Other·January 19, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during an abbreviated standard survey. Complaint # CA00501920 The investigation was limited to the specific complaint and does not represent the findings of a full inspection of the facility. Representing the California Department of Public Health: 34709, Pharmaceutical Consultant II, Specialist. Glossary: ADM - Administrator ADON - Assistant Director of Nursing DON - Director of Nursing DSD - Director of Staff Development IV - intravenous: medication administered directly into the vein MAR - Medication Administration Record LN - Licensed Nurse mg - milligram mL - milliliter

F329 SS=G DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS CFR(s): 483.25(l)

F329 Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8TK911 Facility ID: CA080000050 If continuation sheet 1 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055067 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALOMAR VISTA HEALTHCARE CENTER 201 N Fig St Escondido, CA 92025 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Based on a comprehensive assessment of a resident, the facility must ensure that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to ensure Resident 1's pain medication was not excessive. The facility failed to question an order for a high dose of Morphine Sulfate ER (extended release, longacting medication for pain, also known as MS Contin) with the physician prior to administering three doses of medication to 1 of 1 sampled resident (1). As a result, Resident 1 was transferred to the Emergency Department (ED), and subsequently admitted to the hospital for the treatment of opiate overdose. Findings: Resident 1 was admitted to the facility on 8/26/16, from the hospital, with diagnoses which included after surgery care, high blood pressure, and chronic pain, according to the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8TK911 Facility ID: CA080000050 If continuation sheet 2 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055067 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALOMAR VISTA HEALTHCARE CENTER 201 N Fig St Escondido, CA 92025 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Admission Record. According to the same document, Resident 1's wife was listed as his primary contact. The discharge instructions from the hospital included the medication Morphine Sulfate ER 200 mg, give 1 tablet every 12 hours for pain management for 60 administrations (to be administered 60 times). The total daily dose was 400 mg. Resident 1 ' s clinical record was reviewed on 11/9/16 starting at 2:20 P.M. with the ADON and DSD. According to the nurse's notes, MS Contin was not available. The skilled nursing facility physician (Physician 1) authorized one dose of Percocet 5/325 mg (a strong pain medication), which was administered at 10:59 P.M. on 8/26/16. Physician 1 also instructed the nurse to administer MS Contin 200 mg when the medication arrived from the pharmacy, and administer the second dose of this medication 10 hours later. Resident 1 received the first dose of MS Contin at 00:55 AM on 8/27/16, the second dose of MS Contin 200 mg at 11:09 AM on 8/27/16 and a third dose of MS Contin at 7:30 PM on 8/27/16. On 8/28/16 at 8:35 A.M., Resident 1 was sent to the Emergency Department [ED] at Hospital A via ambulance for, "shortness of breath." On 8/28/16, Resident 1 arrived at Hospital A's ED at 9:34 A.M., with the chief complaint of "shortness of breath, altered mental status." At 10:52 A.M., Resident 1 was administered Naloxone (Narcan, a medication to treat opiate FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8TK911 Facility ID: CA080000050 If continuation sheet 3 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055067 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALOMAR VISTA HEALTHCARE CENTER 201 N Fig St Escondido, CA 92025 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE overdose). According to the ED Notes on 8/28/16 at 11:19 A.M., "After giving narcan 0.4 mg IV pt [patient] ... began speaking, continued with slurred speech and states, " what did you give me." Informed him it was narcan he received... [Patient] states, "I can open my eyes much easier." ... sitting up in bed speaking with wife...." On 8/28/16, at 2:08 P.M., Resident 1 was administered Naloxone continuous infusion at 0.1 mg per hour. On 8/28/16, at 5 P.M., Resident 1 was administered Naloxone continuous infusion at 0.5 mg per hour. On 8/28/16, at 5:12 P.M., Resident 1 was admitted to the Intensive Care Unit (ICU). According to the records received from Hospital A, Resident 1 was admitted from 8/28/16 to 9/10/16. According to the Discharge Summaries, dated 9/10/16, the list of "Active Hospital Problems" included the diagnosis of opiate overdose. An interview was conducted on 11/9/16 at 2:50 P.M. with LN 1, who administered one dose of MS Contin on 8/27/16 at 7:30 P.M. LN 1 stated she had been an LN since 2007, and from her experience, the usual dose for MS Contin was 100 mg. LN 1 acknowledged it was the first time she administered a 200 mg dose. LN 1 said, "I know it's high" and she would normally verify with the physician. However, in this case, she would "assume" it was already verified with the physician by someone else. LN 1 added, when the medication dose was high, she would clarify with the supervisor, then the supervisor would clarify with the physician. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8TK911 Facility ID: CA080000050 If continuation sheet 4 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055067 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALOMAR VISTA HEALTHCARE CENTER 201 N Fig St Escondido, CA 92025 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE LN 1 acknowledged she was not aware if Resident 1 was previously on such high dose, and she did not remember clarifying it with the supervisor. On 11/9/16 at 3:35 PM, Resident 1's clinical record, including the history of pain medication administration from the hospital, which was available to LNs and physicians, was reviewed with the DON. Per the clinical record, when Resident 1 was in the hospital, he received Oxycodone and Morphine for pain. The maximum total amount of pain medication Resident 1 could have received daily was an equivalent of 120 mg of Morphine. Resident 1 had no prior history of receiving 400 mg of Morphine Sulfate daily. The DON acknowledged this information did not justify why the LN at the skilled nursing facility administered 400 mg of MS Contin a day. The DON stated LNs had access to Resident 1 ' s clinical record from the hospital, and should have reviewed the medication history, and questioned the appropriateness of the high dose of MS Contin. Furthermore, the LNs should have brought this to Physician 1 ' s attention. On 11/10/16 at 10:30 AM, Physician 1 was interviewed via telephone. Physician 1 stated when a resident came with medication orders from another physician, she would continue the same medications. She explained, since she would not see the resident for another 48 to 72 hours, and would not have access to the whole medical record that came with the resident, she would continue the same medications unless they were "questionable." Physician 1 acknowledged she did not have access to Resident 1's medical record when she FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8TK911 Facility ID: CA080000050 If continuation sheet 5 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055067 (X3) DATE SURVEY COMPLETED 12/19/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE PALOMAR VISTA HEALTHCARE CENTER 201 N Fig St Escondido, CA 92025 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE prescribed MS Contin. She came in on 8/27/16 to see Resident 1. Even though she had access to the medical record on 8/27/16, Resident 1 was "comfortable," therefore she did not question the dose of MS Contin. Physician 1 acknowledged 400 mg of MS Contin a day was high, "Agreed it's kind of too high." According to the facility's policy, Medication Orders, revised 5/07, "Any dose or order that appears inappropriate considering the resident's age, condition, or diagnosis is verified with the attending physician." According to the facility's policy, Medication Administration - Oral, revised 5/07, "If there is any question in regard to the dosage, the person in doubt should not give the drug until she has obtained information which clarifies drug dosage." The facility ' s failure to follow its existing medication administration policy and procedures has resulted in a significant medication error for Resident 1, requiring an avoidable hospital admission. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 8TK911 Facility ID: CA080000050 If continuation sheet 6 of 6