Palomar Vista Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to ensure home health services were confirmed prior to discharge for three of three sampled residents (1, 2, 3). As a result, the residents were at risk of having unmet care needs, discharge summaries for Resident 1 and Resident 2 were inaccurate, and Resident 1 had to go to a General Acute Care Hospital (GACH) to have his post-discharge needs met.

Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain a safe, clean, comfortable and homelike environment for seven of 21 sampled residents when it:1. Did not repair damaged phone jack boxes that were hanging from the walls and walls damaged from bed and furniture movement.2. Allowed night staff to enter and exit through an alarmed side gate and door during the night, waking residents near to that area.3. Placed a portable air conditioner in the hallway with 12 feet of 8-inch diameter (width) tubing connected to the residents' handrailing with large zip ties. This failure had the potential to increase accidents, disrupt needed sleep, and create an overall depressing atmosphere for the affected residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents receiving antipsychotic (medication for mood, behavior, or thinking) medications were monitored for side effects (SE), including postural hypotension (a drop in blood pressure from standing after lying or sitting down), for two of five residents (Resident 42 and Resident 28) sampled .These deficient practices placed both residents (Resident 42 and Resident 28) at risk for undetected adverse (serious life-threatening SE) drug reactions, which could lead to dizziness, fainting, falls, or other serious complications. Cross-Reference F658Findings: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services provided met professional standards for four of 21 sampled residents (30, 42, 11, 8) when;1. The facility did not accurately account and manage one of 21 sampled resident's personal medications from an outside pharmacy,2. The facility did not monitor side effects (SE) of psychotropics(medications to stabilize mood), and3. The facility did not document giving medication at the time of administration. As a result, the facility may not have been providing necessary services to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standardized recipes during meal preparation on the tray line. This deficient practice placed 69 residents at risk for receiving meals that were not consistent, nutritionally adequate, or in line with physician orders and resident preferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain sanitary conditions in the facility kitchen for 69 residents when:1. The chlorine (common chemical cleaner that kills germs, bacteria, and algae) level with the low-temperature dishwasher was below the required sanitation (reduces harmful bacteria on surfaces) level to fully sanitize and clean dishware and cookware.2. The scoop drawer was unorganized, creating a risk for kitchen staff to touch multiple utensils with unclean hands. These deficient practices placed all 69 residents at risk for foodborne illness, cross-contamination, and unsafe meal service.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure consents were signed by the appropriate person for one of four residents (Resident 8). This failure had the potential for Resident 8 to receive medications for which they did not know the risks and benefits.

Inspectors wroteBased on observations, interviews, and record review the facility failed to keep one out of 21 sampled residents' (79) call bell within reach. This failure had the potential to prevent Resident 79 from summoning help when needed and preventing him from meeting his care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident's right to make choices for two of three residents (Resident 42, Resident 24) sampled when a shower was not provided as requested, and vitamins were taken from a resident's room. This deficient practice placed Resident 42 and Resident 24 at risk for not having their dignity, comfort, and personal preferences respected, which could negatively impact quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to help formulate (assist) an advance directive (AD-a legal document indicating resident preference on end-of-life treatment decisions) for one of three residents (Resident 42) sampled. This deficient practice placed Resident 42 at risk for not having their medical treatment wishes known or respected during an emergency or serious illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 21 residents (Resident 85 and Resident 25) minimum data set (MDS - a federally mandated resident assessment tool) was coded accurately when:1. Resident 85's Hospice status was not coded.2. Resident 28's unstageable pressure ulcer was not coded as present on admission. As a result Resident 85 and Resident 28's MDS were sent to the federal database with inaccurate information.

Inspectors wroteBased on interview and record review, the facility failed to refer a resident with a new mental disorder to the state designated authority for evaluation for one of three sampled residents (10). As a result, the facility may not have been providing necessary services to Resident 10.

Inspectors wroteBased on interview and record review, the facility failed to accurately screen newly admitted residents for a mental disorder for two of three sampled residents (9, 11). As a result, the facility may not have been providing necessary services to Resident 9 and Resident 11.

