Encinitas Post-Acute

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were not left unattended. In addition, the medication cart was left unlocked in one of one (Resident 1) observed for medication storage during an Anonymous complaint investigation. This failure had the potential to affect residents' safety and may lead to drug diversion. Findings. A record review of the facility's undated admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included essential hypertension (high blood pressure) and peripheral vascular disease (a slow progressive circulation disorder involving blood vessels outside the heart and brain, commonly affects the legs). On 6/22/26 at 11:45 A.M., an observation and interview with Licensed Nurse ( LN ) 1 was conducted. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents (Resident 1) had a written plan of care revised after a pressure injury (damage to the skin and underlying structures caused by unrelieved pressure) worsened from a stage 2 (a partial-thickness, or shallow, loss of skin appearing as a shallow open ulcer or a clear fluid filled blister) to unstageable (a full-thickness ulcer where the depth cannot be determined because it is covered with dead tissue) As a result of this deficient practice, there was the potential for Resident 1 to experience further deterioration of the wound.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment and services to heal pressure injuries (damage to the skin and underlying structures caused by unrelieved pressure) for two of three sampled residents (Resident 1 and Resident 2) when: 1. Wound care orders for a pressure injury that worsened from a stage 2 pressure injury (a partial-thickness loss of skin appearing as a shallow open ulcer or a clear fluid filled blister) to an unstageable pressure injury (a full-thickness ulcer where the depth cannot be determined because it is covered with dead tissue) were not implemented, an Interdisciplinary Team (IDT-a group of individuals with different areas of expertise) Meeting was not conducted to address Resident 1's pressure injury and the attending physician was not notified of the worsening of the pressure injury for Resident 1 and 2. [...]

Inspectors wroteBased on observation, record review, interview, facility document review, and facility policy review, the facility failed to maintain its food service equipment in a clean and sanitary manner related to 1 of 1 low temperature dishwashing machine observed. As a result, the residents of the facility were placed at risk for food borne illnesses.

Inspectors wroteBased on interview, record review, and review of the Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure quarterly Minimum Data Set (MDS) assessments were completed at least once every three months and were signed as complete within 14 days of the Assessment Reference Dates (ARDs) for 7 (Residents #41, #47, #100, #26, #31, #110, and #27) of 17 residents reviewed for resident assessments.

Inspectors wroteBased on interview, record review, and facility document review, the facility failed to ensure staff provided appropriate notices of payor source changes to residents when the residents were discharged from Medicare Part A Skilled Services with days of eligibility remaining. This deficient practice affected 2 (Resident #34 and Resident #45) of 3 residents reviewed for beneficiary notification.

Inspectors wrote2. An admission Record revealed the facility admitted Resident #28 on 09/03/2018. According to the admission Record, the resident had a medical history that included diagnoses of Parkinson's disease without dyskinesia (movement disorder characterized by involuntary movements), restless leg syndrome, and schizoaffective disorder. Resident #28's annual MDS, with an ARD of 02/27/2025, revealed Section Z0500 reflected that the Director of Nursing (DON) signed the assessment as complete on 04/25/2025, more than 14 days from the ARD. During an interview on 05/01/2025 at 10:42 AM with the DON, the MDS Manager, and MDS Assistant #4, the MDS Manager stated she had only been working as the MDS Manager for about three weeks. MDS Assistant #4 stated that each month she reviewed each resident's record to identify who required an MDS, so she could open the assessments. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a new Level I Preadmission Screening and Resident Review (PASARR) was submitted after 1 (Resident #110) of 4 sampled residents reviewed for PASARR requirements was diagnosed with additional mental disorders.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a Level I Preadmission Screening and Resident Review (PASARR) accurately reflected the presence of a diagnosed mental illness for 1 (Resident #110) of 4 sampled residents reviewed for PASARR requirements.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure staff implemented interventions as outlined in the resident care plan to minimize or reduce the risk of falls. Specifically, the facility failed to ensure the use of a floor mat for 1 (Resident #107) of 2 sampled residents reviewed for accidents and falls.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure staff stored respiratory equipment in accordance with the facility policy and standard precautions. Specifically, the facility failed to store nebulizer masks and Continuous Positive Airway Pressure (CPAP) masks in a manner which limited the spread of infection for 2 (Resident #202 and Resident #298) of 2 residents reviewed for respiratory care.

Inspectors wroteBased on interview and record review, the facility failed to protect one resident (Resident 2) from physical abuse when Resident 1, who had a history of wandering, wandered into the dining hall unsupervised and hit Resident 2 on the arm. This deficient practice had the potential for Resident 2 and other residents to feel unsafe in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure written care plans for one resident (Resident 1) were resident specific to include interventions that addressed the resident's need for increased supervision when up in her wheelchair and wandering the facility. As a result of this deficient practice, Resident 1 was able to wander around the facility unsupervised which caused altercations with other residents and led to an incident of physical abuse (cross reference F600).

Inspectors wroteBased on interview and record review, the facility failed to send the results of an abuse investigation to the State agency (California Department of Public Health, CDPH-licensing and certification agency) within five working days. This deficient practice had the potential for residents to not be protected from abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and develop a care plan for a resident at risk for abuse for one of two residents investigated. This failure meant that staff was unaware of the resident's risk for abuse and of measures to mitigate those risks.

