Palomar Vista Healthcare Center

In the surveyor’s words

From the most serious findings on record at Palomar Vista Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF600Jun 21, 2022

  Based on observation, interview and record review, the facility did not ensure that 1 of 3 residents (Resident 1) was protected from the potential for sexual abuse when: 1. Resident 2 who had a history of [MEDICAL RECORD OR PHYSICIAN ORDER] . 2.After accepting Resident 2 as a new admission, there was no documented evidence related to the following: Accurate admission and ongoing safety assessment, development of interdisciplinary and core staff communication for the planning, monitoring and evaluating of Resident 2's plan of care to ensure Resident 2 did not interfere with other residents' safety. As a result, Resident 2 was found by staff in Resident 1's room laying in bed with Resident 1. Resident 1's gown was above her hips and her intact brief was exposed. […]

• No harm, potential for more than minimal, patternF627Jan 15, 2026

  Based 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.Findings:1. Per the facility's admission Record, Resident 1 was admitted to the facility on [DATE] with diagnoses to include peritoneal abscess (infection in the abdomen) and change or removal of surgical wound dressing. […]

• No harm, potential for more than minimal, patternF584Sep 12, 2025

  Based 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.Findings: 1. […]

• No harm, potential for more than minimal, patternF605Sep 12, 2025

  Based 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: 1) A review of Resident 42's admission Record indicated Resident 42 was admitted to the facility on [DATE] with diagnoses which included history of Major… […]

• No harm, potential for more than minimal, patternF658Sep 12, 2025

  Based 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.Cross reference F605, F755 Findings:1. […]