Inspectors wroteBased on observation, interview and record review the facility failed to develop a person-centered comprehensive care plan that identified a language preference for one of seven residents (Resident 61) sampled. This deficient practice placed Resident 61at risk for having care provided that did not reflect their individual goals, needs, and choices, that could negatively impact communication, dignity, and quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an activities program that met the interests and needs for one of seven sampled residents (Resident 42). As a result, Resident 42 was not invited to group social activities (movie social, manicures, social coffee, arts and crafts and any social games such as BINGO) that did not support Resident 42's right to participate in activities of choice and placed Resident 42 at risk for social isolation, boredom, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician's (MD) orders for tube feeding for one of one resident (Resident 100) reviewed with enteral (refers to any method of feeding that uses the stomach to deliver nutrition and calories) nutrition. As a result Resident 100 did not receive enteral feeding at scheduled time as per MD order and potential risk for malnutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess residents for the risk of bedrail entrapment (getting caught between the bed and the bedrail), review the risks and benefits of bedrails, and obtain informed consent prior to installing bedrails for two of three sampled residents (11, 98). As a result, Resident 11 and Resident 98 were placed at an increased risk of entrapment related injury.

Inspectors wroteBased on observation, interview and record review the facility failed to accurately acquire, receive, and account for one of 21 sampled residents (30) personal chemotherapy medication. This failure had the potential for harm to Resident 30 related to missing ordered chemotherapy medications. Cross reference F658Findings:Review of admission Record for Resident 30 indicated that resident was admitted on [DATE] for diagnoses which included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store intravenous (IV-a plastic tubing inserted through the vein) supplies for one of 21 residents (Resident 42) when an opened IV flush syringe (device used to inject fluids a water solution through an IV that prevents clogs) and a green IV cap cover was left unattended and stored improperly. This deficient practice placed Resident 42 at risk for contamination, infection and unsafe administration of IV medications and supplies.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly store and dispose of refuse (trash, garbage or rubbish) in a sanitary manner when the outside dumpster lids were opened and accessible to pests. This deficient practice placed all 69 residents at risk for pest infestation, foul odors, and the spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure resident's belongings were documented in the medical record for one of three sampled residents (24). As a result, there was no way to verify where Resident's 24 belongings went.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices for one of 21 residents sampled (Resident 100) when a Certified Nursing Assistant (CNA) provided mouth care without wearing a gown for a resident on Enhanced Barrier Precautions (EBP-infection control precautions to reduce transmission of multi-drug resistant organisms (MDRO) a bacteria that resists treatment with more than one antibiotic). These deficient practices placed all 21 residents at risk for the spread of infection and cross-contamination.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide safety rails in a bathroom that was used by two of four residents (Resident 7 and Resident 11) who had access to the bathroom. This failure had the potential for accidents related to toilet use.

Inspectors wroteBased on interviews and record review, the facility did not ensure patient centered care plans were developed for one of four residents reviewed for care plans when Resident 1 had diarrhea and purple feet with swelling. This failure resulted in delayed care and a decreased physical well-being for Resident 1.

Inspectors wroteBased on interviews, and record review, the facility failed to provide a medication for diarrhea for one of four residents (Resident 1) reviewed for services that meet professional standard, according to professional scope of practice. As a result, Resident 1 continued to have diarrhea and had a skin breakdown on the sacro-coccyx (the triangular shaped bone at the base of the back extending to the tailbone) area. In addition, Resident 1 had the potential for increased infection and discomfort.

Inspectors wroteBased on interviews and record review, the facility did not ensure one of three residents (Resident 1) reviewed for pressure ulcers (bedsores), received the necessary care and services to prevent pressure ulcer formation. This failure resulted in Resident 1 ' s rash to become a deep tissue injury.

