Palomar Heights Post Acute

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a 30-minute visual monitoring intervention for one sampled resident (1) reviewed for elopement and wandering after the resident previously eloped from the facility. As a result, Resident 1 was placed at increased risk of another potential elopement. Resident 1 was admitted to the facility on [DATE] with a diagnosis of schizoaffective disorder (a chronic mental health condition with symptoms of hallucinations, delusions and mood alterations) per the facility admission record. A review of the facility's elopement and wandering risk assessment, dated 4/10/26, indicated Resident 1 was assessed as at risk for wandering or elopement. A review of the facility's progress notes for Resident 1 indicated Resident 1 eloped from the facility on 4/16/26 sometime around 8:00 P.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to explain the discharge plan to one of two sampled residents (1). As a result, Resident 1 may not have been aware of the scheduled post-discharge appointment with his physician.

Inspectors wroteBased on interview and record review, the facility failed to administer medications as ordered for one of four sampled residents (1). As a result, Resident 1 was placed at an increased risk of medication side effects.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were not left unattended at Resident 1's bedside table for 1 out of 3 sampled residents reviewed for medication administration. This failure had the potential to place residents at risk for ingestion of the medications. Findings. An unannounced visit to the facility was conducted on 2/17/26 relative to an anonymous complaint regarding the quality of care the facility provides. A review of the facility's undated admission record indicated Resident 1 was admitted to the facility on [DATE] with diagnoses that included encounter attention to gastrostomy (a medical device inserted through the abdomen directly into the stomach to deliver nutrition, fluids and medication) and seizures (a sudden uncontrolled surge of electrical activity in the brain). [...]

Inspectors wroteBased on Observation, interview and record review, the facility failed to maintain accurate documentation for one of three sampled residents (Resident 1). when Resident 1's medication left unattended at Resident 1's bedside was documented as being given. This failure created inaccurate information which could affect Resident 1's plan of care. Findings. An unannounced visit to the facility was conducted on 2/17/26 relative to an anonymous complaint regarding the quality of care the facility provides. A review of the facility's undated admission record indicated resident 1 was admitted to the facility on [DATE] with diagnoses that included encounter attention to gastrostomy (GT- a medical device inserted through the abdomen directly into the stomach to deliver nutrition, fluids and medication) and seizures (a sudden uncontrolled surge of electrical activity in the brain). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered according to professional standards of practice for one of 24 sampled residents (41) and four unsampled residents (63,80, 191, 36) reviewed for pharmacy services when: 1. Resident 63's Aspirin 81 mg chewable (a prescribed medication as a stroke prophylaxis) was administered over the one hour allotted time frame. 2. The manufacturer's instructions for Fluticasone nasal spray (a nasal spray for allergies) was not followed when the medication was administered to Resident 191. 3. Resident 41's G-tube (a surgical opening fitted with a device to allow feedings or medications to be administered directly to the stomach) was not properly auscultated for placement before medication administration. [...]

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure medications were stored and labeled according to acceptable standard of practice during an inspection of two of three medication carts, and one of two medication rooms when: 1. Expired insulin (medication to lower blood sugar levels) was stored in a medication cart. 2. Ipratropium/albuterol inhalation (breathing medication) was stored unprotected from light in the medication cart. 3. A box of Ampicillin 3 grams vials was stored inside a drawer in the medication room without the medication label. These failures had the potential for medications to have reduced effectiveness and/or medication misuse.

Inspectors wroteBased on observation and interview the facility failed to cook food in a way to preserve the palatability of the food. As a result, residents may not want to eat the food served to them and have the potential for weight loss.

Inspectors wroteBased on interview and record review, the facility's Quality Assessment and Assurance Committee (QAA-facility group that monitors concerning trends in a facility) failed to identify and include in the facility's Quality Assurance Performance Improvement (QAPI-plan developed by QAA to help improve conditions in the facility) Plan, trends found by surveyors during the recertification and relicensing survey concerning resident's nailcare and grooming, and the annual staff performance evaluations. This failure had the potential for the facility to overlook trends in resident care that might have affected residents' dignity and/or health and staff performance. Cross Reference:

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 6 sampled residents reviewed for resident dignity was provided care in a manner that promoted dignity and respect. (Resident 57) This deficient practice had the potential to intimidate and be disrespectful towards the resident.

