Deficiencies (last 4 years)
Deficiencies (over 4 years)
10.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
158% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 19, 2025
Visit Reason
The inspection was conducted following a complaint received on 3/17/25 alleging that a CNA forced Resident 1 to walk without using a wheelchair or walking aids on 3/13 and 3/14/25.
Complaint Details
Complaint received from Family Member 2 alleging CNA 2 forced Resident 1 to walk without a wheelchair or walking aids on 3/13 and 3/14/25. The complaint was substantiated by interviews and medical record review.
Findings
The facility failed to ensure Resident 1 was provided with two-person assistance for transfers as required by the care plan, placing the resident at risk for serious injuries. Interviews and medical record reviews confirmed that Resident 1 was unstable while ambulating and was not cleared to ambulate by physical therapy.
Deficiencies (1)
Failure to ensure Resident 1 was provided with two-person assistance for transfers, contrary to care plan requirements.
Report Facts
Residents Affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 2 | Certified Nursing Assistant | Named in complaint and interview regarding assistance provided to Resident 1 |
| Family Member 1 | Interviewed regarding Resident 1's ambulation and instability | |
| Family Member 2 | Filed complaint alleging improper assistance to Resident 1 | |
| DON | Director of Nursing | Interviewed and acknowledged findings related to Resident 1 |
Inspection Report
Routine
Deficiencies: 13
Date: Feb 7, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to medication self-administration, fall management, hydration, respiratory care, medication storage, nutrition, food safety, infection control, and antibiotic use.
Findings
The facility was found deficient in multiple areas including failure to ensure safe self-administration of medications, incomplete post-fall neurological assessments, inadequate fall risk monitoring, inaccurate fluid intake monitoring, improper respiratory care including incorrect oxygen administration, unsafe medication storage, failure to follow menus for pureed diets, unsanitary kitchen practices, inadequate handling of foods brought from outside, incomplete infection surveillance and control practices, and failure to monitor antibiotic use according to McGeer's criteria.
Deficiencies (13)
Failed to ensure one resident was safe to self-administer medications found at bedside without assessment or physician orders.
Failed to complete accurate post-fall neurological assessments for two residents.
Failed to implement fall care plan interventions and complete fall risk monitoring documentation for one resident.
Failed to maintain acceptable fluid intake parameters and accurate documentation for one resident with fluid restriction.
Failed to provide appropriate respiratory care including correct oxygen rates and timely nebulizer equipment changes for six residents.
Failed to ensure residents on anticoagulant medications were adequately monitored for signs and symptoms of bleeding.
Failed to ensure accurate monitoring and documentation of psychotropic medication use and meal intake for one resident.
Failed to ensure safe storage of medications and supplies including unlocked medication carts, improper storage of disinfectants, and medications at bedside.
Failed to follow menus for pureed diets including incorrect vegetable mix and missing sauce on pureed beef.
Failed to maintain sanitary kitchen conditions including improper hand hygiene, rusty equipment, unclean utensils, improper storage of personal items, uncalibrated thermometers, and improper sanitizing procedures.
Failed to ensure safe handling and storage of foods brought in by residents' families or visitors.
Failed to maintain infection control program including lack of receptacle for used gowns, inaccurate infection surveillance logs, improper storage of nasal cannula, unclean medication carts, and failure to follow Enhanced Barrier Precautions for a resident with ESBL infection.
Failed to implement a program that monitors antibiotic use including incomplete McGeer's Criteria for Infection Surveillance Checklist for one resident.
Report Facts
Residents on pureed diet: 17
Fluid intake limits: 1000
Medication administration times: 2
Oxygen flow rates: 2
Sanitizer solution checks: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 3 | Registered Nurse | Verified lack of monitoring for signs and symptoms of bleeding for Resident 39 |
| LVN 2 | Licensed Vocational Nurse | Verified medication and oxygen administration deficiencies and fall risk monitoring issues |
| DON | Director of Nursing | Acknowledged multiple findings including fall risk monitoring, oxygen administration, and infection control |
| IP | Infection Preventionist | Interviewed regarding infection surveillance and control program deficiencies |
| DSS | Dietary Services Supervisor | Verified kitchen sanitation and food handling deficiencies |
| LVN 5 | Licensed Vocational Nurse | Observed oxygen administration and medication cart cleanliness issues |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 27, 2024
Visit Reason
The inspection was conducted due to a complaint alleging physical abuse of a resident by facility staff.
Complaint Details
The complaint investigation found that Resident 1 was slapped on the face by CNA 1 on 8/21/24, resulting in redness and psychological harm. Interviews with Resident 1, nursing staff, and supervisors confirmed the incident. CNA 1 admitted to the physical abuse and was terminated on 8/21/24.
