Health inspection·August 29, 2024

F 0656 resident that includes measurable objectives and timeframes to meet a resident ' s medical, nursing, mental and psychosocial needs . Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055067 If continuation sheet Page 2 of 6 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 08/29/2024 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)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to provide a medication for diarrhea for one of four residents (Resident 1) reviewed for services that meet professional standard, according to professional scope of practice. Residents Affected - Few As a result, Resident 1 continued to have diarrhea and had a skin breakdown on the sacro-coccyx (the triangular shaped bone at the base of the back extending to the tailbone) area. In addition, Resident 1 had the potential for increased infection and discomfort. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total or partial paralysis of one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebrovascular disease (a condition affecting blood flow and blood vessels in the brain) according to the facility ' s admission Record. The MDS (a clinical assessment tool) dated 7/19/24 for Resident 1, listed a cognitive (mental process involved in knowing, learning, and understanding things) score of 14, indicating cognition was intact. During an interview and concurrent record review on 8/29/24 at 10:32 A.M. with LN 1, LN 1 stated an open area on Resident 1 ' s coccyx (tailbone) was identified on 8/28/24. LN 1 reviewed Resident 1 ' s bowel movement record and stated Resident 1 had loose bowel movements from 8/16/24 through 8/23/24. LN 1 further stated CNAs were expected to change the resident after each episode of diarrhea and notify the LN to apply a barrier cream. LN 1 reviewed Resident 1 ' s medication administration record (MAR) and stated Resident 1 had an order for a medication for diarrhea ordered on 8/2/24 and an order for a stool softener (medication for constipation). LN 1 stated the medication for diarrhea was administered to Resident 1 once on 8/14/24. LN 1 stated the stool softener was not administered to Resident 1 on 8/1/24, 8/2/24, 8/5/24, 8/8/24 and Resident 1 refused the medication on 8/14/24. LN 1 further stated he was not sure why the medication for diarrhea was not given to Resident 1 and why the stool softener was not held. A review of Resident 1 ' s medication administration record (MAR) for August 2024 was conducted. The MAR indicated, Loperamide HCL Oral Tablet (medication for diarrhea) 2 MG (milligrams) .Give 1 tablet by mouth every 8 hours as needed for loose bowel .Order Date- 08/02/2024 . In addition, the MAR indicated, Colace Oral Capsule (a stool softener) 100 MG .Give 1 capsule by mouth two times a day for constipation prevention Hold for loose stools .Order Date- 8/17/24 1453 (2:53 P.M.) . A phone interview on 8/30/24 at 11:41 A.M. with the Director of Nurses (DON) was conducted. The DON stated she reviewed Resident 1 ' s record of bowel movements and stated Resident 1 had loose bowel movements/diarrhea documented on: 8/1/24, 8/3/24. 8/5/24, 8/6/24, 8/7/24, 8/10/24, 8/12/24, 8/12/24, 8/14/24, 8/16/24, 8/20/24 through 8/23/24 (12 days total). The DON stated upon review of Resident 1 ' s MAR, there was a medication for diarrhea as needed and it was only administered on 8/14/24. The DON stated there was also an order for a stool softener for Resident 1 and it was held on 8/14/24. The DON stated Resident 1 refused the stool softener on 8/2/24, 8/5/24, 8/8/24 and on 8/22/24. The DON stated the licensed nurses should have held the stool softener due to Resident 1 having diarrhea. The DON further stated Resident 1 was at risk for fluid deficit (loss of body fluid) and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055067 If continuation sheet Page 3 of 6 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 08/29/2024 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)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete dehydration (a dangerous loss of body fluid which can cause problems with blood pressure, heart rate, kidneys, and brain) due to diarrhea. During a review of the facility ' s policy and procedure (P&P) titled, Medication Administration, dated 7/2024, the P&P indicated, .Medications must be administered in accordance with the written orders of the attending physician . Event ID: Facility ID: 055067 If continuation sheet Page 4 of 6 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 08/29/2024 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)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility did not ensure one of three residents (Resident 1) reviewed for pressure ulcers (bedsores), received the necessary care and services to prevent pressure ulcer formation. Residents Affected - Few This failure resulted in Resident 1 ' s rash to become a deep tissue injury. Findings: Resident 1 was admitted to the facility on [DATE] with diagnoses including hemiplegia (total or partial paralysis of