Inspection Reports for
Highland Palms Healthcare Center
7534 Palm Ave, Highland, CA 92346, CA, 92346
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
8.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
113% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 7
Date: Oct 31, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, infection control, and facility policies at Highland Palms Healthcare Center.
Findings
The facility was found deficient in multiple areas including failure to document changes in resident condition, lack of comprehensive care plans, failure to follow physician orders for feeding tubes, inadequate respiratory care monitoring, improper medication disposal and storage, and failure to maintain infection control practices related to contact precautions.
Deficiencies (7)
Failed to document a change of condition for Resident 42 regarding moisture associated skin damage (MASD).
Failed to develop a comprehensive care plan for smoking for Resident 70.
Failed to follow physician orders for Resident 44's enteral feeding rate, which was running at 65 mL/hr instead of 60 mL/hr.
Failed to monitor Resident 73's tracheostomy for redness, discharge, and discoloration every shift as ordered.
Failed to properly dispose of six medication tablets, which were found on top of the medication waste receptacle.
Failed to remove expired intravenous antibiotic medication from the medication supply room.
Failed to maintain infection control practices when a Certified Nursing Assistant did not don a gown before entering the room of a resident on contact precautions.
Report Facts
Enteral feeding rate: 65
Enteral feeding rate ordered: 60
Medication tablets improperly disposed: 6
Expired medication date: 1
Residents affected by infection control failure: 91
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Did not don gown before entering room of resident on contact precautions. |
| Director of Nursing | Director of Nursing | Interviewed multiple times regarding deficiencies and policy noncompliance. |
| Licensed Vocational Nurse 1 | Licensed Vocational Nurse | Provided information about Resident 44's feeding orders. |
| Licensed Vocational Nurse 2 | Licensed Vocational Nurse | Observed medication tablets improperly disposed. |
| Registered Nurse 1 | Registered Nurse | Confirmed expired medication and improper disposal of medication tablets. |
| Infection Preventionist | Infection Preventionist | Provided information on infection control practices and deficiencies. |
Inspection Report
Deficiencies: 1
Date: Sep 26, 2024
Visit Reason
The inspection was conducted to assess compliance with medication storage policies and procedures, specifically to ensure drugs and biologicals were properly labeled and stored in locked compartments according to professional standards.
Findings
The facility failed to ensure medications were properly stored as one resident was observed to have medications stored unlocked at his bedside, which posed a potential risk for drug abuse and ingestion of unsanitary drugs. The Director of Nursing acknowledged the facility did not follow its policy requiring medications to be stored in locked compartments under proper temperature.
Deficiencies (1)
Medications (Genvoya and Ozempic) were stored unlocked at Resident 3's bedside, contrary to facility policy requiring locked storage.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse | LVN 1 | Interviewed regarding Resident 3 keeping medications at bedside |
| Director of Nursing | DON | Interviewed regarding medication storage policy and Resident 3's medication storage |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 26, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction related to a nursing home survey conducted to assess compliance with professional standards of care.
Findings
The facility failed to ensure one of four sampled residents received treatment and care according to physician's orders, specifically failing to cover a surgical site with a dry dressing as ordered, which had the potential to delay wound healing.
Deficiencies (1)
Failure to cover the surgical site with dry dressing per physician's order for Resident 1.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Wound Treatment Nurse (WTN 2) | Interviewed regarding failure to cover surgical site during dressing change. | |
| Director of Nurse (DON) | Interviewed regarding expectations for nursing staff to follow physician's orders. |
Inspection Report
Deficiencies: 1
Date: Jun 5, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care planning requirements, specifically regarding the development and implementation of a comprehensive person-centered care plan for a resident who tested positive for an illicit drug.
Findings
The facility failed to provide a comprehensive person-centered care plan for one resident with a history of illicit drug use, which had the potential to place the resident's health and safety at risk. Interviews and record reviews confirmed the absence of a care plan to monitor and treat the resident's condition, despite facility policies requiring such plans.
Deficiencies (1)
Failure to develop and implement a complete care plan that meets all the resident's needs, with measurable timetables and actions.
Report Facts
Residents Affected: 4
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Vocational Nurse | Interviewed regarding lack of information about resident's illicit drug condition | |
| Director of Nursing | Interviewed regarding absence of care plan and facility policies |
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Feb 22, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with care standards related to treatment and notification procedures following a significant weight loss and foot discoloration in a resident.
Findings
The facility failed to follow its policy and procedure for change of condition reporting related to weight loss and failed to notify the responsible party about left foot discoloration for Resident 1. This resulted in unplanned weight loss and the family being uninformed about the foot discoloration.
