Palomar Heights Post Acute

In the surveyor’s words

From the most serious findings on record at Palomar Heights Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF684Jun 21, 2024

  Based 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. Findings: Resident 6 was admitted to the facility on [DATE] with diagnoses including congestive heart failure (a condition in which the heart does not pump or fill blood as well as it should) and ischemic cardiomyopathy (damaged heart muscle from lack of blood flow) according to the facility's Admission Record. […]

• No harm, potential for more than minimal, widespreadF812Aug 21, 2026

  Based on observations, interviews, and record reviews, the facility failed to ensure safe and sanitary practices were met in the Food and Nutrition Services Department when eight cutting boards were observed to have deep cuts and discoloration. These failures had the potential to cause widespread foodborne illness in the residents who consume food from the facility's kitchen. The facility census was 93.Findings: A joint kitchen observation on 8/18/26, at 7:54 A.M. was conducted with the Dietary Director (DD). Cutting boards were observed on a rack under a counter. Four white cutting boards had deep cuts and discoloration. A red and yellow cutting boards were pulled and showed deep cuts and discoloration. […]

• No harm, potential for more than minimal, patternF755May 30, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF761May 30, 2025

  Based 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. Findings: On [DATE] at 2:34 P.M., an observation and interview was conducted with Licensed Nurse (LN) 35. […]

• No harm, potential for more than minimal, patternF804May 30, 2025

  Based 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. Findings: 1. After the initial resident screening and confidential group interview it was determined there were resident complaints about the food served at the facility. The resident complaints included the food was served cold and did not taste good. During initial tour from 5/27/25 to 5/28/25 the following resident comments regarding food complaints were: On 5/27/25 at 08:28 A.M., during the initial screening Resident 36 stated the food does not taste good and looks cheap. […]