Inspectors wroteBased on interview and record review, the facility failed to provide a registered nurse (RN) coverage eight consecutive hours a day, seven days a week. As a result, there was not consistent oversight by an RN for the coordination, management, and overall delivery of care to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe and sanitary environment that mitigated the risk for foodborne illness and cross contamination when: 1. The kitchen walk in refrigerator contained ketchup, soy sauce, and Italian dressing that did not have a use by date, staff's plastic water bottle, and beverage were also in the kitchen refrigerator. In addition, shredded carrots in a plastic bag, pack of hot dogs, tortilla in an opened plastic bag containers and two onions in plastic wrap were not identified and labeled in the refrigerator, 2. A coil above the food shelf in the refrigerator had gray debris covering the entire coil attached to a light fixture. These failures exposed residents to contaminated food and unsanitary practices, which had the potential to place them at risk of developing a foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat one of two residents (59) with dignity and respect when incontinent care was not provided on a timely basis. This failure resulted in Resident 59 feeling upset towards staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Pre-admission Screening and Resident Review Level II (PASRR II - an evaluation of the resident's psychiatric treatment requirements) was followed up and completed for one of one resident reviewed for PASRR. (Resident 10) This failure had the potential for Resident 10 to not receive necessary mental health care services in an appropriate healthcare setting.

Inspectors wroteBased on observation, interview, and record review, the facility did not develop patient centered care plans for two of eight residents reviewed for care plans (Resident 169 and 170). These failures had the potential for the residents to not receive care and services specific to the residents' needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a CPAP machine was functioning for one of two residents (Resident 169) reviewed for respiratory care. This failure had the potential to adversely affect the health and well-being of the resident. Resident 169 was admitted to the facility on [DATE] with diagnoses including obstructive sleep apnea (OSA- a problem in which breathing pauses during sleep due to blocked airways) according to the facility's admission Record. The Minimum Data Set (MDS- a clinical assessment tool) for Resident 169 dated 6/20/24, listed a cognitive score of 14 (13 to 15 meant cognitively intact), indicated cognition was intact. During an observation and interview on 6/25/24 at 9:02 A.M., Resident 169 was sitting up in bed watching TV. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to consistently provide dialysis (a procedure to remove waste products from the body when the kidneys stop working properly) access site care and assessment for one of three sampled residents (Resident 13) reviewed for dialysis. As a result, there was the potential for the resident to have complications after receiving dialysis treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure current infection control practices were followed for three of three residents reviewed for infection control when: 1. Resident 169's continuous positive airway pressure (CPAP- a machine that delivers mild air pressure through the nose to keep breathing airways open while asleep) mask was left on top of the machine open to air, 2. Resident 170's IV (intravenous- into the vein) tubing did not have a date used and the peripherally inserted central catheter (PICC- a type of long catheter inserted through a vein in the arm into a larger vein in the body) line site did not have a date when the dressing was last changed, 3. Resident 126's CPAP mask and tubing were not stored in sanitary manner. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess a resident's ability to self-administer medications for one of one resident reviewed for self-administration of medications. (Resident 3). This failure had the potential for Resident 3 to over or under medicate himself. In addition, staff had no knowledge if Resident 3 took the medications.

Inspectors wroteBased on interview and record review the facility failed to provide one of three sampled residents a written notification of bed hold at transfer to the hospital. This deficient practice resulted on resident (Resident 1) not receiving notification of the right to return to a bed at the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received care in a safe setting when nursing staff did not follow the facility ' s drug and alcohol policy. As a result, a Licensed Nurse (LN) administered medications to 18 of 18 residents (1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18) after consuming an alcoholic beverage during break. In addition, the facility did not identify the affected residents until two weeks after the incident. These failures had the potential to negatively affect the health and well-being of the residents.