Deficiencies (1)
Failure to follow policy and procedure for change of condition for weight loss and failure to notify responsible party of left foot discoloration.
Report Facts
Weight loss percentage: 16.19
Weight loss in pounds: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding Resident 1's medical record and care |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 30, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding an alleged physical abuse incident involving a staff member and a resident (Resident 1) reported on November 26, 2023.
Complaint Details
The complaint investigation was substantiated by interviews and record review showing failure to report an alleged physical abuse incident involving Resident 1 by a staff member on November 26, 2023. The police investigated the allegation, but the facility did not follow proper reporting protocols to the state agency.
Findings
The facility failed to timely report the suspected abuse of Resident 1 to the state agency and local ombudsman as required by policy. Interviews revealed that the Director of Nursing and staff did not document or report the incident properly, despite police involvement and an ongoing investigation. The facility's policy requires immediate reporting of abuse allegations, which was not followed.
Deficiencies (1)
Failure to timely report suspected abuse of Resident 1 to the state agency and local ombudsman as required by facility policy and procedure.
Report Facts
Residents Affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| License Vocational Nurse (LVN1) | Interviewed regarding the abuse allegation and failure to document the incident | |
| Director of Nursing (DON) | Interviewed regarding the abuse allegation, investigation, and failure to report to CDPH |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Mar 30, 2023
Visit Reason
An abbreviated survey was conducted on March 30, 2023, to investigate a complaint related to Admission, Transfer & Discharge Rights.
Complaint Details
The visit was complaint-related, investigating a complaint about Admission, Transfer & Discharge Rights. The complaint was substantiated as the facility failed to notify the Ombudsman and did not document an Integrated Discharge Team meeting for the transfer.
Findings
The facility failed to notify the resident, resident representative, and Ombudsman of a facility-initiated transfer for one sampled resident, resulting in the resident being transferred without capacity to understand and make decisions and without being informed of rights regarding transfer/discharge.
Deficiencies (1)
Failure to provide timely notification to the resident, resident representative, and Ombudsman before transfer or discharge, including appeal rights.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding the resident's transfer and lack of documentation for Ombudsman notification and IDT meeting. | |
| Social Services (SSD) | Interviewed regarding the transfer decision and level of care at the receiving facility. |
Inspection Report
Routine
Deficiencies: 9
Date: Oct 28, 2022
Visit Reason
The inspection was conducted to evaluate compliance with federal and state regulations regarding resident rights, care planning, assessment completion, infection control, food safety, and advance directives at Highland Palms Healthcare Center.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' rights to dignified care and communication, timely completion of Minimum Data Set assessments, re-evaluation of PASRR after significant status changes, development of individualized care plans, implementation of smoking care plans, provision of pain management during wound care, maintenance of sanitary kitchen conditions, completion of POLST forms, and adherence to infection control protocols including proper nebulizer equipment storage and hand hygiene.
Deficiencies (9)
Failure to ensure residents' right to dignified existence, self-determination, and communication for Residents 75 and 42.
Failure to complete Minimum Data Set assessments within CMS federal timeframes for Residents 2 and 90.
Failure to re-evaluate PASRR after Significant Change in Status Assessment for Residents 6, 32, and 90.
Failure to develop an individualized comprehensive care plan for pain management for Resident 10.
Failure to implement smoking care plans for Residents 56 and 77, specifically not checking clothes for cigarette burns after smoking.
Failure to provide pain management before, during, and after wound care treatment for Resident 63.
Failure to maintain sanitary kitchen conditions including wet food containers, food crumbs, grime, and unclean ice machine.
Failure to complete Physician Orders for Life-Sustaining Treatment (POLST) forms fully for Residents 22, 34, 56, 58, 71, 77, and 85.
Failure to implement infection prevention and control measures including improper storage of nebulizer equipment for Residents 10 and 25, and failure of licensed nurse to perform hand hygiene during medication administration for Residents 42 and 85.
