Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Palomar Vista Healthcare Center during CMS and state inspections, most recent first.
The facility failed to confirm HH services and accurately document post-discharge arrangements before discharging three residents who required ongoing skilled care at home. One resident with a peritoneal abscess and a wound VAC was discharged with orders for RN, wound care, and PT visits, and the discharge paperwork named a specific HHA, but the referral was not sent until after discharge and was then declined, with no discharge-planning notes until days later. Another resident with impaired mobility and pneumocystosis was discharged with orders for RN and PT visits; the discharge summary listed an HHA as arranged even though acceptance was still pending, and only hours after discharge was it documented that the agency had declined, with a different HHA accepting the referral the following day. A third resident with acute cholecystitis and digestive tract ostomies had a discharge summary stating HH services were arranged, while documentation showed the referral was still pending and staff later acknowledged they never confirmed acceptance or followed up before or after discharge. Interviews with leadership and existing policy confirmed that HH referrals should have been initiated early and agencies confirmed prior to discharge, which did not occur in these cases.
Two residents in a facility were using a bathroom without safety rails, which are crucial for safe toilet transfers. One resident required substantial assistance due to conditions like malignant neoplasm and chronic respiratory failure, while the other needed supervision due to gait abnormalities and a history of falls. The absence of safety rails was confirmed by staff and the facility's administrator, who stated they were removed for wall repairs and not replaced, despite the facility's policy requiring them.
A resident with hemiplegia and hemiparesis experienced ongoing diarrhea and developed purple, swollen feet, but the facility failed to create a care plan addressing these issues. Despite documentation of the resident's symptoms, no care plan was developed, leading to delayed care and decreased physical well-being. The facility's policy required comprehensive care plans, which were not implemented in this case.
A resident with hemiplegia and hemiparesis experienced continued diarrhea and skin breakdown due to the facility's failure to administer prescribed diarrhea medication. Despite having an order for Loperamide HCL, it was only given once, and the stool softener was not consistently held. The facility's policy required adherence to physician orders, which was not followed, putting the resident at risk for fluid deficit and dehydration.
A resident with hemiplegia and hemiparesis developed a deep tissue injury due to inadequate care and monitoring of a rash and diarrhea episodes. The facility failed to reposition the resident every two hours and did not document or follow up on the resident's skin condition, leading to the development of a pressure ulcer.
The facility failed to provide RN coverage for eight consecutive hours daily, leading to inconsistent care oversight. Payroll data showed low weekend staffing and a 1-star quality rating. Interviews revealed challenges in maintaining RN staffing, with the DON occasionally assisting on the floor. The facility lacked a staffing policy, contributing to the deficiency.
The facility failed to ensure a sanitary kitchen environment, with unlabeled food items and staff personal items improperly stored in the refrigerator. Additionally, a coil above the food shelf was covered in debris, posing a contamination risk. These issues violated FDA Food Code requirements and increased the risk of foodborne illness.
A resident with neuromuscular dysfunction of the bladder experienced delays in incontinent care, leading to feelings of upset and neglect. The resident reported waiting for hours to be changed, as CNAs were occupied with other tasks. The DON acknowledged the discomfort and potential skin issues resulting from such neglect.
A facility failed to complete the PASRR II evaluation for a resident with schizoaffective disorder, despite a positive Level I screening. The resident, who had been in and out of the facility since 2021, was observed experiencing visual hallucinations. Interviews with staff revealed confusion and lack of responsibility regarding the PASRR process, with no assigned personnel to review and follow up on screenings. The facility's policy required proper PASRR screening, but it was not followed, risking the resident's access to necessary mental health care.
Two residents in the facility did not have appropriate care plans developed to address their specific medical needs. One resident, with obstructive sleep apnea, lacked a care plan for CPAP use, while another, receiving IV antibiotics through a PICC line, had no care plan for its management. These deficiencies were identified through observations, interviews, and record reviews, highlighting a failure to meet the residents' care requirements.
A resident with obstructive sleep apnea reported that their CPAP machine was not working well and had requested a replacement since admission. Observations revealed the CPAP mask and tubing were held together with tape, indicating a need for replacement. A licensed nurse confirmed the machine needed replacement, and the Director of Nursing expected checks before use. However, the facility's policy lacked guidance on checking the machine's function.