one side of the body) and hemiparesis (muscle weakness on one side of the body) following cerebrovascular disease (a condition affecting blood flow and blood vessels in the brain) according to the facility ' s admission Record. During an interview with licensed nurse (LN) 2 on 8/29/24 at 10:03 A.M., LN 2 stated Resident1 was transferred to the hospital on 8/28/24. LN 2 stated Resident 1 was on a low air loss mattress (mattress designed to distribute the resident ' s body weight and help prevent skin breakdown) due to skin problems. LN 2 stated to prevent pressure ulcers, residents should be repositioned every two hours, keep their skin dry by changing briefs. LN 2 stated if a resident had diarrhea the resident ' s brief should be changed after each episode of diarrhea to prevent the skin problem from worsening and getting infected. During an interview and concurrent record review on 8/29/24 at 10:32 A.M. with LN 1, LN 1 stated Resident 1 was transferred to the hospital on 8/28/24 due to low oxygen saturation (oxygen level) and edema (swelling). LN 1 stated an open area on Resident 1 ' s coccyx (tailbone) was also identified on 8/28/24. LN 1 reviewed Resident 1 ' s bowel movement record and stated Resident 1 had loose bowel movements from 8/16/24 through 8/23/24. LN 1 further stated CNAs were expected to change the resident after each episode of diarrhea and notify the LN to apply a barrier cream. An interview on 8/29/24 at 10:47 A.M. was conducted with the treatment nurse (TN). The TN stated Resident 1 had a rash in the perianal area (area where stool leaves the body and the private parts between the thighs). The TN stated on 8/28/24, Resident 1 was found to have a deep tissue injury (DTI- a pressure ulcer with purple or maroon areas of intact skin or blood blister due to pressure or shear) on Resident 1 ' s sacro-coccyx (the triangular shaped bone at the base of the back extending to the tailbone). A review of nursing progress notes (PN) for Resident 1 was conducted. The PN titled Change in Condition dated 8/10/24,11:36 A.M., indicated Resident 1 had a change in condition due to, Hemorrhoids (swollen and inflamed veins in the anus) and moisture associated dermatitis (MASD-skin inflammation and damage due exposure to moisture for a prolonged period of time; rash) in the perianal region. Further review of PNs for Resident 1 indicated no documentation regarding Resident 1 ' s diarrhea and rash on 8/11/24 through 8/16/24. The PNs titled, Daily Skilled Note dated from 8/17/24 through 8/20/24 indicated rash in the perianal area, but no description of the rash if it had improved or worsened. The facility ' s Daily Skilled Note dated 8/21/24 through 8/27/24 in Resident 1 ' s PN indicated, .No active gastrointestinal symptoms observed .No active skin condition (s) or treatments observed . Then on 8/28/24 at 10:13 A.M., a PN titled, Change in Condition indicated, .Symptoms or signs noted of Condition change: Skin wound or ulcer . There was no description of the wound or ulcer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055067 If continuation sheet Page 5 of 6 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 08/29/2024 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)

F 0686 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few documented in Resident 1 ' s progress notes. The PN dated 8/28/24 at 2:09 P.M. indicated resident had a change in condition, .O2 desaturation (low oxygen level) . PN dated 8/28/24 at 2:25 P.M. indicated resident was transferred out via 911 (emergency number). A phone interview on 8/30/24 at 11:41 A.M. with the Director of Nursing (DON) was conducted. The DON reviewed Resident 1 ' s PNs and stated Resident 1 had a change in condition on 8/10/24 due to hemorrhoids and MASD in the perineal region. The DON stated there was no measurement documented and no follow up documentation regarding the MASD. The DON stated she expected licensed nurses to document every shift. The DON further stated the description of the rash was needed to determine if Resident 1 ' s rash was worsening or improving. At 1:03 P.M. the DON called this writer and stated a skin evaluation form was completed for Resident 1 on 8/28/24 which indicated a DTI on Resident 1 ' s sacro-coccyx that measured 15 cm (centimeters) by 8 cm. A review of the facility ' s policy and procedure (P&P) titled, Skin and Wound Monitoring and Management, dated 7/2024 was conducted. The P&P indicated .A licensed nurse will assess/evaluate each pressure injury and/or non-pressure injury that exists on the resident. This assessment/evaluation should .include .1) Measuring the skin injury 2) Staging the skin injury (when the cause is pressure) 3) Describing the nature of the injury .4) Describing the location of the skin alteration 5) Describing the characteristics of the skin alteration .A licensed nurse will assess/evaluate a resident ' s skin at least weekly .Licensed nurse should document skin evaluations . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055067 If continuation sheet Page 6 of 6