Report Facts
Residents affected: 91
Deficiencies cited: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Named in pain management deficiency for Resident 63 wound care |
| LVN 4 | Licensed Vocational Nurse | Named in hand hygiene deficiency during medication administration for Residents 42 and 85 |
| RNS 1 | Registered Nurse Supervisor | Named in communication deficiency for Resident 75 |
| DON | Director of Nursing | Interviewed and acknowledged multiple deficiencies including communication, PASRR, care plans, smoking care, pain management, POLST completion, and infection control |
| SSD | Social Services Director | Interviewed regarding communication barriers with Resident 75 |
| MDS 1 | Minimum Data Set Nurse | Interviewed regarding MDS assessment and PASRR deficiencies |
| MDS 2 | Minimum Data Set Nurse | Interviewed regarding care plan deficiency for pain management for Resident 10 |
| DSS | Dietary Services Supervisor | Interviewed regarding kitchen sanitation deficiencies |
| RD | Registered Dietitian | Interviewed regarding kitchen sanitation deficiencies |
| IPN | Infection Preventionist Nurse | Interviewed regarding infection control deficiencies including nebulizer storage and hand hygiene |
Inspection Report
Complaint Investigation
Deficiencies: 12
Date: Mar 7, 2019
Visit Reason
The inspection was conducted based on complaints and allegations regarding failure to inventory and document residents' personal belongings, misappropriation of resident property, inadequate care planning, failure to provide assistance with activities of daily living, inaccurate resident assessments, medication availability issues, improper medication storage, inaccurate documentation, and infection prevention concerns.
Complaint Details
The visit was complaint-related, triggered by allegations of failure to inventory personal belongings, misappropriation of property, inadequate care planning, medication issues, inaccurate documentation, and infection control breaches. The investigation found multiple deficiencies as detailed in the findings.
Findings
The facility failed to ensure proper inventory and documentation of residents' personal belongings, timely investigation and reporting of alleged misappropriation, initiation of individualized care plans, assistance with activities of daily living, accurate resident assessments, availability and proper storage of medications, accurate documentation of meal intake and resident sign-in/out, and adherence to infection prevention protocols. These failures posed risks of loss of personal property, inadequate care, potential medication errors, and infection spread.
Deficiencies (12)
Failure to inventory and document Resident 56's personal belongings upon admission.
Failure to implement abuse policy and investigate misappropriation of Resident 8's property.
Failure to timely report alleged misappropriation of Resident 8's property to appropriate agencies.
Failure to maintain documented evidence of investigation of alleged misappropriation of Resident 8's property.
Failure to initiate individualized comprehensive care plan for Resident 55's anxiety and IV antibiotic use.
Failure to provide assistance with activities of daily living including grooming and hygiene for Residents 18 and 39.
Failure to accurately assess Resident 245 as a smoker, resulting in unsafe smoking practices.
Failure to ensure medication (Bengay Ultra Strength topical cream) was available for Resident 348 as ordered.
Failure to store controlled medication (Lorazepam) in a separately locked compartment within the medication cart.
Failure to ensure accurate documentation of meal percentages for Residents 36 and 8, and inconsistent Physician Orders for Life-Sustaining Treatment for Resident 68.
Failure to ensure Resident 8 signed in upon return from pass and complete Release of Responsibility for Leave of Absence form.
Failure to follow infection prevention practices by leaving uncovered, unlabeled urinals with urine in shared rooms for Residents 7, 76, and 68.
Report Facts
Residents sampled: 44
Weight loss: 19
Meal percentages undocumented: 171
Medication quantity: 28
Medication order delay: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Unable to find documented evidence of inventory of Resident 56's belongings; found unsecured Lorazepam |
| LVN 4 | Licensed Vocational Nurse | Reported Resident 8's missing money to SSD and ADM but did not document; confirmed Lorazepam storage error |
| LVN 5 | Licensed Vocational Nurse | Unable to locate Bengay Ultra Strength topical cream for Resident 348 |
| LVN 8 | Licensed Vocational Nurse | Confirmed Resident 39's poor nail hygiene |
| CNA 3 | Certified Nursing Assistant | Observed Resident 39's poor nail hygiene |
| CNA 6 | Certified Nursing Assistant | Confirmed uncovered, unlabeled urinals for Residents 7 and 76 |
| CNA 7 | Certified Nursing Assistant | Confirmed uncovered, unlabeled urinal for Resident 68 |
| RN 1 | Registered Nurse | Acknowledged discrepancy in Resident 68's POLST and physician orders; unsure about inaccurate meal documentation for Resident 8 |
| RN 2 | Registered Nurse | Acknowledged discrepancy in Resident 68's POLST and physician orders |
| DSD | Director of Staff Development | Acknowledged missing meal documentation, improper infection control practices, and policy noncompliance |
| DON | Director of Nursing | Acknowledged inaccurate smoking assessment, medication availability issues, and incomplete resident sign-in documentation |
| SSD | Social Services Director | Acknowledged failure to investigate and report Resident 8's complaints and discrepancies in POLST documentation |
| LVN 11 | Licensed Vocational Nurse | Notified physician of Resident 55's elevated white blood cells |
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