Inspectors wroteBased on observation, interviews, and record review, the facility did not ensure adequate supervision and safe environment was provided for one sampled resident (1), when the resident wheeled herself out the facility unattended by staff. This failure put Resident 1 at risk for injury and the potential to affect Resident 1's psychosocial well - being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to appropriately administer resident's medication, and ensure a system of storage, reconciliation, and disposition of Controlled Substances (CS- a drug or other substance that is tightly controlled by the government because it may be abused or cause addiction) were established and implemented when: 1. The facility did not appropriately store Resident 801's-controlled medications: hydrocodone/acetaminophen 10/325 mg (milligram- unit of measure) and lorazepam 0.5 mg tablets (drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence), log Resident 13's controlled medication carisoprodol 350 mg tablets (pain medication) for disposition, and did not have a system in place in sufficient detail to periodically reconcile controlled drugs; 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were stored and/or labeled in accordance with current accepted professional principles and facility policies and procedures, for seven sampled residents (Residents 801, 59, 44, 40, 59, 124, 14) when: 1. In the facility's medication room, Resident 801's hydrocodone/acetaminophen 10/325 mg and 20.5 tablets of lorazepam 0.5 mg tablets were stored in an unlocked cabinet. 2. In the facility's medication room, Resident 59's discontinued amoxicillin/clavulanate (antibiotic) 500 mg (milligram- unit of measurement) medication was found in the medication cabinet not separated from medications that were in use for facility residents. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all food items were labeled and dated. In addition, the facility did not ensure that there were no expired food items.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control practices when two out of two nursing staff (Licensed Nurse (LN) 44, and 45) in two out of two nursing stations did not properly disinfect shared glucometers (blood glucose meter to measure and display the amount of sugar [glucose] in your blood) according to the manufacturer's instructions and accepted professional standards of practice. In addition, one LN (42) did not perform hand hygiene during wound care and handled a wound dressing in an unsanitary manner for one (Resident 374). [...]

Inspectors wroteBased on observation, interview, and record review, facility failed to provide privacy for one of four residents (Resident 42) reviewed for dignity. As a result, Resident 42 felt embarrassed during personal care and not treated with dignity.

Inspectors wroteBased on interview and record review, the facility failed to accurately code a discharge disposition for one resident (Resident 73). This failure had the potential to cause delays in services needed after discharge and inaccurate transmission via Minimum Data Set (MDS- an assessment tool).

Inspectors wroteBased on interview and record review, the facility failed to identify and accurately coded the PASRR (Preadmission Screening and Resident Review, a federally required document to ensure residents are appropriately placed and/or for services) evaluation for three of 19 residents (Resident 22, 49 and 52) when: 1. Resident 22's PASRR was not coded for a neurocognitive disorder (decreased in mental function due to a medical disease), 2. Resident 49's PASRR was not accurately assessed for mental illness, and, 3. Resident 52's PASRR was not accurately assessed for mental illness and completed for Level 1 screening. These failures had the potential for Residents 22, 49, and 52, to not receive the care and necessary services in the most appropriate setting.

Inspectors wroteBased on record review and interview, the facility failed to implement a baseline care plan within the 48-hour time frame as required and included the physician orders for one of one sampled residents (Resident 374). This failure had the potential for Resident 374 having incorrect care provided.

Inspectors wrote2. A review of Resident 724's admission Record indicated, the resident was admitted to the facility on [DATE], with diagnoses that include displaced comminuted fracture of the right patella (a broken bone in two or more pieces), person injured in unspecified motor-vehicle accident. On 5/15/23 at 1:10 P.M., an observation of Resident 724 was conducted. Resident 724 was in his bed with his eyes open. Resident 724 spoke Spanish during an attempted interview. There was no translation line information posted on the wall and no communication tools were visible in the room. On 5/15/23 at 1:20 P.M., a record review of Resident 724's admission record was conducted. The admission record indicated, Resident 724's primary language was Spanish. On 5/15/23 at 1:28 P.M., an interview and a joint record review was conducted with licensed nurse (LN) 44. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a timely and accurate assessment, related to pressure ulcers for one of one resident (Resident 374). In addition, the facility failed to ensure the care plan for one of three hospice (a type of healthcare focusing on symptom management in the final six months of life) residents (Resident 44) was developed collaboratively with hospice. These failures had the potential for Resident 374 not receiving the care and treatment for a pressure ulcer, and the potential for Resident 44 to experience duplication or omission of services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify and provide care and treatment to one of one sampled resident (Resident 374) admitted with a pressure ulcer (a wound caused by immobility). This failure caused Resident 374 a delay in treatment of her wound and a delay in care required to prevent further skin problems.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to consistently provide dialysis (treatment to remove waste from the body) access care, including removal of dressing and assessment of the site, for three of three sampled residents (3, 59, 126), reviewed for dialysis. As a result, there was the potential for complications after dialysis.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that the conditions set forth in the Hospice Services Agreement were followed. This failure has the potential for the duplication or the omission of services, the potential for harm, and/or the potential for duplicate billing (see F-tag 684).