Health inspection·June 21, 2024

F 0684 Level of Harm - Actual harm changes. LN 3 stated at approximately 5 A.M., the CNA notified him that Resident 6 was unresponsive. LN 3 stated he ran to the room and called another LN. LN 3 stated he and the other LN placed Resident 6 on the floor and initiated CPR until the paramedics (health care professionals who responds to emergency calls) arrived. Residents Affected - Few An interview was conducted on [DATE] at 2:06 P.M., with LN 4. LN 4 stated he was assigned to Resident 6 on [DATE] 2:30 P.M. until 11 P.M. LN 4 stated CNA 6 notified him at around 9:30 P.M. to 10 P.M. that Resident 6 refused to take a shower because Resident 6 was not feeling well. LN 4 stated he requested for Resident 6's vital signs (VS- temperature, heart rate, breathing), but CNA 6 did not provide Resident 6's VS. LN 4 stated he did not follow up to take Resident 6's VS or check on Resident 6's condition because he was busy. LN 4 was asked when he would check on a resident and replied, It depended on the needs of the resident. If there was a change in condition it would be a priority. During an interview on [DATE] at 2:57 P.M., with CNA 6, CNA 6 stated she worked on the [DATE] afternoon shift and was assigned to provide a shower for Resident 6. CNA 6 stated CNA 3 was assigned to Resident 6 for the afternoon shift. CNA 6 stated Resident 6 was offered a shower at 3:30 P.M. and Resident 6 refused because he was not feeling well. CNA 6 stated Resident 6 requested to return later. CNA 6 stated she offered a shower again to Resident 6 at 4:30 P.M., and Resident 6 stated he still did not feel well and looked pale and sweaty. CNA 6 stated she reported to LN 4 that Resident 6 refused shower and did not feel well. CNA 6 stated LN 4 instructed her to have the assigned CNA take Resident 6's VS. CNA 6 stated LN 4 got upset because CNA 3 brought the VS machine to LN 4 with Resident 6's VS instead of writing them on a piece of paper. After dinner, CNA 6 stated she offered the shower to Resident 6 again with CNA 3 as the witness, but Resident 6 was still pale and sweaty. CNA 6 stated she notified LN 4 again and LN 4 asked how Resident 6 looked. CNA 6 stated she reported that Resident 6 looked like he had flu symptoms. CNA 6 further stated LN 4 did not check on Resident 6. During a review of Weights and Vitals Summary for Resident 6, there was no documentation of Resident 6's temperature and respirations on [DATE] afternoon shift. An interview was conducted on [DATE] at 3:50 P.M., with the director of nurses (DON). The DON confirmed CNA 3 was assigned to Resident 7 on [DATE] afternoon shift. The DON stated if she was the licensed nurse and a CNA did not take a resident's VS per her instruction, she then would take the VS herself and complete an assessment prior to physician notification. An interview was conducted on [DATE] at 3:06 P.M., with LN 7 regarding a resident's change in condition. LN 7 stated she would assess the resident, take the resident's VS, and notify the physician. The facility's director of staff development (DSD- a licensed nurse certified for staff training) was interviewed on [DATE] at 3:14 P.M. The DSD stated she had conducted an in-service for the facility's licensed nurses regarding resident change in condition. The DSD stated licensed nurses were taught to complete the e-Interact (Interventions to Reduce Acute Care Transfers- an electronic quality improvement program designed to improve identification, evaluation, and communication about changes in resident status) form which triggered staff to notify the physician. The DSD further stated assessment of a resident with a change in condition should be performed prior to physician notification. During a review of an In-service Attendance Record, dated [DATE] titled, COC (change of condition) documentation and Processes ., the in-service attendance record did not have LN 4's signature under Attendance. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555764 If continuation sheet Page 2 of 3 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 06/21/2024 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)

F 0684 Level of Harm - Actual harm Residents Affected - Few Resident 6's physician was interviewed on [DATE] at 9 A.M. The physician stated Resident 6 had diagnoses including CHF, ischemic cardiomyopathy, and a history of myocardial infarction (MI- a heart attack). The physician stated he was not aware that Resident 6 had symptoms of sweating and being pale. The physician stated symptoms of being sweaty and pale were signs of ischemia (lack of blood flow to a part of the body). The physician further stated he expected the facility staff to assess (evaluate) Resident 6 and to notify him of the change in condition. A review of the facility's policy and procedure (P&P) titled, Change in a Resident's Condition or Status, dated February 2021, the P&P indicated, Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status .Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555764 If continuation sheet Page 3 of 3