Inspectors wroteBased on interview and record review, the facility failed to assist with or obtain an Advanced Directive (AD-a legal document that allows a person to specify their healthcare preferences in the event that residents become unable to make medical decisions for themselves due to illness, injury, or other circumstances) for two of 24 sampled residents (Residents 22 & 56). This deficient practice placed Residents 22 & 56 at risk for not having their medical treatment wishes known or followed during a health emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure four of 24 residents (33, 56, 76, 27) had a safe and homelike environment when the facility did not: 1. Replace or reimburse lost belongings for Resident 33. 2. Provide a living environment that was clean and well maintained for Residents 56, 76 and 27. As a result, Resident 33 did not have the ability to have a different shirt for each day of the week. In addition, there was the potential for Residents 56, 76 and 27 to feel uncomfortable in their environment.

Inspectors wroteBased on interview and record review, the facility failed to review, a Minimum Data Set (MDS- a federally mandated resident assessment tool) to determine the Significant Change of Status Assessment (SCSA-an improvement or decline), and/or update a care plan for one of five residents sampled (Resident 9) according to the Resident Assessment Instrument (RAI-MDS manual). This deficient practice placed Resident 9 for delayed care planning and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to complete the Minimum Data Set (MDS - a federally mandated resident assessment tool) and Care Area Assessment (CAA) on time, as required by the Resident Assessment Instrument (RAI-MDS manual), for one of five sampled residents (Resident 9). This deficient practice placed Resident 9 at risk for delays in care planning and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a person-centered care plan that included activities based on resident's preferences for one of five sampled residents (Resident 9). This deficient practice placed Resident 9 at risk for not having their individual needs and interests supported, which could negatively affect their emotional well-being and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to update the care plan after a Significant Change of Status Assessment (SCSA), as required by the federal guidelines, for one of five sampled residents (Resident 9). This deficient practice placed Resident 9 at risk for receiving care that did not reflect their current condition, which could delay needed support, and negatively affecting their health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three of six residents, who were unable to carry out activities of daily living (ADL-self- care activities such as grooming, bathing, and toileting), received assistance with nail care (cleaning, trimming and/or filing of nails) and shaving (Resident 5, 26 and 39). This failure resulted in residents having long and dirty fingernails which had the potential to negatively impact the residents' self-esteem and comfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide meaningful activities that matched the preferences and needs of one of five sampled residents (Resident 9) based on their comprehensive, resident-centered care plan and assessment. This deficient practice placed Resident 9 at risk for decreased mental and emotional well-being, social isolation, and reduced quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four residents reviewed for accidents was free of accidents during the use of a Hoyer lift (mechanical lift device used to move immobile residents). (Resident 26) This failure resulted in the Hoyer lift hitting Resident 26's left knee which caused Resident 26 pain.

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident 40) with Post Traumatic Stress Disorder (PTSD) out of 24 sampled residents received trauma-informed care. This failure had the potential to re-trigger trauma for Resident 40.

Inspectors wroteBased on interview and record review the facility failed to ensure employee performance evaluations were completed annually for two of five Certified Nurse Assistants (CNA) reviewed for performance reviews. This deficient practice had the potential for CNAs to provide inadequate care to the residents.

Inspectors wroteBased on observation and interview the facility failed to ensure the meal tray diets were verified by a licensed nurse prior to distributing to residents. As a result, the residents may have been given a diet that was incorrect.

Inspectors wroteBased on interview and record review, the facility failed to ensure a licensed nurse (LN 37) documented a resident incident in the resident's clinical record for one of 24 sampled residents (48). As a result of this failure, it could not be determined if Resident 48 had fallen on 5/15/25.

Inspectors wroteBased on interview and record review, the facility failed to ensure there was a process for communicating hospice services for one of two residents reviewed for hospice services (Resident 5). This failure had the potential to put Resident 5 at risk for uncoordinated medical care and treatment between the facility and the hospice agency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper infection control practices by not discarding an unlabeled intravenous (IV) hydration bag and uncapped IV tubing that was left hanging in a residents room, for one of 5 sampled residents (Resident 2). This deficient practice placed facility residents at risk for exposure to infection and the spread of harmful bacteria.

