cook stated the parmesan was mixed in as desired unless a resident said they did not want it, and stated there were no individual parmesan packets to give residents. The tomato sauce, tomato paste, and ground beef had already been prepared on the stove and were combined with the dried ingredients and onions in the pot. The Dietary Supervisor stated it was important to use appropriate portions and follow the recipe, and that using the wrong measurements could affect the taste and nutritional value of the meal.
Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen when the low-temperature dishwasher was observed with a chlorine level of 10 PPM on a test strip, which was below the facility’s stated sanitizing range of 50-100 PPM. During the initial kitchen tour, the Cook tested the dishwasher and stated he did not know the chlorine level range needed to sanitize dishware and cookware. The Dietary Supervisor later stated that the chlorine test on litmus paper should be within 50-100 PPM to properly sanitize dishware and cookware, and that this was important to prevent food-borne illnesses for residents served from the kitchen. The facility also had a disorganized scoop drawer during meal preparation. While the Cook was looking for scoops for dried ingredients, another cook resource and the Dietary Supervisor assisted by searching through the same drawer, with their hands touching and moving around the scattered scoops. The Dietary Supervisor acknowledged that multiple hands touched the scoops and stated the drawer was messy and should be organized so staff could get the needed scoops without touching everything else in the drawer. The facility policy titled Sanitation stated that utensils, counters, shelves, and equipment shall be kept clean.
Invalid Consent Signatures for Resident Without Capacity
Penalty
Summary
The facility failed to ensure consents were signed by the appropriate person for one resident who was documented as not having capacity to make medical decisions. The resident was admitted with a diagnosis of late syphilitic neuropathy, and a nurse practitioner note dated January 24, 2025 stated that the patient did not have capacity to make medical decisions. Despite this, multiple treatment consent forms in the resident’s electronic medical record were signed only by the resident for medications including zolpidem tartrate 5 mg, buspirone HCL 100 mg, valproic acid 250 mg/5 mL, and gabapentin 600 mg. During interviews, CNA31, LN3, the DSD, and DON2 each stated that a resident without capacity should not sign a consent form and that the responsible party or resident representative should sign instead. DON2 also stated that if a resident does not have capacity, the consent would not be valid. The facility did not provide a policy and procedure document regarding informed consent.
Call Bell Not Within Reach
Penalty
Summary
The facility failed to keep one sampled resident's call bell within reach. Resident 79 was admitted with diagnoses including spastic quadriplegic cerebral palsy, muscle weakness, and neuromuscular dysfunction of the bladder. The resident's MDS dated 8/8/25 showed a BIMS score of 12, indicating moderate cognitive impairment. On 9/9/25 at 3:40 P.M., Resident 79 was observed verbally asking for a urinal, and the call light was observed on the floor. During follow-up observations and interviews, CNA 21 and LN 22 both stated that the resident's call light should be within reach so he could make his needs known. On 9/12/2025, the DON stated that all residents' call lights should be within reach to provide the care they need. The facility policy titled Resident's Rights, Accommodation of Needs, dated 3/2023, stated that the facility provides accommodation of reasonable needs to residents, including call lights.
Failure to Honor Resident Choice for Bathing and Personal Items
Penalty
Summary
The facility failed to honor resident choice for bathing for two residents. One resident, admitted with a history of major depressive disorder and assessed with a BIMS score of 15/15, stated she was upset that she did not receive a shower when she requested one and was instead told she could not have one because she had an IV in her left arm. She was observed lying in bed in a facility gown and later stated she still had not received a shower and did not feel clean. A licensed nurse stated the resident was given a sponge bath, that her shower schedule was Mondays and Thursdays, and that a sponge bath was not the same as a shower. A CNA and another nurse stated the resident should have received a shower if she requested one, and the DON stated the expectation was that staff honor the resident’s preference for a shower. The facility also failed to respect another resident’s control over personal items when vitamins were removed from her room. The resident, admitted with generalized anxiety disorder, stated that vitamins in her room went missing and that she reported this to the administrator and other staff, but nothing was done to help her. The administrator stated the facility searched resident rooms throughout the facility and took the resident’s vitamins from her room. The social worker stated the vitamins were taken because the resident was not allowed to store them in her room. The DON stated that when the vitamins were taken, no one notified the doctor, the resident should have been told why the vitamins were being removed, and the resident should have been evaluated for the ability to self-administer her vitamins. An observation of the vitamins showed a bag labeled with the resident’s name and dated 9/6/25 containing multiple dietary supplements, including vision defense, hair skin and nails, eye health, and vitamin E. The report also noted there was no documentation from the time of the incident.
