Health inspection·January 21, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to provide safety rails in a bathroom that was used by two of four residents (Resident 7 and Resident 11) who had access to the bathroom. This failure had the potential for accidents related to toilet use. Findings: Per the facility's admission Record, Resident 7 (R7) was admitted on [DATE] for Respite Care (short-term relief for primary caregivers, giving them time to rest, travel, or spend time with other family and friends). R7 had diagnoses which included Malignant Neoplasm (a cancerous tumor, which is an abnormal growth of cells that have the potential to spread to other parts of the body) of bladder, Surgery of the Genitourinary (the urinary and genital organs) System, Chronic Respiratory Failure (a long-term condition that prevents the lungs from exchanging enough oxygen and carbon dioxide with the body). Record review of Minimum Data Set (MDS-standardized assessment tool used to comprehensively evaluate the health status of nursing home residents) Section GG-Functional Abilities-Admission for R7 was conducted. Record review indicated R7 was assessed for the category F, Toilet Transfer: The ability to get on and off commode as . Substantial/ maximal assistance-Helper does MORE THAN HALF the effort. Helper holds trunk or limbs but provides more than half the effort. Per admission Record, Resident 11 (R11) was admitted on [DATE] with diagnoses which included abnormalities of gait (a person's manner of walking) and mobility, muscle weakness, Cerebral Infarction (medical condition that occurs when blood flow to the brain is disrupted, depriving brain cells of oxygen and nutrients), and Falls. Record review of MDS Section GG-Functional Abilities-Admission for R11 was conducted. Record review indicated R11 was assessed for the category F, Toilet Transfer: The ability to get on and off commode as .Supervision or touching assistance-Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity . On 12/31/24 at 9:27 A.M., an interview was conducted with Complainant 1 (C1). C1 stated that her husband, R7 had a bathroom with no safety rails near the toilet or anywhere in the bathroom. On 12/31/24 at 12:29 P.M., an observation of the bathroom that connected room [ROOM NUMBER] and room [ROOM NUMBER] was conducted. There were no safety rails by the toilet or anywhere in the bathroom. Page 1 of 3 055067 055067 01/21/2025 Palomar Vista Healthcare Center 201 N Fig Street Escondido, CA 92025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 12/31/24 at 2:05 P.M., a concurrent observation and interview was conducted with Resident 11. Resident 11 was observed ambulating into the room with irregular gait while holding onto a walker. Resident 11 stated that his bathroom did not have safety rails. Resident 11 stated that he could use the toilet with his walker, but it would be easier with safety rails. On 12/31/24 at 2:15 P.M., a concurrent observation of bathroom for room [ROOM NUMBER] & 3 and interview was conducted with CNA 4. CNA 4 stated that there were no safety rails by the toilet. CNA 4 stated that the expectation is that all resident bathrooms should have safety rails by the toilet. CNA 4 stated the importance of safety rails is to help the resident ' s balance when sitting and to transfer safely off the toilet. On 12/31/24 at 2:25 P.M., a concurrent observation of bathroom for rooms 2 & 3 and interview with Licensed Nurse 2 (LN2) was conducted. LN2 stated that there were no safety rails by the toilet. LN2 stated that the expectation is that all resident bathrooms should have safety rails by the toilet. LN2 stated the importance of safety rails is to help the resident ' s balance when sitting and to transfer safely off the toilet. On 12/31/24 AT 2:45 P.M., a concurrent observation of bathroom for room [ROOM NUMBER] & 3 and interview with the Administrator (ADM) was conducted. ADM stated that there were no safety rails for this bathroom because the room had flooded, and the walls had to be repaired. ADM stated while work was done on walls, the safety rails were removed. ADM stated the safety rails had not be replaced. ADM stated they expectation is that all resident bathrooms should have safety rails by the toilet. ADM stated the importance of having safety rails is to help residents balance and to transfer safely, and to prevent accidents in bathroom. Review of facility policy titled, PHYSICAL ENVIRONMENT, RESIDENT ROOMS, dated 11/2007 indicated It is the policy of this facility that a resident room must .5. Bathrooms must be equipped with safety rails . Based on observation, interview, and