Poway Healthcare Center

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF700May 8, 2025

  Based on observation, interview, record review, and facility policy review, the facility failed to obtain consent for the use of bed rails for 2 (Resident #9 and Resident #24) of 3 sampled residents with bed rails installed; and failed to complete assessments for the continued use of bed rails for 3 (Residents #9, #24, and #54) of 3 sampled residents reviewed for accidents. Findings included: A facility policy titled, Bed Safety and Bed Rails, revised 08/2022, revealed, 3. The use of bed rails or side rails (including temporarily raising the side rails for episodic use during care) is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternatives, interdisciplinary evaluation, resident assessment, and informed consent. The policy specified, 8. […]

• No harm, potential for more than minimal, patternF880May 8, 2025

  Based on observation, interview, record review, and facility policy review, the facility failed to store continuous positive airway pressure (CPAP) masks in a manner that limited the spread of infection for 2 (Resident #22 and Resident #47) of 2 sampled residents reviewed for respiratory care. Findings included: A facility policy titled, CPAP/BiPAP [bilevel positive airway pressure] Support, revised 03/2015, revealed, General Guidelines for Cleaning, that specified, 9. Storage of equipment: Head gear/mask/nasal pillows when not in use will be stored in a bag labeled with date and changed weekly. 1. An Admission Record revealed the facility admitted Resident #22 on 03/05/2025. […]

• No harm, potential for more than minimal, patternF880Apr 5, 2022

  Based on observation, interview, and record review, the facility failed to implement appropriate infection control practice during a norovirus (a food-borne, highly contagious virus that causes vomiting and diarrhea) outbreak. This failure had the potential to spread the norovirus in the facility. Findings: On 6/25/21, the California Department of Public Health received notification of a norovirus outbreak at the facility. On 6/29/21, an unannounced visit was conducted at the facility. A tour of the facility was conducted on 6/29/21 at 10:05 A.M. to observe for implementation of infection control practices. The tour included observations in the facility's kitchen. A red bucket (a bucket containing disinfectant used on kitchen surfaces where food is prepared) was located on a shelf. […]

• No harm, potential for more than minimal, patternF558Mar 17, 2022

  Based on observation, interview, and record review, the facility failed to consistently provide non-English communication boards (a board in a specific language use to communicate) to non- English speaking residents for one of one sampled resident (Resident 53) and three non-sampled residents (Resident 141, 140, 46) reviewed for communication. This failure had the potential for Residents' 46, 53, 140, and 141, to not have their needs known or met, and for decreased socialization. 1. Resident 141 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . On 3/14/22 at 9 A.M., an observation was conducted inside Resident 141's room. Resident 141 was lying flat in bed with his eyes open, with the lights off, curtain pulled, and no TV or radio on. […]

• No harm, potential for more than minimal, patternF658Mar 17, 2022

  Based on observation, interview, and record review, the facility failed to ensure nursing standards of practice were followed when: 1a. A peripherally inserted central catheter (PICC-a main intravenous line) was not consistently monitored or documented for one of two residents (Resident 11), reviewed for Professional Standards of Practice; 1b. Intravenous (IV) antibiotic medication was not documented as administered via the PICC line for one of two residents (Resident 11), reviewed for Professional Standards of Practice; and 2. […]