Failure to Assist Resident With Advance Directive Formulation
Penalty
Summary
The facility failed to help formulate an advance directive for one of three sampled residents, Resident 42. Resident 42 was admitted with a history of Major Depressive Disorder and had a BIMS score of 15 out of 15 on the 6/10/25 MDS, indicating no cognitive deficits. A review of the electronic health record and live chart on 9/9/25 showed Resident 42's POLST was marked "No Advance Directive." During an interview on 9/10/25, Resident 42 stated the acute hospital had given her information about an advance directive before transfer, but it was not completed. She stated she was not asked whether she had an advance directive and would have wanted assistance to formulate one if it had been offered. The SSD stated she completed the SSAE on 6/9/25 but did not check whether Resident 42 was asked if she needed assistance to formulate an AD or whether she had one, and only indicated that Resident 42 would be using the POLST. The SSD stated a POLST is not an AD. The DON stated her expectation was for the SSD to help Resident 42 formulate an AD because a POLST is not an AD. The facility policy stated adult residents are to be informed and provided written information concerning the right to accept or refuse treatment and, at the resident's option, formulate an advance directive.
Inaccurate MDS Coding for Hospice Status and Pressure Ulcer Admission Status
Penalty
Summary
The facility failed to ensure accurate MDS coding for Resident 85 by not coding hospice status on the quarterly assessment. Resident 85 was admitted with a history of cerebral infarction and had severe cognitive deficits, with a BIMS score of 6 out of 15. During observation, the resident was unable to carry on a full conversation and was receiving oxygen through a nasal cannula. Record review showed hospice orders had been active since 3/13/25, and a licensed nurse stated the resident had remained on hospice and that hospice status was never discontinued. The MDS Coordinator later stated the 6/20/25 quarterly MDS was coded inaccurately in Section O, that no documentation was found showing hospice orders were discontinued during the look-back period, and that the MDS had been sent to CMS with incorrect information. The facility also failed to code Resident 28’s unstageable pressure ulcer as present on admission. Resident 28 stated he had pressure ulcers before admission, and the medical record showed four stage 4 pressure ulcers and one unstageable pressure ulcer present on admission. However, the MDS dated 3/19/25 coded four stage 4 pressure ulcers and zero unstageable pressure ulcers on admission. The MDS Coordinator stated the unstageable pressure ulcer was not documented on the MDS and that the facility’s usual MDS Coordinator should have recorded it. The DON also stated the unstageable pressure ulcer should have been documented on the MDS.
Failure to Update PASRR After New Serious Mental Illness Diagnosis
Penalty
Summary
The facility failed to refer Resident 10 to the state designated authority for evaluation after the resident developed a new diagnosis of major depressive disorder, which is a serious mental illness. Resident 10 was admitted with a diagnosis of major depressive disorder dated 7/31/24, while the facility's PASRR Level 1 Screening dated 6/6/24 had previously found the resident negative for serious mental illness and closed the case. During interview and record review, the MDS Coordinator stated that when a resident has a new diagnosis of a serious mental illness such as major depressive disorder, the facility should complete a new resident review and update the PASRR. The Admissions Director stated that the latest PASRR on file for Resident 10 was dated 6/6/24, and the DON stated that the PASRR should have been updated when Resident 10 received the new diagnosis.