record review the facility failed to provide safety rails in a bathroom that was used by two of four residents (Resident 7 and Resident 11) who had access to the bathroom. This failure had the potential for accidents related to toilet use. Findings: Per the facility's admission Record, Resident 7 (R7) was admitted on [DATE] for Respite Care (short-term relief for primary caregivers, giving them time to rest, travel, or spend time with other family and friends). R7 had diagnoses which included Malignant Neoplasm (a cancerous tumor, which is an abnormal growth of cells that have the potential to spread to other parts of the body) of bladder, Surgery of the Genitourinary (the urinary and genital organs) System, Chronic Respiratory Failure (a long-term condition that prevents the lungs from exchanging enough oxygen and carbon dioxide with the body). Record review of Minimum Data Set (MDS-standardized assessment tool used to comprehensively evaluate the health status of nursing home residents) Section GG-Functional Abilities-admission for R7 was conducted. Record review indicated R7 was assessed for the category F, Toilet Transfer: The ability to get on and off commode as . Substantial/ maximal assistance-Helper does MORE THAN HALF the 055067 Page 2 of 3 055067 01/21/2025 Palomar Vista Healthcare Center 201 N Fig Street Escondido, CA 92025

F 0689 effort. Helper holds trunk or limbs but provides more than half the effort . Level of Harm - Minimal harm or potential for actual harm Per admission Record, Resident 11 (R11) was admitted on [DATE] with diagnoses which included abnormalities of gait (a person's manner of walking) and mobility, muscle weakness, Cerebral Infarction (medical condition that occurs when blood flow to the brain is disrupted, depriving brain cells of oxygen and nutrients), and Falls. Residents Affected - Few Record review of MDS Section GG-Functional Abilities-admission for R11 was conducted. Record review indicated R11 was assessed for the category F, Toilet Transfer: The ability to get on and off commode as .Supervision or touching assistance-Helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes activity . On 12/31/24 at 9:27 A.M., an interview was conducted with Complainant 1 (C1). C1 stated that her husband, R7 had a bathroom with no safety rails near the toilet or anywhere in the bathroom. On 12/31/24 at 12:29 P.M., an observation of the bathroom that connected room [ROOM NUMBER] and room [ROOM NUMBER] was conducted. There were no safety rails by the toilet or anywhere in the bathroom. On 12/31/24 at 2:05 P.M., a concurrent observation and interview was conducted with Resident 11. Resident 11 was observed ambulating into the room with irregular gait while holding onto a walker. Resident 11 stated that his bathroom did not have safety rails. Resident 11 stated that he could use the toilet with his walker, but it would be easier with safety rails. On 12/31/24 at 2:15 P.M., a concurrent observation of bathroom for room [ROOM NUMBER] & 3 and interview was conducted with CNA 4. CNA 4 stated that there were no safety rails by the toilet. CNA 4 stated that the expectation is that all resident bathrooms should have safety rails by the toilet. CNA 4 stated the importance of safety rails is to help the resident's balance when sitting and to transfer safely off the toilet. On 12/31/24 at 2:25 P.M., a concurrent observation of bathroom for rooms 2 & 3 and interview with Licensed Nurse 2 (LN2) was conducted. LN2 stated that there were no safety rails by the toilet. LN2 stated that the expectation is that all resident bathrooms should have safety rails by the toilet. LN2 stated the importance of safety rails is to help the resident's balance when sitting and to transfer safely off the toilet. On 12/31/24 AT 2:45 P.M., a concurrent observation of bathroom for room [ROOM NUMBER] & 3 and interview with the Administrator (ADM) was conducted. ADM stated that there were no safety rails for this bathroom because the room had flooded, and the walls had to be repaired. ADM stated while work was done on walls, the safety rails were removed. ADM stated the safety rails had not be replaced. ADM stated they expectation is that all resident bathrooms should have safety rails by the toilet. ADM stated the importance of having safety rails is to help residents balance and to transfer safely, and to prevent accidents in bathroom. Review of facility policy titled, PHYSICAL ENVIRONMENT, RESIDENT ROOMS, dated 11/2007 indicated It is the policy of this facility that a resident room must .5. Bathrooms must be equipped with safety rails . 055067 Page 3 of 3