Pillars of North County Health & Rehab Center, The

In the surveyor’s words

From the most serious findings on record at Pillars of North County Health & Rehab Center, The, in the surveyor’s own words.

• Actual harm, isolatedF686Jul 2, 2024

  Based on observation, interview and record review, the facility failed to follow their pressure ulcer and wound care policies/procedures by failing to ensure Resident #3's wound care Physician's orders were initiated when ordered, and Registered Dietician's (RD) recommendations were promptly followed. The facility also failed to promptly identify, assess, document and notify the resident's Physician regarding the resident's pressure ulcers located on both feet/heels. In addition, the facility failed to ensure Resident #2, who was admitted on [DATE], with a pressure ulcer on the coccyx (the tailbone), had a treatment order in place until 7/1/24, failed to ensure a nurse contacted the physician for a treatment order prior to administering a treatment to the coccyx, failed to ensure the wound… […]

• No harm, potential for more than minimal, patternF805Mar 21, 2025

  Based on observation, record review, interviews, and facility recipe review, the facility Dietary [NAME] (DC) failed to ensure the puree chicken lunch entree was proper texture for four of four residents (Resident (R) 6, R13, R39, and R262) reviewed for pureed diet of 22 sample residents. This failure had the potential to make the entree unpalatable and difficult to swallow for the residents who required a puree meal. Findings include: Review of the Chicken Maple Glazed Puree Thick recipe found in the dietary department recipe folder for week five lunch, dated 10/15/24, revealed .Maple Glazed Chicken 10 serving 1 breast. Chicken Base 1 1/8 teaspoon. Water 1 cup 2 tablespoons. Food Thickener 2 2/3 cup. WASH HANDS. 1. Place prepared Maple Glazed Chicken into food processor. 2. […]

• No harm, potential for more than minimal, patternF812Mar 21, 2025

  Based on observations, interviews, and facility policy review, the facility failed to maintain the walk-in refrigerator at 41 degrees Fahrenheit (F) or below during two of two observations in one of one kitchen of 55 of 71 census residents which could have caused food spoilage and failed to distribute and maintain clean water pitchers for three of three residents (Resident (R) 47, R61, and R38) observed for cleanliness. This failure had the potential to affect resident safety. Findings include: Review of the facility's policy titled, Safe Food Preparation and Safe Handling, dated January 2012, revealed . […]

• No harm, potential for more than minimal, patternF921Mar 21, 2025

  Based on observations, record review, interviews, and policy review, the facility failed to maintain clean and bug-free bathroom vents, store urinals and plungers in a sanitary manner, and maintain fixtures/equipment in a safe and functional manner for 11 of 26 residents (Resident (R) 27, R24, R43, R111, R14, R9, R112, R56, R11, R26, and R30) observed for the environment. These failures had the potential cause avoidable allergies or spread of infection and injury from broken fixtures/ equipment. Findings include: Review of the facility's policy titled, Routine Maintenance, dated 08/06/22, revealed Maintenance staff is responsible to ensure that preventative, routine maintenance is completed in compliance with applicable life safety standards and needs of the facility. […]

• No harm, potential for more than minimal, patternF558Nov 1, 2023

  Based on observation, interview and record review, facility staff failed to provide reasonable accommodation of individual needs and preferences by failing to ensure call lights were within reach for four sampled residents (Residents #204, #18, 406 and #405) with mobility limitations, and by failing to ensure a call light was installed at the bedside for one resident (Resident #407). The census was 58. Review of the facility's Answering the Call Light policy, revised July 2014, showed: -Policy: The purpose of this procedure is to respond to the resident's requests and needs; -General guidelines, included: --Be sure that the call light is plugged in at all times; --When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. 1. […]