Health inspection·December 8, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Based 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. Residents Affected - Few 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. Findings: On 11/1/23 at 11:40 A.M. the Director of Nursing (DON) stated during an interview that LN 2 reported to the DON on 10/15/23 that LN 1 had slurred speech and was not herself after returning from break. The DON then called LN 1 who admitted that she had a drink of beer and sushi on break, so the DON sent her home. The DON stated that LN 2 seemed normal when she spoke with her on the phone. The DON further stated that she was made aware that LN 1 did evening med pass after consuming an alcoholic beverage on break, but the DON did not immediately identify the affected residents. According to the DON, There was a lot going on so that ' s why I didn ' t think about checking the Medication Administration Record (MAR) and med pass to see if other residents were affected. The Clinical Resource Nurse (CRN) stated during an interview on 11/1/23 at 11:51 A.M. that she was just made aware of the med pass part two days ago on 10/30/23. Per the CRN, That ' s why I ' m here, to check for any errors and any affected residents. The CRN acknowledged that She [LN 1] did med pass while under the influence. LN 1 ' s employment file was reviewed on 11/1/23. LN 1 ' s hire date was 8/2/23. There was a signed attestation by LN 1, dated 8/1/23, agreeing to comply with the facility ' s policy on drug/alcohol use. During an interview on 11/2/23 at 11:47 A.M., LN 1 stated that she was working the evening shift on 10/15/23. LN 1 stated, Around 8pm, I went to a sushi place for dinner break. I had one beer but didn ' t finish it. LN 1 further stated, I came back to work but was not intoxicated and could competently provide care. According to LN 1, she did med pass between 8:30 P.M. and 9:30 P.M. that evening. LN 1 then got a call from the DON who told her to go home. LN 1 acknowledged she signed an attestation upon employment regarding the facility ' s policy on drug/alcohol use. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 055067 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055067 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palomar Vista Healthcare Center 201 N Fig Street Escondido, CA 92025 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)