Escondido Post Acute

Inspectors wroteBased on observation, interview, and record review, the facility did not develop patient centered care plans for two of four residents reviewed for care plans (Resident 1 and Resident 3) when: 1. A care plan was not developed to address Resident 1's behavior at the facility's garden area, 2. A care plan was not developed to address Resident 1's discharge plan and intent to leave the facility against medical advice (AMA), 3. A care plan was not developed for Resident 3's placement preference. This failure had the potential for residents not to receive care based on their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to submit a five-day (5-day) summary of investigation to the California Department of Public Health (CDPH- state agency that protect the public's health and enforces state and federal laws) related to an abuse allegation for one of two residents reviewed for abuse. (Resident 6) This failure had the potential to result in a delay in determining the occurrence of abuse and had the potential to affect Resident 6's safety and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide privacy and dignity by covering a urinary catheter bag (a flexible tube that drains urine into a collection bag) for one of three resident's (Resident 1), when reviewed for Resident Rights. This failure had the potential for Resident 1 to be embarrassed and exposed with a urinary catheter collection bag.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician when parameters for blood sugar levels were out of range, for one of three residents (Resident 1), when reviewed for Quality of Care. This failure resulted in the physician being uninformed when additional insulin (a hormone which regulates blood sugar levels in the blood) could have been ordered to reduce the risk of hyperglycemia (high blood sugar levels which can lead to health problems that affect the eyes, kidneys, nerves and heart).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were not left unattended for one resident (Res 1). This failure had the potential to affect Resident 1 ' s safety and staff 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 Atrial Fibrillation (irregular rapid heart rate) and Urinary Tract Infection (bladder infection). An observation during a facility reported investigation on 5/12/24 at 10:00 A.M., in Resident 1 ' s room was conducted. Resident 1 had multiple number of medications, inside a small clear cup sitting on Resident 1's bedside table. Resident 1 stated, I think the nurse left the medications there for me to take, but I was still asleep. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to assess a resident's ability to self-administer their medication for 1 (Resident #153) of 33 sampled residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure beneficiary notifications were completed accurately for 2 (Resident #128 and Resident #143) of 3 sampled residents reviewed for beneficiary notices.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to report timely, an allegation of verbal abuse to the state survey agency for 1 (Resident #23) of 1 sampled resident reviewed for abuse.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure staff submitted a new Preadmission Screening and Resident Review (PASRR) to the state agency for review after a significant change in status occurred for 1 (Resident # 53) of 5 residents reviewed for PASRR.

Inspectors wroteBased on observation, interview, facility document review, and facility policy review, the facility failed to provide necessary treatments and services consistent with professional standards of practice during wound care for 1 (Resident #150) of 2 residents reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to implement infection control practices during wound care for 1 (Resident #150) of 2 residents reviewed for pressure ulcers, and failed to ensure proper storage of oxygen and nebulizer equipment, when not in use, to prevent the spread of infection for 1 (Resident #278) of 1 resident reviewed for respiratory care.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to post nurse staffing information at the beginning of each shift during three of four days of the survey. This deficient practice had the potential to affect all residents who currently resided in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1). Correctly re- position the resident with the correct orthopedic devices as ordered by the physician. 2). Provide continued care with Restorative Nursing services 3). Failed to notify the physician that physical therapy services and restorative services were not provided. 4). Failed to notify the physician the brace was not being used as ordered, for 1 of 3 residents reviewed (Resident 1) for mobility. As a result of these failures, Resident 1 was at risk for a decrease in range of motion, and experienced psychosocial distress and fear of not achieving independence with Activities of Daily Living (ADL ' s) such as dressing, grooming, and being up in her wheelchair for periods of time. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify residents and their representatives of the facility bed hold policy for four of four residents reviewed for notifications regarding bed holds before or as soon as possible after transfer to hospital. This failure had the potential for psychological harm related to uncertainty if the resident could return when their condition improved.

Inspectors wroteBased on observation and interview, the facility failed to treat one of seven sampled residents with dignity and respect. This failure had the potential for Resident 6 to feel ashamed and embarassed.