A resident with end-stage renal disease did not receive consistent dialysis access site care as required. The resident, who had mild cognitive impairment, was observed with an intact dressing on the dialysis site, which he often removed himself. Facility staff interviews revealed that the dressing should be removed three hours post-dialysis to prevent infection and allow for assessment, as per physician's orders. The facility's policy required licensed nurses to provide vascular access site care, but this was not consistently followed.
The facility failed to follow infection control practices for three residents, leading to potential contamination of medical equipment. A resident's CPAP mask was left exposed, another's IV tubing and PICC line dressing were undated, and a third resident's CPAP mask was improperly stored. The facility's policies lacked guidance on proper storage and labeling, contributing to these deficiencies.
The facility failed to assess a resident's ability to self-administer medications, leading to a potential risk of over or under medication. The resident, with hemiplegia and hemiparesis, self-administered antibiotics and an ointment without any assessment or supervision from the nursing staff. The facility's policy for self-administration of medications was not followed.
Failure to Confirm Home Health Services Prior to Discharge
Penalty
Summary
The deficiency involves the facility’s failure to ensure that home health (HH) services were confirmed and accurately reflected in discharge documentation prior to residents’ discharge. For Resident 1, who was admitted with a peritoneal abscess and required surgical wound dressing changes, there was an order for discharge with HH services for RN visits, wound care, and PT. The discharge summary and post-discharge plan of care identified a specific home health agency as arranged, and the resident was discharged with a wound VAC in place. However, the referral to that agency was not faxed until approximately 29 minutes after the resident had already left the facility, and the agency did not accept the referral. There were no progress notes documenting discharge planning prior to the social services assistant’s (SSA) notes four days after discharge. The resident later reported to a GACH that no nurse had come to his home and that he did not know how to care for his wound VAC. For Resident 2, admitted with difficulty walking and pneumocystosis, an order was written for discharge to home with HH services for RN and PT visits. A discharge progress note documented that a referral had been sent to a home health agency and was pending review and acceptance, yet the discharge summary and post-discharge plan of care stated that this same agency had been arranged to provide services. The resident was discharged home, and more than three hours after discharge, a discharge planning note documented that the agency did not accept the referral. Over 24 hours after discharge, the SSA documented that a different home health agency confirmed acceptance of the referral. The SSA later stated that the day she documented the acceptance was the day the second agency confirmed, which was the day after the resident’s discharge. For Resident 3, admitted with acute cholecystitis and artificial openings of the digestive tract, the discharge summary stated that HH services had been arranged with a specific home health agency. A discharge planning note documented that a referral had been made to that agency and was pending review and acceptance. The social services staff stated she sent the referral but did not hear back from the agency regarding acceptance and did not have a chance to follow up on the referral before or after the resident’s discharge. In interviews, the administrator stated that referrals to HH agencies should have been initiated as soon as the facility became aware of a resident’s discharge date, and the DON in training stated that HH agencies should have been confirmed prior to residents’ discharges. The facility’s own policy required that discharge needs be identified on admission and that a discharge plan be developed and implemented in a timely manner to effectively transition residents to post-discharge care.
Absence of Safety Rails in Resident Bathroom
Penalty
Summary
The facility failed to provide safety rails in a bathroom used by two residents, which had the potential to lead to accidents related to toilet use. Resident 7, admitted for respite care, required substantial or maximal assistance for toilet transfers due to conditions such as malignant neoplasm of the bladder, surgery of the genitourinary system, and chronic respiratory failure. Resident 11, who had abnormalities of gait, muscle weakness, cerebral infarction, and a history of falls, required supervision or touching assistance for toilet transfers. Both residents had access to a bathroom that lacked safety rails, which are essential for maintaining balance and ensuring safe transfers. Observations and interviews conducted on the same day revealed that the bathroom connecting two rooms did not have safety rails by the toilet or anywhere else in the bathroom. Complainant 1, the spouse of Resident 7, confirmed the absence of safety rails. Resident 11, observed using a walker with an irregular gait, also confirmed the lack of safety rails and expressed that using the toilet would be easier with them. Both a CNA and a licensed nurse confirmed the absence of safety rails and emphasized their importance for resident safety during toilet use. The facility's administrator explained that the safety rails had been removed due to wall repairs following a flood, and they had not been replaced. The facility's policy, dated November 2007, mandates that bathrooms must be equipped with safety rails. The failure to replace the safety rails after the repairs created a potential hazard for residents who required assistance with toilet transfers, as confirmed by multiple staff members and the facility's policy.