Inaccurate PASRR Screening for Two Newly Admitted Residents
Penalty
Summary
The facility failed to accurately screen newly admitted residents for mental disorders on two of three sampled residents. One resident was admitted with diagnoses including Huntington's disease, PTSD, and major depressive disorder, but the facility's PASRR Level 1 Screening dated 10/17/24 stated the resident did not have a diagnosed mental disorder such as depressive disorder or mood disturbance and did not require a level 2 mental health evaluation. During interview, the Admissions Director stated that the latest PASRR for this resident was the 10/17/24 screening and that the MDS nurse checked PASRRs of newly admitted residents for accuracy. The DON later stated the facility should have reviewed the admission PASRR for accuracy and updated it if it was inaccurate. A second resident was admitted with schizophrenia and had a Notice of Exempted Hospital Discharge stating that if the individual remained in the nursing facility longer than 30 days, a new level 1 screening had to be resubmitted on the 31st day. The resident's PASRR Level 1 Screening dated 2/13/25 was positive for schizophrenia and required a level 2 mental health evaluation, but the Notice of Attempted Evaluation stated the facility was unresponsive to two or more separate attempts of communication within 48 hours and the case was closed. The Admissions Director stated the resident had PASRR screenings on 8/21/24 and 2/13/25, and the MDS Coordinator stated the facility should have completed the PASRR reevaluation on the 31st day and followed up when the level 2 evaluation was not completed. The DON also stated the facility should have reevaluated the resident's PASRR.
Failure to Include Resident Language Preference in Care Plan
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan that identified Resident 61’s language preference. Resident 61 was admitted with diagnoses including a history of respiratory failure, and the MDS comprehensive assessment dated 8/26/25 indicated a BIMS score of 11, showing moderate cognitive deficits. The MDS comprehensive assessment and the Social Services Assessment/Evaluation both identified Vietnamese as the resident’s preferred or primary language, and the resident verbalized the need for an interpreter to communicate with medical staff. During interviews and observation, Resident 61’s son stated she was not fluent in English and spoke Vietnamese. Resident 61 stated through a Vietnamese interpreter that she did not know how to speak English, that her son spoke for her when he visited, and that she had a language barrier with staff when her son was not present. She also stated she preferred Vietnamese food from home and said the facility did not offer alternatives or tell her there were alternatives if she did not like the food. CNA 3 stated she was unsure what language Resident 61 spoke and did not know of any coworkers who spoke Vietnamese, and LN 3 stated Resident 61 did not have written or visual translation or communication methods in her room. LN 3 also stated Resident 61’s care plan did not include her language preference, and the DON stated the care plan should include the resident’s language preference as captured in the comprehensive assessment.
Failure to Invite Resident to Preferred Activities
Penalty
Summary
The facility failed to provide an activities program that met the interests and needs of one sampled resident, Resident 42. Resident 42 was admitted with a history of Major Depressive Disorder and had an MDS BIMS score of 15 out of 15, indicating no cognitive deficits. During observations and interviews, Resident 42 was found lying in bed in a facility gown and stated she wanted to get out of bed, had not been given an activities calendar, and believed staff no longer asked her to participate because they assumed she did not want to go. She reported liking painting, drawing, manicures, BINGO, and social coffee, and stated she had done nothing all week but lie in bed. Resident 42 also stated she was not given an activity schedule and was not asked to join social activities she would have wanted to attend. An Activities Assistant stated Resident 42 liked social activities such as BINGO and any available social activities, but had not participated on multiple days because she was not invited and assisted to the dining room for activities. The assistant stated Resident 42 should have been invited and that BINGO was important because it made her happy and kept her busy from feeling depressed. The resident’s care plan identified her as dependent on staff for activities, cognitive stimulation, and social interaction, with an intervention to invite her to scheduled activities. Her activity record showed participation on multiple dates in July, August, and September, and the AD and DON both stated it was important for Resident 42 to attend activities of her choice. The facility policy stated residents who wish to participate in social, religious, or community activities are encouraged to do so.