Inspectors wroteBased upon observation, interview and record review, the faclity failed to provide privacy for one unsampled resident (Resident 3) during bathing. As a result the facility failed to provide dignified care when bathing Resident 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer six out of 14 medications ordered by the physician for a total of eight days for one of three residents (Resident 1) reviewed for significant medication error. As a result, Resident 1 did not receive medications as ordered by a physician and there was no treatment provided for diagnosed health conditions. Resident 1 was at risk for worsening breathing problems, increased blood pressure, increased heart rate, and possible stroke from blood clot formation.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a written care plan related to refusal of medications for one of three sampled residents (Resident 1). This failure had the potential to not meet the goals of treatment and needs of Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe infection control practices when: 1. CNA 22 did not properly don (to put on) the required personal protective equipment (PPE) prior to entering one of 15 COVID positive (a highly contagious virus), resident rooms; 2. A urinary catheter drainage bag was in contact with the floor for one of three residents (Resident 83), reviewed for urinary catheter care; 3. A wound vac on floor was on the floor for one of one resident (Resident 55) reviewed for pressure ulcers and; 4. An oxygen tubing was not dated for one of one resident (Resident 38) reviewed for respiratory care. As a result, residents, staff and medical equipment were at risk for cross contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain a written informed consent for the use of a psychotropic (medication that affect the chemical make-up of the brain), medication prior to administration for one of three residents (Resident 77), reviewed for medication review. As a result, Resident 77 was not informed of the risk, benefits, or possible side effects when taking this medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to adequately train staff to perform PASRR (Preadmission Screening and Resident Review- a federally required document screening to ensure residents are appropriately placed and/or receive appropriate services) screening for one of one resident (Resident 346), reviewed for PASRR completion. This failure had the potential to place Resident 346 at risk for unmet care needs and inappropriate placement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a person-centered care plan for one of two residents (Resident 198), reviewed for dialysis (the process of removing excess fluid and toxins from the blood in people whose kidneys no longer function). As a result, there was the potential for Resident 198 to be at risk for fluid overload, infection, bleeding, swelling, and for the staff to not consistently assess for these risks.

Inspectors wroteBased on observation, interview, and record review, the facility failed to secure one of two (north/east hallway) housekeeping closets, which contained chemicals and disinfectants. As a result, there was the potential for confused residents to have access to chemicals which could be toxic if ingested.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the oxygen level was being administered according to physician's order for one of one resident (Resident 38) reviewed for oxygen therapy. As a result, Resident 38 did not receive oxygen therapy as ordered by the physician.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure pain medication was administered timely prior to wound treatment for one of three residents (Resident 55) reviewed for pain management. This failure resulted in the Resident 55 enduring pain during wound treatment.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure staff were knowledgeable in assessing a resident's dialysis (procedure done by a trained professional to remove wastes and excess fluids from the body) access site for one of two residents (Resident 11) reviewed for dialysis. This failure had the potential for the delayed detection, reporting, and/or management of complications from the dialysis access site for Resident 11.

Inspectors wroteBased on observation, interview, and record review the facility did not assure two of six residents (16, 17) were free from unnecessary use of psychotropic medication (major tranquilizer used when the resident may harm himself or others) when: 1. Resident 16 was ordered an antipsychotic medication without a clear indication for its use. 2. Resident 17 was ordered an antipsychotic medication without a clear indication for its use. As a result, Resident 16 and Resident 17 had the potential to be expose to unnecessary side effects of the medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the medication error rate was less than five percent. The facility's medication error rate was 12.9%. Four medication errors were observed out of 31 opportunities, during the medication administration process for two of three randomly observed residents (Resident 4, 27, 66). As a result, the facility could not ensure medications were correctly administered to all residents.

Inspectors wroteBased on observation, interview, and record review, the facility did not assure that one of one resident (31) received medication ordered by the physician for her blood pressure, reviewed during significant medication error. As a result, Resident 31 was at risk to experience high blood pressure.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure: 1. The temperature log for a medication refrigerator was complete for May 2023 and 2. The temperature for medication refrigerator was consistently monitored for one of two medication refrigerators and 3. Medications were stored and labeled according to the manufacturer's specifications and policy. As a result, the facility could not ensure medications were safely stored to ensure their integrity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safely document used-by-date and seal food containers stored in two of four stand-alone refrigerators (Refrigerators 2 and 3), during initial kitchen inspection. As a result, residents were at risk of food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure prescribed treatments were implemented for one of six residents (12) reviewed for pressure ulcers. In addition, interventions to prevent the progression of pressure ulcers were not consistently implemented for one of six sampled residents (229) reviewed for pressure ulcers. These failures had the potential for pressure ulcers to worsen and affect healing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nursing staff knew the correct procedure for assessing and monitoring the AV fistula (connection between a vein and an artery) used for renal dialysis (an artificial process of removing waste products and extra fluid from the body) for 1 of 3 residents (26) reviewed for dialysis care. This failure had the potential to cause complications related to dialysis monitoring and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two facility staff were able to demonstrate or verbalize the proper facility process for monitoring side effects of psychotropic medications (medicine used to treat a group of mental disorders). In addition, psychotropic medication side effect monitoring was not documented for one of three residents (6) reviewed for psychotropic medication. This failure had the potential for side effects of residents' psychotropic medication to go unnoticed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one un-sampled resident's (3) lunch tray provided the diet recommended by the registered dietician, as indicated on Resident 3's dietary tray ticket. This failure had the potential to contribute to Resident 3's weight loss.

Inspectors wroteBased on interview, and record review, the facility failed to ensure documentation of post dialysis nursing assessments were recorded in a readily accessible way for 1 of 3 residents (26) reviewed for dialysis care. This failure had the potential to affect the resident's care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the consistent implementation of their infection prevention and control program when: 1. Dirty gloves were not removed and hand hygiene was not performed at the completion of a dressing change before touching one resident (19) and her belongings. 2. After the irrigation of a wound the soiled barrier was not removed from under a resident (19) at the completion of the dressing change for one resident. 3. A laundry hand washing sink was used for cleaning paint brushes. These failures had the potential to cause cross-contamination (an unintended transfer of germs from one surface to another) of soiled items to both residents and staff.