Failure to Develop Care Plan for Resident's Diarrhea and Swollen Feet
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who experienced diarrhea and purple feet with swelling. The resident, admitted with hemiplegia and hemiparesis following cerebrovascular disease, had loose bowel movements documented over several days and a change in condition noted with swelling and discoloration of the feet. Despite these ongoing issues, the facility did not create a care plan to address these specific health concerns. Interviews and record reviews revealed that the Director of Nurses acknowledged the absence of care plans for the resident's diarrhea and foot condition. The facility's policy required the interdisciplinary team to develop person-centered care plans with measurable objectives and timeframes to meet residents' needs. The lack of a care plan resulted in delayed care and decreased physical well-being for the resident, as staff were not guided or alerted to the necessary interventions for the resident's conditions.
Failure to Administer Diarrhea Medication
Penalty
Summary
The facility failed to administer a medication for diarrhea to a resident, leading to continued diarrhea and skin breakdown on the sacro-coccyx area. The resident, who was admitted with hemiplegia and hemiparesis following cerebrovascular disease, had an intact cognitive score. Despite having an order for Loperamide HCL for diarrhea, the medication was only administered once, and the resident experienced loose bowel movements over a period of 12 days. Additionally, a stool softener was ordered but not consistently held despite the presence of diarrhea, and the resident refused the stool softener on several occasions. Interviews with the licensed nurse and the Director of Nurses revealed that the medication for diarrhea was not administered as needed, and the stool softener was not appropriately held. The facility's policy required medications to be administered according to the physician's written orders, which was not followed in this case. This oversight resulted in the resident being at risk for fluid deficit and dehydration due to the ongoing diarrhea.
Failure to Prevent Pressure Ulcer Formation
Penalty
Summary
The facility failed to provide necessary care and services to prevent pressure ulcer formation for a resident with hemiplegia and hemiparesis following cerebrovascular disease. The resident was admitted with a low air loss mattress to prevent skin breakdown, but the facility did not ensure proper repositioning every two hours or timely changing of briefs after episodes of diarrhea. This lack of care led to the resident developing a deep tissue injury on the sacro-coccyx, which was identified upon transfer to the hospital. Interviews with licensed nurses and the treatment nurse revealed that the resident had a rash in the perianal area, which was not adequately documented or monitored. The nursing progress notes lacked detailed descriptions of the rash and its progression, and there was no follow-up documentation regarding the moisture-associated dermatitis. The Director of Nursing confirmed the absence of necessary documentation and stated that licensed nurses were expected to document skin evaluations every shift, which was not done in this case.
Inadequate RN Coverage and Oversight
Penalty
Summary
The facility failed to provide registered nurse (RN) coverage for eight consecutive hours a day, seven days a week, resulting in inconsistent oversight for the coordination, management, and overall delivery of care to residents. The facility's payroll-based journal data indicated low weekend staffing and a 1-star rating for quality of healthcare service in 2024. A review of the facility's daily census for April, May, and June 2024 revealed multiple instances where there was less than eight hours of RN coverage or no RN present for the required duration on specific dates. Interviews with the Staffing Coordinator and the Director of Nursing (DON) highlighted challenges in maintaining adequate RN staffing, particularly on weekends. The Staffing Coordinator mentioned that the DON would sometimes act as a charge nurse and assist on the floor. The DON admitted to not knowing the required RN hours due to the facility's census being below 74 and acknowledged the importance of RN oversight for assessments. It was also noted that the facility lacked a staffing policy, contributing to the deficiency in RN coverage.