Failure to Start Ordered Tube Feeding on Time
Penalty
Summary
The facility failed to follow physician orders for enteral feeding for one resident who was re-admitted with a history of prostate cancer and had a BIMS score of 15, indicating no cognitive deficits. The resident had active orders for tube feeding and water flushes, including an enteral feed order to run from 2:00 P.M. to 8:00 A.M. with continuous water flushes. The resident’s care plan also identified dependence on tube feeding and water flushes. On observation and interview, the resident’s TF machine was found turned off with no water flushes or nutritional feeding hung on the TF pole. This was observed on more than one occasion, including when the resident stated he was not sure if he had eaten or had TF running that day, and later stated his TF had not been given and had been off all day. A licensed nurse stated she was unsure why the enteral feeding orders were not initiated at 2:00 P.M. and acknowledged that if the TF was off all day, the resident could have complications including dehydration, hypoglycemia, loss of consciousness, and further health decline. Record review and staff interviews showed the resident did not receive the ordered enteral feeding as scheduled. The nurse stated the resident did not eat breakfast but ate 45% of lunch, and there was no baseline weight taken upon admission; the first weight was obtained later at 135.4 lbs without weight monitoring recommendations from the RD. The RD stated the nutrition evaluation was opened before being completed, that weights are taken on Monday and Thursday, and that he did not know the policy for when weights should be taken for new admissions. The DON stated the TF was not connected after 4:00 P.M. even though the physician’s order required it to start at 2:00 P.M., and the facility policy required physician orders to be accurately transcribed and implemented.
Failure to Assess and Obtain Consent Before Installing Bedrails
Penalty
Summary
The facility failed to assess residents for the risk of bedrail entrapment, review the risks and benefits of bedrails, and obtain informed consent before installing bedrails for two sampled residents. Resident 11 was admitted with muscle weakness, and the medical record contained two LN-Restraint/Enabling Device/Safety Device Evaluation forms dated 1/28/25 and 2/24/25 that were blank, including the sections for consent and risks and benefits. During an interview and observation, Resident 11’s bed was found with bedrails attached, and the resident stated she did not use the bedrails and wanted them removed. The Medical Records Director was unable to locate a bedrail consent or a completed bedrail entrapment risk assessment in the record, and both the MRD and DON stated the required evaluation and consent should have been completed before the bedrails were installed. Resident 98 was admitted with age-related physical debility, and an observation of the resident’s bed showed bedrails attached. During record review and interview, the Medical Records Director stated she was unable to find documentation of a bedrail entrapment risk assessment for Resident 98, and DON 2 stated the risk assessment should have been completed for this resident. The facility also did not have a policy on bedrails.
Failure to Account for Resident’s Personal Chemotherapy Medication
Penalty
Summary
The facility failed to accurately acquire, receive, and account for one resident’s personal chemotherapy medication, Verzenio, for a resident admitted with diagnoses including breast cancer, joint replacement surgery, muscle weakness, recurrent left hip dislocation, and major depressive disorder. The resident’s MDS indicated intact cognition with a BIMS score of 15. During an interview, the resident stated she believed she had three packages of seven pills each from the hospital and that only one package was available for use at the facility, with two packages missing. Physician orders dated 8/28/25 directed Verzenio 100 mg by mouth twice daily for breast cancer. The eMAR showed the medication was documented as not available on multiple dates, and a note on 9/10/25 stated the resident was seen by MD and the facility was waiting for supply. The resident later stated that the admissions director picked up her medications from the hospital and brought them to the facility, where a nurse reviewed them with her and kept the chemotherapy pills in the medication cart while giving the other medications to her boyfriend. Interviews with staff showed inconsistent accounts of how the medication was received and handled. The admissions director stated she remembered only one packet of seven chemotherapy pills in the hospital bag, while one nurse stated he kept one box of chemotherapy pills and documented it in the EMR, and another nurse stated he gave the medication and signed it off despite not being aware of the proper process for verifying personal medications or creating an inventory sheet. The DON stated the nurse should have notified the physician when the medication was about to expire and should have completed an inventory sheet to accurately account for the resident’s personal medication. The facility policy required specialty medications brought from outside pharmacies or by family to have an account sheet reflecting the number received.