Inspectors wroteF883 Influenza and Pneumococcal Immunizations §483.80(d) Influenza and pneumococcal immunizations §483.80(d)(1) Influenza. The facility must develop policies and procedures to ensure that- (i) Before offering the influenza immunization, each resident or the resident ' s representative receives education regarding the benefits and potential side effects of the immunization; (ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period; (iii) The resident or the resident ' s representative has the opportunity to refuse immunization; and (iv)The resident ' s medical record includes documentation that indicates, at a minimum, the following: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent Resident 1 from falling while transferring from bed to a wheelchair with nonfunctioning brakes. This failure had the potential to cause injury due to unnecessary falls caused by nonfunctioning brakes on Resident 1 ' s wheelchair.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a medical equipment (wheelchair) was maintained in good, proper condition on one of one resident (Resident 1) reviewed for medical equipment. As a result, Resident 1 fell due to the wheelchair's brakes not functioning.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide care and services according to professional standards of practice to one (Resident 6) of four residents reviewed for quality of care when: 1. The facility did not assess Resident 6's change in condition and, 2. The facility did not notify the physician of Resident 6's change in condition. As a result, the physician was not aware of Resident 6's change of condition and Resident 6 expired.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse to the State Survey Agency for one of two sampled residents (1). As a result, the State Survey Agency ' s abuse investigation was delayed.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide supervision for one of three residents with a fall history (Resident 2). As a result, Resident 2 had a repeat fall and sustained injuries. Resident 2 was admitted to the facility on [DATE] with diagnoses including dementia (a condition characterized by loss of memory, language, problem solving and other thinking abilities) and repeated falls according to the facility ' s admission Record. A review of the facility ' s document titled, Fall Risk Observation/Assessment, dated 9/29/23 indicated a score of 20. The document indicated, .A. Low risk 0-8 B. Moderate risk 9-15 C. High risk 16-42 . During a review of Resident 2 ' s progress notes (PN) dated 10/11/23, the PN indicated Resident 2 was found on the floor face down with swelling on the right eye, nosebleed, and erythema (redness) on both upper arms. [...]

Inspectors wroteBased on interview and record review, the facility failed to check the blood sugar as ordered for one of two sampled residents (1). As a result, Resident 1 had an episode of low blood sugar which was not immediately identified.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow and implement policies and procedures for an allegation of abuse when, 1. The facility did not provide results of an abuse investigation within five days of the incident for Resident 4 and, 2. The alleged perpetrator was not placed on administrative leave until completion of the abuse investigation. This failure had the potential for Resident 4 and other residents to be vulnerable and exposed to the alleged perpetrator. In addition, this failure resulted in the delay of the facility's investigation of abuse allegation, and a delay in determining the occurrence of abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident 1 was free from involuntary seclusion (confined to room against her will) when Certified Nursing Assistant (CNA) 1, tied a plastic bag from Resident 1's door to the hallway handrail to prevent Resident 1 from wandering outside the room while undressed. This failure had the potential to result in psychosocial trauma or unwitnessed fall for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to conduct a quarterly (every 92 days) MDS assessment for 11 of 18 residents reviewed for Resident Assessment (3, 4, 5, 6, 7, 8, 11, 15, 17, 22, and 32). This failure had the potential for any changes to the resident's clinical status to go unrecognized and unmonitored.

Inspectors wroteBased on interview and record review, the facility failed to submit and transmit MDS assessments for 18 of 18 residents reviewed for Resident Assessment (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 13, 14, 15, 16, 17, 22, and 32). This failure had the potential to result in delayed quality measurements from the data.