Deficiencies in Kitchen Sanitation and Food Labeling
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in the kitchen, which increased the risk of foodborne illness and cross-contamination. During an observation, it was noted that the kitchen walk-in refrigerator contained items such as ketchup, soy sauce, and Italian dressing without a use-by date. Additionally, a staff member's plastic water bottle and beverage were improperly stored in the refrigerator. Other food items, including shredded carrots, hot dogs, tortillas, and onions, were not labeled or identified, violating the 2022 US FDA Food Code requirements for food labeling. Further inspection revealed a coil above the food shelf in the refrigerator covered with gray debris, which could potentially contaminate food. The registered dietician acknowledged the issue and indicated that maintenance would be notified. The facility's policies and procedures lacked specific guidance on maintaining the kitchen refrigerator, contributing to these deficiencies. The failure to properly label food and maintain equipment as per the FDA Food Code posed a risk to resident health by potentially exposing them to contaminated food.
Failure to Provide Timely Incontinent Care
Penalty
Summary
The facility failed to provide timely incontinent care to Resident 59, who was admitted with neuromuscular dysfunction of the bladder and muscle weakness. The resident, who was cognitively intact and dependent on assistance for toileting hygiene, reported feeling upset due to delays in receiving care. On one occasion, the resident waited from 6:30 AM to be changed, as the CNA was occupied with passing breakfast trays. This delay in care led to the resident feeling upset and neglected. Further observations revealed that Resident 59 experienced another incident where he was left wet and smelling of urine after a condom catheter came off during the night. The resident called for assistance at 4 AM, but the night shift CNA did not attend to him until 5:25 AM, and even then, deferred the task to the morning CNA. The morning CNA confirmed that the resident's brief was wet at the start of her shift. The Director of Nurses acknowledged that such neglect could cause discomfort and potential skin problems for residents.
Failure to Complete PASRR II Evaluation for Resident with Schizoaffective Disorder
Penalty
Summary
The facility failed to ensure the completion of the Pre-Admission Screening and Resident Review Level II (PASRR II) for a resident with a mental disorder, specifically schizoaffective disorder. The resident, who had been in and out of the facility since 2021, was readmitted with a diagnosis of schizoaffective disorder. Despite a positive Level I screening indicating the need for a Level II mental health evaluation, the evaluation was not completed due to inaccurate information provided to the State of California-Health and Human Services. The facility's staff, including the Director of Nurses (DON), admitted that there was no assigned personnel to review and follow up on PASRR Level I screenings. Interviews with various staff members, including the certified nurse assistant (CNA), licensed nurse (LN), minimum data set nurse (MDSN), and admissions director (AD), revealed a lack of clarity and responsibility regarding the PASRR process. The CNA noted the resident's refusal of certain care activities, while the LN observed the resident experiencing visual hallucinations. The MDSN and AD both indicated that PASRRs were received from the hospital, but there was confusion about who was responsible for their review and follow-up. The facility's policy stated the requirement for proper PASRR screening, yet it was not adhered to, leading to the potential for the resident not receiving necessary mental health care services in an appropriate setting.
Failure to Develop Care Plans for Residents with Specific Needs
Penalty
Summary
The facility failed to develop patient-centered care plans for two residents, which could potentially lead to unmet care needs. Resident 169, who was admitted with obstructive sleep apnea and chronic hypoxia, was observed using a CPAP machine at night. However, there was no care plan in place to guide staff on monitoring the resident's breathing, cleaning the CPAP machine, or adding water to it. This oversight was confirmed during a record review and interview with a licensed nurse, who acknowledged the absence of a care plan for the CPAP use. Similarly, Resident 170, admitted with sepsis and receiving IV antibiotics through a PICC line, also lacked a care plan addressing the management of the PICC line. The physician's orders required daily site checks and flushing of the PICC line, but no care plan was developed to ensure these tasks were performed. The Director of Nurses confirmed that care plans should be completed within 14 days, yet this was not done for Resident 170, as revealed during an interview and record review.