Unsecured IV Supplies Left Unattended in Resident Room
Penalty
Summary
Drugs and biologicals were not properly stored when an opened IV flush syringe and a green IV cap cover were left unattended on the dresser in Resident 42’s room. Resident 42 was admitted with a history of IBS and had an MDS BIMS score of 15 out of 15, indicating no cognitive deficits. During an observation in the resident’s room, Resident 42 was lying in bed with an IV medication infusing into the left lower arm, and the resident’s gray purse was on the dresser with the opened IV flush and green IV cap cover left unattended. During a later observation and interview, the DON, who stated she was the only RN on the floor and the IV nurse responsible for IV medication administration, observed the unattended IV supplies on the dresser and stated they should not have been there. The DON identified this as a safety issue and stated the IV supplies needed to be stored properly in the IV cart and locked when unattended. The facility policy titled Medication Administration/Med cart and Storage, revised 3/2025, stated drugs and/or biologicals should not be left unsecured or unattended and should be stored immediately after delivery.
Improper Dumpster Storage and Refuse Disposal
Penalty
Summary
The facility failed to properly store and dispose of refuse in a sanitary manner when outside dumpster lids were left open and accessible to pests. During an observation and interview outside the kitchen back exit, two dumpsters were seen outside, with one dumpster lid open. The open dumpster contained garbage in clear plastic bags and cardboard boxes scattered inside, and there was a foul odor coming from the dumpster. The Dietary Supervisor stated the dumpster lids needed to be closed to contain the garbage and prevent pests such as rats and flies from entering the dumpster and potentially spreading infection. A review of the facility policy titled, Miscellaneous Areas, dated 2023, stated that garbage and trashcans must be inspected daily to ensure no debris is on the ground or surrounding area and that the lids are closed.
Failure to Document Resident Belongings Incident
Penalty
Summary
The facility failed to ensure resident belongings were documented in the medical record for one of three sampled residents, Resident 24, who was admitted with generalized anxiety disorder. On review of the record, there were no progress notes documenting the incident and no progress notes of any kind on 9/6/25. Resident 24 stated that vitamins in her room went missing and that she told the administrator and other facility staff, but they told her they could not find them and did nothing to help her. The SW stated that the vitamins were taken because Resident 24 was not allowed to store them in her room, but the SW did not remember whether nursing was involved and did not document the incident. The DON stated there was no documentation regarding the taking of the vitamins and that the facility should have documented the incident and what was done. The facility was unable to provide a policy on documentation.
Failure to Use Required PPE During Mouth Care for a Resident on EBP
Penalty
Summary
Provide and implement an infection prevention and control program was deficient when a CNA provided mouth care to a resident on Enhanced Barrier Precautions without wearing a gown. Resident 100 was re-admitted to the facility with a history of prostate cancer, had a BIMS score of 15/15, and had care plan and MD orders indicating the use of EBP due to an indwelling G-tube and history of infection or MDRO status. The resident was observed in bed with tube feeding turned off and disconnected, while a CNA sat at the bedside as a sitter and then returned to the room to provide mouth care with a wet towel. During the observation, the CNA performed hand hygiene and put on gloves but did not wear a gown while providing direct contact mouth care, then left the room. Another CNA stated the CNA was providing mouth care without a gown while the resident was on EBP and that gown and gloves were important for direct contact care. The IPN stated the resident was on EBP because of immunocompromised status due to prostate cancer, a history of MDRO, and a G-tube, and stated the CNA should have worn proper PPE during mouth care. The DON stated the expectation was for staff to wear proper PPE, including a gown and gloves, when providing direct contact care such as mouth care to this resident.
Absence of Safety Rails in Resident Bathroom
Penalty
Summary
The facility failed to provide safety rails in a bathroom used by two residents, which had the potential to lead to accidents related to toilet use. Resident 7, admitted for respite care, required substantial or maximal assistance for toilet transfers due to conditions such as malignant neoplasm of the bladder, surgery of the genitourinary system, and chronic respiratory failure. Resident 11, who had abnormalities of gait, muscle weakness, cerebral infarction, and a history of falls, required supervision or touching assistance for toilet transfers. Both residents had access to a bathroom that lacked safety rails, which are essential for maintaining balance and ensuring safe transfers. Observations and interviews conducted on the same day revealed that the bathroom connecting two rooms did not have safety rails by the toilet or anywhere else in the bathroom. Complainant 1, the spouse of Resident 7, confirmed the absence of safety rails. Resident 11, observed using a walker with an irregular gait, also confirmed the lack of safety rails and expressed that using the toilet would be easier with them. Both a CNA and a licensed nurse confirmed the absence of safety rails and emphasized their importance for resident safety during toilet use. The facility's administrator explained that the safety rails had been removed due to wall repairs following a flood, and they had not been replaced. The facility's policy, dated November 2007, mandates that bathrooms must be equipped with safety rails. The failure to replace the safety rails after the repairs created a potential hazard for residents who required assistance with toilet transfers, as confirmed by multiple staff members and the facility's policy.