Inspectors wroteBased on observation, interview and document review the facility did not ensure the Dietary Supervisor (DS) was competent to oversee the food and nutrition services at the facility when: 1. The DS did not follow the manufacturers guidelines when cleaning the kitchen's ice machine. 2. The DS did not have a kitchen cleaning schedule per the facility's policy. 3. The DS did not conduct proper oversite of the food and nutrition service staff to competently perform their job duties when: a. A Dietary employee did not wear a mask while preparing food. b. Dietary employees did not do hand hygiene after loading the dishwasher with dirty dishes. c. Dietary employees did not correctly label and date foods in the kitchen per the facility's policy. d. A cook did not prepare food in a form designed to meet the individual needs for residents on a mechanical soft and a chopped solid diet. e. [...]

Inspectors wroteBased on observation, interview and document review the facility did not ensure food and nutrition service staff were able to competently carry out their job duties when: 1. A Dietary employee did not wear a mask while preparing food. 2. Dietary employees did not do hand hygiene after loading the dishwasher with dirty dishes. 3. Dietary employees did not correctly label and date foods in the kitchen per the facility's policy. As a result, residents were at risk for foodborne illnesses. 1. On 3/14/22 at 8:40 A.M., a concurrent observation and interview was conducted with [NAME] 1. [NAME] 1 was observed preparing potatoes without wearing a mask over his mouth or nose. [NAME] 1 stated it was the facility's policy he must wear a mask when in the kitchen. On 3/15/22 at 3:08 P.M. an interview was conducted with the DS. [...]

Inspectors wroteBased on observation, interview and document review the facility's food and nutrition services did not follow the approved menu or recipe when: 1. A cook did not follow the recipe when he prepared pureed food for lunch. 2. A cook prepared food for lunch that was not listed on the facility's approved lunch menu. 3. A cook did not use correct measuring scoops per the menu when preparing lunch trays. As a result, residents at the facility were at risk for nutritional deficits and weight loss. 1. On 3/16/22 at 10:43 A.M., a concurrent observation, document review and interview was conducted with [NAME] 1. [NAME] 1 was observed placing nine servings of cooked broccoli into the blender to prepare the lunch puree. Cook 1 was observed adding three heaping spoonfuls of chicken broth base, using a disposable plastic spoon, directly into the blender. [...]

Inspectors wroteBased on observation, document review and interview, the facility's food and nutrition services did not prepare food in a form that met the individuals needs. As a result, residents on a mechanical soft and a chopped solid diet were at risk for choking. On 3/14/22 at 12:41 P.M., an observation was conducted in the facility's dining room. Resident 21 and Resident 254 were observed eating lunch. Both Resident 21 and Resident 254 had mechanical soft trays per the meal tickets located on the trays. Resident 21 and 254 were observed with a broccoli salad with large 1-1.5 inch in diameter of partially cooked whole broccoli florets with stems. Resident 51 was observed trying to eat a large raw broccoli floret which was approximately 2-2.5 inches in diameter. Resident 51's tray ticket indicated he was prescribed a chopped solid diet. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from abuse for one of two sampled resident (154). As a result, Resident 154 was at risk for injury, pain or mental anguish.

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive MDS (a standardized assessment and care planning tool) was completed within the required timeframe for three of 18 residents reviewed for MDS completion (13, 14, 16). This failure had the potential for Residents 13, 14 and 16 to not receive the appropriate care. On 3/17/22 at 4 P.M., a record review was conducted. Resident 13 was due for an annual MDS assessment on 1/8/22. Per the MDS 3.0 Resident Assessments list, the annual review was, In process. Resident 14 was due for an annual MDS assessment on 1/8/22. Per the MDS 3.0 Resident Assessments list, the annual review was, In process. Resident 16 was due for an annual MDS assessment on 1/15/22. Per the MDS 3.0 Resident Assessments list, the annual review status was, In process. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary care and services for two of 14 sampled residents when: 1. Resident 11 was not provided continuity of care when a dentist appointment was not scheduled, and 2. Residents 11 and 25 were not provided wound care per physician orders. These failures resulted in delays in treatments for the residents.