Inspectors wroteBased on observation, interview and record review, the facility failed to exercise care in protecting 1 residents' (Resident 2) property from loss and physical damage out of 11 property loss reports reviewed. As a result, the resident's painting was reported lost. Resident 2 was admitted to the facility on [DATE] with health conditions including osteomyelitis (infection of the bone) right tibia and fibula (lower leg bones); diabetes type 2 (a chronic disease of the body not producing insulin, causing high blood sugars). Resident 2 was transferred from the facility to an Acute Care Hospital (ACH) due to a new cough, with difficulty breathing and a need for oxygen on 11/1/24 at 4:50 P.M., according to the SBAR communication form dated 11/1/24. On 11/25/24 at 4:30 P.M. [...]

Inspectors wroteBased on observation, interview, and record review the facility did not implement interventions to prevent a fall for one of three residents (Resident 1) reviewed for a fall. This failure increased the risk of injury related to falls for Resident 1.

Inspectors wroteBased on observation, interview, and record review the facility did not implement interventions to prevent a fall for one of three residents (Resident 1) reviewed for a fall. This failure increased the risk of injury related to falls for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to develop person-centered care plans for one of five residents (Resident 1), related to: a. The potential for falls; b. Pain; c. Urinary tract infection (UTI-an infection in the urine); d. Anticoagulant (blood thinning medication) therapy; and e. The potential for skin injuries. As a result, there was the potential Resident 1's care was not being provided consistently and potential problem areas were not identified.

Inspectors wroteBased on interview and record review, the facility failed to perform and document skin assessments prior to a discharge for one of five residents (Resident 1), reviewed for services meeting professional standards of practice. As a result, Resident 1 was discharged , and family were unaware of the bruises and skin injuries caused while at the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a person-centered comprehensive care plan was developed and or implemented in regard to four sampled residents (141, 59, 81,103). These failures had the potential for an increased risk of oral infection and to negatively impact the residents' (141, 59, 81, 103) quality of life, as well as the quality of care and services received.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement policies and procedures for the provision of pharmaceutical services when: 1. Licensed staff failed to administer prescribed medications to Resident 39 and Resident 34. 2. Oxycodone (narcotic pain medication) 5 mg (milligram - unit of measure) tablets dated as 7/26/21 were found in the disposition locker and licensed staff were unable to determine when the medication was stored for disposition leading to inaccurate reconciliation. 3. Oxycodone 100mg(milligram)/5ml (milliliter unit of liquid measure) for Resident 1 was not accurately reconciled on the controlled drug count sheet. These failures had a potential of not effectively treating residents due to delayed or missed medications and controlled substance discrepancies leading to diversion.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their infection control program for COVID-19 Mitigation Plan/Policies and Procedures dated 9/9/21. In addition, the facility failed to implement general infection control practices, which included: 1. The staff and visitors who entered the facility did not wear Personal Protective Equipment (PPE) which included wearing, N95 masks, gowns, gloves, and eye protection. Transmission Based Precaution's (TBP) were not followed for the entire facility (which was declared a yellow isolation zone) 2. The visitors who entered the facility did not undergo the COVID-19 screening process. 3. The licensed staff did not sanitize (to clean and make free of disease-causing elements) equipment during medication administration according to manufacturer specification. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect and treat the residents with respect and dignity for one sampled resident. (58). This failure had the potential to affect the resident's psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to notify the Office of the State Long Term Care Ombudsman when one sampled resident (Resident 21) was transferred to the hospital. As a result, Resident 21 was not fully protected from an inappropriate discharge when the facility did not communicate Resident 21's transfer with an advocate from the Ombudsman office.

Inspectors wroteBased on interview and record review the facility consultant pharmacist (CP) failed to identify irregularities in psychotropic (a medication that affects a person's mental state) medication use for Resident 103 when: 1. Seroquel (antipsychotic medication to treat mental health issues) administered without adequate monitoring of A1c (lab value for average blood sugar in past 3 months), 2. Seroquel administered without adequate indication for use affective (mood) psychosis (a condition that affects the way your brain processes information), 3. Paxil administered without GDR (gradual dose reduction). These failures caused the resident to potentially not receive the necessary care for their needs and increased the potential for adverse reactions and death.