Failure to Develop Care Plan for Resident's Diarrhea and Swollen Feet
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who experienced diarrhea and purple feet with swelling. The resident, admitted with hemiplegia and hemiparesis following cerebrovascular disease, had loose bowel movements documented over several days and a change in condition noted with swelling and discoloration of the feet. Despite these ongoing issues, the facility did not create a care plan to address these specific health concerns. Interviews and record reviews revealed that the Director of Nurses acknowledged the absence of care plans for the resident's diarrhea and foot condition. The facility's policy required the interdisciplinary team to develop person-centered care plans with measurable objectives and timeframes to meet residents' needs. The lack of a care plan resulted in delayed care and decreased physical well-being for the resident, as staff were not guided or alerted to the necessary interventions for the resident's conditions.
Failure to Administer Diarrhea Medication
Penalty
Summary
The facility failed to administer a medication for diarrhea to a resident, leading to continued diarrhea and skin breakdown on the sacro-coccyx area. The resident, who was admitted with hemiplegia and hemiparesis following cerebrovascular disease, had an intact cognitive score. Despite having an order for Loperamide HCL for diarrhea, the medication was only administered once, and the resident experienced loose bowel movements over a period of 12 days. Additionally, a stool softener was ordered but not consistently held despite the presence of diarrhea, and the resident refused the stool softener on several occasions. Interviews with the licensed nurse and the Director of Nurses revealed that the medication for diarrhea was not administered as needed, and the stool softener was not appropriately held. The facility's policy required medications to be administered according to the physician's written orders, which was not followed in this case. This oversight resulted in the resident being at risk for fluid deficit and dehydration due to the ongoing diarrhea.
Failure to Prevent Pressure Ulcer Formation
Penalty
Summary
The facility failed to provide necessary care and services to prevent pressure ulcer formation for a resident with hemiplegia and hemiparesis following cerebrovascular disease. The resident was admitted with a low air loss mattress to prevent skin breakdown, but the facility did not ensure proper repositioning every two hours or timely changing of briefs after episodes of diarrhea. This lack of care led to the resident developing a deep tissue injury on the sacro-coccyx, which was identified upon transfer to the hospital. Interviews with licensed nurses and the treatment nurse revealed that the resident had a rash in the perianal area, which was not adequately documented or monitored. The nursing progress notes lacked detailed descriptions of the rash and its progression, and there was no follow-up documentation regarding the moisture-associated dermatitis. The Director of Nursing confirmed the absence of necessary documentation and stated that licensed nurses were expected to document skin evaluations every shift, which was not done in this case.
Inadequate RN Coverage and Oversight
Penalty
Summary
The facility failed to provide registered nurse (RN) coverage for eight consecutive hours a day, seven days a week, resulting in inconsistent oversight for the coordination, management, and overall delivery of care to residents. The facility's payroll-based journal data indicated low weekend staffing and a 1-star rating for quality of healthcare service in 2024. A review of the facility's daily census for April, May, and June 2024 revealed multiple instances where there was less than eight hours of RN coverage or no RN present for the required duration on specific dates. Interviews with the Staffing Coordinator and the Director of Nursing (DON) highlighted challenges in maintaining adequate RN staffing, particularly on weekends. The Staffing Coordinator mentioned that the DON would sometimes act as a charge nurse and assist on the floor. The DON admitted to not knowing the required RN hours due to the facility's census being below 74 and acknowledged the importance of RN oversight for assessments. It was also noted that the facility lacked a staffing policy, contributing to the deficiency in RN coverage.