Inspectors wroteBased on observation, interview and document review the facility failed to maintain kitchen equipment in a safe operating condition. As a result, the steam table had the potential for causing foodborne illnesses by not holding foods at appropriate temperatures. On 3/14/22 at 8:40 A.M., a concurrent observation and interview was conducted with the DS. Standing water and tan/white marks were observed on a shelf under the steam table. The DS stated the steam table had been leaking. On 3/16/22 at 10:29 A.M., an interview was conducted with the DS. The DS stated he was aware the steam table in the kitchen was leaking and was notified by the kitchen on Saturday 3/12/22 verbally from the DS. On 3/16/22 a facility document titled Food & Nutrition-Administrator's Monthly Inspection Checklist dated 1/29/22 was reviewed. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure safe and sanitary practices were met in the facility's kitchen. 1. There was no label on the bulk cereal bin. 2. The bulk flour and thickener bins had no lids. 3. Nestle Café coffee drink dispenser was not clean with old dark black grime on it. 4. The industrial can opener was not clean as it was covered with dark black grime and dark black remnants. 5. A dented can was stored in the the ready for use storage area. 6. Containers of resident ice cream were kept in a small stand-alone refrigerator that were found below the required temperature. 7. Spoiled onions were in an open bin underneath the kitchen steamer and small nats/fruit flies were flying around the bin. 8. The food trays were being used wet and not allowed to air dry. 9. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure resident requested modifications made to the Physician's Orders for Life-Sustaining Treatment (POLST-instructions for care provided in a medical emergency) were signed by the physician for two of three residents (9, 54) sampled for advance directives (person's wishes regarding medical treatment). This failure had the potential to affect the treatment and provided to the residents in the event of a medical emergency.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the care plan for one of 18 sampled residents (8) was revised to reflect a change in condition related to contractures (shortening and hardening of muscles). The failure had the potential for miscommunication amongst care givers and decreased well-being of the resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care that met professional standards of practice when: 1. Treatment and assessment were not done for Resident 31's left great toe wound. 2. Resident 45's emotional well being was not assessed. 3. Physician's orders were not followed for Resident 18. 4. A change of condition was not reported to the physician for Resident 18. This failure had the potential to affect the residents' physical health, and psychological well-being.

Inspectors wroteThe facility failed to ensure staff acted within their scope of practice when oxygen therapy was provided to one of three residents (18) sampled for oxygen use. This failure affected Resident 18's ability to breathe, which could have affected his physical health and psychological well-being.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure an expired hydrogen peroxide solution and a bottle of lotion with an unreadable label, had been removed. As a result, there was potential for a resident to receive care with an expired hydrogen peroxide solution and/or receive the incorrect lotion treatment.

Inspectors wroteBased on a food service observation, interviews and record review the facility failed to ensure dietary staff competency when: 1. One kitchen staff member was unable to articulate or demonstrate how to correctly calibrate a thermometer used to assure proper temperature of resident food. 2. One kitchen staff member used the incorrect scoop size when preparing food trays. This failure had the potential to put residents at risk for widespread foodborne illness and receive an incorrect portion of food.

Inspectors wrote2. Resident 45 was admitted to the facility on [DATE], per the facility's Resident Face Sheet. On 11/4/19 at 1:12 P.M., an observation was conducted. CNA 1 retrieved a meal cart from the kitchen and pushed it down the hallway. CNA 1 removed a meal tray from the cart and delivered it to Resident 45, then exited the room. On 11/4/19 at 1:20 P.M., an interview with CNA 1 was conducted. CNA 1 stated he brought the meal cart down the hall and had delivered the trays to resident's in their rooms. CNA 1 stated dietary staff had been responsible for ensuring the correct diet was placed on a resident's meal tray. CNA 1 stated it was important resident's received the correct diet, because if they had been given the wrong consistency of foods, the resident could choke. On 11/4/19 at 1:30 P.M., an observation and interview is conducted with Resident 45. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure accurate documentation in the Medication Administration Record (MAR), for one of 18 residents (21) sampled for nutrition. This failure had the potential to affect Resident 21's nutritional status, and cause weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure infection control practices were implemented when: 1. Proper handwashing was not implemented by an LN when caring for one of two residents (173) sampled for infections and 2. Oxygen concentrators (machines that create oxygen) had not been serviced for one of three residents (44) sampled for oxygen. These failures had the potential to spread infection to the residents, visitors and facility staff.