Failure to Ensure Functioning CPAP Machine for Resident
Penalty
Summary
The facility failed to ensure that a CPAP machine was functioning properly for a resident diagnosed with obstructive sleep apnea. The resident, who was cognitively intact, reported that the CPAP machine was not working well and had requested a replacement since admission. During an observation, it was noted that the CPAP mask and tubing were held together with gray tape, indicating a need for replacement. A licensed nurse confirmed that the CPAP machine needed to be replaced and acknowledged that it should be functional for the resident to receive its intended benefits. The Director of Nursing stated that licensed nurses were expected to check the CPAP machine before each use to ensure it was functioning properly. However, the facility's policy and procedure for CPAP/BiPAP monitoring and management did not provide guidance for staff to check the machine's function. This oversight had the potential to adversely affect the health and well-being of the resident, as the CPAP machine was essential for managing the resident's obstructive sleep apnea.
Failure to Provide Proper Dialysis Access Site Care
Penalty
Summary
The facility failed to consistently provide appropriate dialysis access site care and assessment for a resident with end-stage renal disease who was dependent on renal dialysis. The resident, who had mild cognitive impairment, was observed to have a dialysis access site on the right upper arm with a dressing intact. The resident reported that he often removed the dialysis dressing himself, which was contrary to the physician's orders that specified the dressing should be removed three hours after dialysis treatment. The resident's dialysis treatments were scheduled for Tuesdays, Thursdays, and Saturdays, and the last recorded dialysis appointment was on a Saturday. Interviews with facility staff, including a licensed nurse and the Director of Nursing, revealed that the dressing should be removed to allow for proper assessment and to prevent infection and bleeding. The facility's policy indicated that vascular access site care should be provided by a licensed nurse according to physician's orders. However, the failure to remove the dressing as required meant that the site could not be assessed, potentially leading to complications. This deficiency was identified through observations, interviews, and record reviews conducted by the surveyors.
Infection Control Deficiencies in CPAP and IV Management
Penalty
Summary
The facility failed to adhere to current infection control practices for three residents, leading to potential contamination of medical equipment. Resident 169's CPAP mask was observed left on top of the CPAP machine, exposed to air, rather than being stored in a plastic bag as required for infection control. This was confirmed by a licensed nurse who acknowledged the improper storage of the CPAP mask. Resident 170's IV tubing and PICC line dressing were not properly labeled with dates, which is a critical step in preventing infections. The IV bag and tubing were observed without a date, and the PICC line dressing was undated and worn out. The Director of Nurses confirmed that the lack of labeling and proper dressing changes could be a route for infection, and the facility's policy did not provide adequate guidance on labeling PICC line dressings. Resident 126's CPAP mask was also found uncovered on the bed, contrary to infection control protocols that require it to be stored in a plastic bag. The resident admitted to not cleaning the CPAP machine regularly, and the Infection Preventionist Nurse emphasized the importance of storing the mask properly to prevent exposure to microorganisms. The facility's policy lacked guidance on CPAP mask storage, contributing to the deficiency.
Failure to Assess Resident's Ability to Self-Administer Medications
Penalty
Summary
The facility failed to assess a resident's ability to self-administer medications, which led to a potential risk of over or under medication. Resident 3, who was admitted with hemiplegia and hemiparesis following a cerebral infarction, reported having a red rash on his right leg and had been prescribed antibiotics and an ointment by a dermatologist. Resident 3 picked up the medications from the pharmacy and self-administered them without any assessment or supervision from the nursing staff. The resident stated that the nursing staff did not check if he was able to self-administer medications. During interviews, the assigned medication nurse and the Director of Nurses (DON) confirmed that they were aware Resident 3 brought in medications from an outside pharmacy but had not conducted an assessment for self-administration. The facility's policy required a physician's order, an assessment, a care plan, and a lock box for self-administration of medications, none of which were followed. The DON acknowledged the importance of knowing if a resident kept medications at bedside to prevent potential drug interactions and overdoses. The facility's policy and procedure for self-administration of medications were not adhered to in this case.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
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Nursing homes near Escondido
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Palomar Heights Post Acute | 0.6 mi | — | 4 | 0 |
| Escondido Post Acute | 0.7 mi | — | 2 | 0 |
| Redwood Terrace Health Center | 1.4 mi | — | 0 | 0 |
| Valley Vista Post Acute | 1.5 mi | — | 24 | 0 |
| Ocean View Post Acute | 2 mi | — | 0 | 0 |
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