Deficiencies in Kitchen Sanitation and Food Labeling
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the kitchen, which increased the risk of foodborne illness and cross-contamination. During an observation, it was noted that the kitchen walk-in refrigerator contained items such as ketchup, soy sauce, and Italian dressing without a use-by date. Additionally, a staff member's plastic water bottle and beverage were improperly stored in the refrigerator. Other food items, including shredded carrots, hot dogs, tortillas, and onions, were not labeled or identified, violating the 2022 US FDA Food Code requirements for food labeling. Further inspection revealed a coil above the food shelf in the refrigerator covered with gray debris, which could potentially contaminate food. The registered dietician acknowledged the issue and indicated that maintenance would be notified. The facility's policies and procedures lacked specific guidance on maintaining the kitchen refrigerator, contributing to these deficiencies. The failure to properly label food and maintain equipment as per the FDA Food Code posed a risk to resident health by potentially exposing them to contaminated food.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide timely incontinent care to Resident 59, who was admitted with neuromuscular dysfunction of the bladder and muscle weakness. The resident, who was cognitively intact and dependent on assistance for toileting hygiene, reported feeling upset due to delays in receiving care. On one occasion, the resident waited from 6:30 AM to be changed, as the CNA was occupied with passing breakfast trays. This delay in care led to the resident feeling upset and neglected. Further observations revealed that Resident 59 experienced another incident where he was left wet and smelling of urine after a condom catheter came off during the night. The resident called for assistance at 4 AM, but the night shift CNA did not attend to him until 5:25 AM, and even then, deferred the task to the morning CNA. The morning CNA confirmed that the resident's brief was wet at the start of her shift. The Director of Nurses acknowledged that such neglect could cause discomfort and potential skin problems for residents.
Failure to Complete PASRR II Evaluation for Resident with Schizoaffective Disorder
Penalty
Summary
The facility failed to ensure the completion of the Pre-Admission Screening and Resident Review Level II (PASRR II) for a resident with a mental disorder, specifically schizoaffective disorder. The resident, who had been in and out of the facility since 2021, was readmitted with a diagnosis of schizoaffective disorder. Despite a positive Level I screening indicating the need for a Level II mental health evaluation, the evaluation was not completed due to inaccurate information provided to the State of California-Health and Human Services. The facility's staff, including the Director of Nurses (DON), admitted that there was no assigned personnel to review and follow up on PASRR Level I screenings. Interviews with various staff members, including the certified nurse assistant (CNA), licensed nurse (LN), minimum data set nurse (MDSN), and admissions director (AD), revealed a lack of clarity and responsibility regarding the PASRR process. The CNA noted the resident's refusal of certain care activities, while the LN observed the resident experiencing visual hallucinations. The MDSN and AD both indicated that PASRRs were received from the hospital, but there was confusion about who was responsible for their review and follow-up. The facility's policy stated the requirement for proper PASRR screening, yet it was not adhered to, leading to the potential for the resident not receiving necessary mental health care services in an appropriate setting.
Failure to Develop Care Plans for Residents with Specific Needs
Penalty
Summary
The facility failed to develop patient-centered care plans for two residents, which could potentially lead to unmet care needs. Resident 169, who was admitted with obstructive sleep apnea and chronic hypoxia, was observed using a CPAP machine at night. However, there was no care plan in place to guide staff on monitoring the resident's breathing, cleaning the CPAP machine, or adding water to it. This oversight was confirmed during a record review and interview with a licensed nurse, who acknowledged the absence of a care plan for the CPAP use. Similarly, Resident 170, admitted with sepsis and receiving IV antibiotics through a PICC line, also lacked a care plan addressing the management of the PICC line. The physician's orders required daily site checks and flushing of the PICC line, but no care plan was developed to ensure these tasks were performed. The Director of Nurses confirmed that care plans should be completed within 14 days, yet this was not done for Resident 170, as revealed during an interview and record review.
