Health inspection·February 15, 2024

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 supervision for one of three residents with a fall history (Resident 2). As a result, Resident 2 had a repeat fall and sustained injuries. Resident 2 was admitted to the facility on [DATE] with diagnoses including dementia (a condition characterized by loss of memory, language, problem solving and other thinking abilities) and repeated falls according to the facility ' s admission Record. A review of the facility ' s document titled, Fall Risk Observation/Assessment, dated 9/29/23 indicated a score of 20. The document indicated, .A. Low risk 0-8 B. Moderate risk 9-15 C. High risk 16-42 . During a review of Resident 2 ' s progress notes (PN) dated 10/11/23, the PN indicated Resident 2 was found on the floor face down with swelling on the right eye, nosebleed, and erythema (redness) on both upper arms. During a review of the Interdisciplinary Team (IDT- team members with various areas of expertise who work together toward the goals of their residents) fall PN dated 10/12/23, the PN indicated resident was sitting alone in the wheelchair in her room and fell. The PN indicated interventions to not to leave resident unattended in the room. A review of Resident 2 ' s care plans did not include Resident 2 ' s fall incident on 10/11/23. During a review of the facility's document titled, SBAR (Situation, Background, Assessment, Recommendation) Communication Form and Progress Notes for RNs/LPN/LVNs, dated 12/23/23, the SBAR indicated Resident 2 was taken inside the room for medication administration. The SBAR indicated Resident 2 was found on the floor prior to giving the medication. The IDT PN dated 12/26/23 was reviewed. The PN indicated Resident 2 was taken to the room and a CNA who was assisting Resident 2 went out to call for assistance but Resident 2 leaned forward and fell on the floor. The PN indicated an intervention, Not to leave Resident 2 inside the room unless Resident 2 was in bed. During an observation on 2/9/24 at 9:59 A.M., Resident 2 was sitting in the wheelchair in the hallway across the nurse ' s station. Resident 2 ' s eyes were closed and was holding on to a small white stuffed bear. Resident 2 opened her eyes as Certified Nurse Assistant (CNA) 1 approached her. (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: 555764 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 555764 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/15/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palomar Heights Post Acute 1260 E Ohio Avenue Escondido, CA 92027 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)