Inspectors wroteBased on interview, and document review, the facility failed to ensure Resident 103 was free from unnecessary psychotropic (drugs that affects brain activities associated with mental processes and behavior) medications when: 1. Seroquel (antipsychotic medication to treat mental health issues) administered without adequate monitoring of A1c (lab value for average blood sugar in past 3 months), 2. Seroquel administered without adequate indication for use affective (mood) psychosis (a condition that affects the way your brain processes information), 3. Seroquel, trazodone (medication for mood), Paxil (a medication to treat depression) administered without behavioral interventions (non-pharmacological methods to manage behavior issues), 4. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free from a medication error rate of 5 percent or greater when Residents 39 and 34 were not administered three morning medications. A total of 3 medication errors were observed within a sample size of 26 opportunities for error. The facility's medication error rate was 11.54%. These failures had the potential of medications administered to residents as not treating residents effectively and exposing them to medication errors.

Inspectors wroteBased on observation, interview and record review, the facility failed to: 1. Ensure expired medications were not available for use. 2. Properly label resident medication with open dates, expiration dates and resident identification tags. These failures placed the residents at risk for receiving ineffective or expired medications and had the potential of exposing residents to infections due to cross contamination.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure sanitary conditions were maintained during food storage when: 1. Expired sandwiches were found inside the refrigerator. 2. Two nursing unit refrigerators had expired drinks and the temperatures were out of normal range. These deficient practices had the potential to expose all residents who receive food from the kitchen to unsanitary practices and potentially unsafe foods that could lead to widespread foodborne illness.

Inspectors wroteThe facility failed to accommodate the needs of three of nine residents (4, 76, and 399). These failure had the potential to affect the resident's dignity, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to fully promote and facilitate resident self-determination through support of resident choice for two of 34 sampled Resident's (54, 122). There was a lack of communication amongst staff when Resident 54 requested a room change and when Resident 122 requested possession of own wheelchair for use. The lack of communication did not afford both Residents the opportunity to have their choices honored and ensure continuity of care was maintained. As a result, Resident 54 did not have access to his electric wheelchair, and Resident 122 remained in a room with an incompatible roommate.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly store resident's medical and financial records in a secured location. This failure had the potential for resident's confidential health information, and financial information to be viewed by unauthorized staff, residents and visitors.

Inspectors wroteBased on observation, interview and record review, the facility failed to revise care plan interventions for two of 32 sampled residents (67) (138). 1. This failure had the potential to contribute to Resident 67 repeatedly falling and sustaining injuries, affecting his quality of life. 2. This failure had the potential to cause miscommunication about Resident 138's mobility limitations.

Inspectors wroteThe facility failed to provide the necessary care and services for three of nine residents (400, 46, 101) sampled for activities of daily living when: 1. Resident 400 was not provided assistance when eating. 2. Residents 46 and 101 did not receive assistance with shaving or trimming facial hair.

Inspectors wroteBased on interview and record review, the facility failed to consistently document neurological examinations (an assessment for level of consciousness, pupil reaction, vital signs, sensory and motor responses related to a head injury) for one of three residents (5) reviewed for unwitnessed falls. This failure had the potential for Resident 5 to have an undetected closed head injury with a delay in treatment.

Inspectors wroteThe facility failed to provide proper shift assessments of the Arteriovenous Fistula (The AV Fistula is a blood vessel made wider and stronger by a surgeon to allow blood to flow out to and return from a dialysis machine) for two of nine (137,401) residents who received dialysis services. As a result, Resident 137 and Resident 401 did not receive proper assessment of their AV fistula's which could have hindered or caused complications with their dialysis care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove a discontinued narcotic (medication with a high potential for abuse) from one of six medication carts reviewed for medication storage. This deficient practice had the potential for diversion (theft) of controlled narcotic medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to document daily refrigerator temperatures for one of two refrigerators used to store resident food. This deficient practice had the potential for residents food to acquire food borne illnesses when stored at improper temperatures.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure coordination of care with hospice (end of life care) and ensure hospice services were provided for one unsampled resident (46). As a result, there was the potential for Resident 46 to have not received appropriate and timely hospice care services.

Inspectors wroteBased on observation, interview, and record review the facility staff failed to observe infection control precautions for one of 34 (38) sampled residents. This failure had the potential to transmit an infection to other residents, visitors, and staff members.