Failure to Ensure Functioning CPAP Machine for Resident
Penalty
Summary
The facility failed to ensure that a CPAP machine was functioning properly for a resident diagnosed with obstructive sleep apnea. The resident, who was cognitively intact, reported that the CPAP machine was not working well and had requested a replacement since admission. During an observation, it was noted that the CPAP mask and tubing were held together with gray tape, indicating a need for replacement. A licensed nurse confirmed that the CPAP machine needed to be replaced and acknowledged that it should be functional for the resident to receive its intended benefits. The Director of Nursing stated that licensed nurses were expected to check the CPAP machine before each use to ensure it was functioning properly. However, the facility's policy and procedure for CPAP/BiPAP monitoring and management did not provide guidance for staff to check the machine's function. This oversight had the potential to adversely affect the health and well-being of the resident, as the CPAP machine was essential for managing the resident's obstructive sleep apnea.
Failure to Provide Proper Dialysis Access Site Care
Penalty
Summary
The facility failed to consistently provide appropriate dialysis access site care and assessment for a resident with end-stage renal disease who was dependent on renal dialysis. The resident, who had mild cognitive impairment, was observed to have a dialysis access site on the right upper arm with a dressing intact. The resident reported that he often removed the dialysis dressing himself, which was contrary to the physician's orders that specified the dressing should be removed three hours after dialysis treatment. The resident's dialysis treatments were scheduled for Tuesdays, Thursdays, and Saturdays, and the last recorded dialysis appointment was on a Saturday. Interviews with facility staff, including a licensed nurse and the Director of Nursing, revealed that the dressing should be removed to allow for proper assessment and to prevent infection and bleeding. The facility's policy indicated that vascular access site care should be provided by a licensed nurse according to physician's orders. However, the failure to remove the dressing as required meant that the site could not be assessed, potentially leading to complications. This deficiency was identified through observations, interviews, and record reviews conducted by the surveyors.
Infection Control Deficiencies in CPAP and IV Management
Penalty
Summary
The facility failed to adhere to current infection control practices for three residents, leading to potential contamination of medical equipment. Resident 169's CPAP mask was observed left on top of the CPAP machine, exposed to air, rather than being stored in a plastic bag as required for infection control. This was confirmed by a licensed nurse who acknowledged the improper storage of the CPAP mask. Resident 170's IV tubing and PICC line dressing were not properly labeled with dates, which is a critical step in preventing infections. The IV bag and tubing were observed without a date, and the PICC line dressing was undated and worn out. The Director of Nurses confirmed that the lack of labeling and proper dressing changes could be a route for infection, and the facility's policy did not provide adequate guidance on labeling PICC line dressings. Resident 126's CPAP mask was also found uncovered on the bed, contrary to infection control protocols that require it to be stored in a plastic bag. The resident admitted to not cleaning the CPAP machine regularly, and the Infection Preventionist Nurse emphasized the importance of storing the mask properly to prevent exposure to microorganisms. The facility's policy lacked guidance on CPAP mask storage, contributing to the deficiency.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to assess a resident's ability to self-administer medications, which led to a potential risk of over or under medication. Resident 3, who was admitted with hemiplegia and hemiparesis following a cerebral infarction, reported having a red rash on his right leg and had been prescribed antibiotics and an ointment by a dermatologist. Resident 3 picked up the medications from the pharmacy and self-administered them without any assessment or supervision from the nursing staff. The resident stated that the nursing staff did not check if he was able to self-administer medications. During interviews, the assigned medication nurse and the Director of Nurses (DON) confirmed that they were aware Resident 3 brought in medications from an outside pharmacy but had not conducted an assessment for self-administration. The facility's policy required a physician's order, an assessment, a care plan, and a lock box for self-administration of medications, none of which were followed. The DON acknowledged the importance of knowing if a resident kept medications at bedside to prevent potential drug interactions and overdoses. The facility's policy and procedure for self-administration of medications were not adhered to in this case.
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Illustrative
What surveyors actually found near you
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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
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Illustrative
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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 Heights Post Acute | 0.6 mi | ★★★★★ | 5 | 0 |
| Escondido Post Acute | 0.7 mi | ★★★★★ | 2 | 0 |
| Redwood Terrace Health Center | 1.4 mi | ★★★★★ | 0 | 0 |
| Valley Vista Post Acute | 1.5 mi | ★★★★★ | 24 | 0 |
| Ocean View Post Acute | 2 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.