Findings
The facility failed to protect a resident from physical abuse by a CNA who slapped the resident on the face, causing redness and psychological distress. The CNA admitted to the abuse and was terminated.
Deficiencies (1)
Failure to protect the resident's rights to be free from physical abuse by facility staff.
Report Facts
Residents Affected: 3
Disciplinary actions: 2
Termination date: Aug 21, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Admitted to slapping Resident 1; subject of abuse finding and termination |
| RN 1 | Registered Nurse | Interviewed Resident 1 and observed redness on the resident's cheek |
| SSD | Staff Supervisor Director | Interviewed Resident 1 and CNA 1; verified abuse and termination |
| DSD | Director of Staff Development | Conducted interviews with CNA 1 and verified admission of abuse |
| Administrator | Facility Administrator | Interviewed CNA 1 and confirmed inappropriate behavior and termination |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 24, 2024
Visit Reason
The inspection was conducted based on complaints regarding the facility's failure to ensure call lights were within reach for residents and failure to promptly assess and notify the physician and responsible party after a change in condition (COC) was identified for sampled residents.
Complaint Details
The complaint investigation found substantiated failures related to call light accessibility for Resident 2 and delayed assessment and notification for Resident 1 after a change in condition.
Findings
The facility failed to ensure the call light was within reach for Resident 2, potentially preventing timely care. Additionally, the facility failed to promptly assess and notify the physician and responsible party for Resident 1 after a significant change in condition, risking inadequate care and adverse complications.
Deficiencies (2)
Failed to ensure the call light was within reach for Resident 2.
Failed to promptly assess and notify physician and responsible party after a change in condition for Resident 1.
Report Facts
Residents sampled: 2
Date of survey completion: Jan 24, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 2 | Licensed Vocational Nurse | Verified call light was not within reach for Resident 2. |
| RN 1 | Registered Nurse | Verified call light was not within reach for Resident 2. |
| LVN 1 | Licensed Vocational Nurse | Acknowledged failure to promptly assess and notify physician and family for Resident 1. |
| RN 2 | Registered Nurse | Verified Resident 1's condition and transfer to hospital; confirmed facility's COC protocol. |
| Administrator | Verified findings related to both deficiencies. | |
| DON | Director of Nursing | Verified findings related to both deficiencies. |
Inspection Report
Routine
Deficiencies: 12
Date: Mar 23, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, food preparation, infection control, and medication storage at Mission Palms Healthcare Center.
Findings
The facility was found deficient in multiple areas including failure to ensure informed consent for psychotropic medications, inaccurate resident assessments, incomplete care plans, improper medication administration and storage, failure to follow puree food recipes, unsanitary kitchen conditions, and inadequate infection control practices.
Deficiencies (12)
Failure to ensure one resident was informed and provided education on psychotropic medications prior to signing informed consent.
Failure to accommodate individual needs and preferences when call lights were placed out of reach for two residents.
Failure to ensure accurate completion of MDS assessments for two residents.
Failure to develop a comprehensive, person-centered care plan for one resident's psychotropic medication use.
Failure to provide accurate doses of prescribed vitamin C supplement for one resident.
Failure to ensure comprehensive assessment and management for psychotropic medication use for one resident, including lack of physician assessment and documentation of non-pharmacological interventions.
Medications found unattended and unlocked in nurse's station drawer, including discontinued and expired medications, and improper storage of treatment supplies.
Failure to ensure medications were not left unattended at bedside during administration.
Failure to ensure medications and biologicals were stored in locked compartments and properly disposed of discontinued medications.
Failure to follow puree food recipes during preparation, including omission of margarine and substitution of water for chicken broth.
Failure to maintain sanitary conditions in kitchen including rusty meat slicer, improperly stored cooked food, failure to check beverage temperatures, improper handling of dirty and clean dishes, and inadequate hand hygiene by dietary staff.
Failure to perform hand hygiene before patient contact and after glove use during medication administration.
Report Facts
Residents sampled: 20
Residents affected: 18
Residents affected: 85
Medications found unattended: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 2 | Licensed Vocational Nurse | Interviewed regarding informed consent, medication administration, and medication storage findings |
| RN 1 | Registered Nurse | Interviewed regarding care plans, psychotropic medication policy, and medication storage |
| RN 2 | Registered Nurse | Interviewed regarding medication storage and disposal |
| DON | Director of Nursing | Informed and acknowledged multiple findings |
| MDS Coordinator | Interviewed regarding inaccurate MDS assessments | |
| Medical Director | Interviewed regarding psychotropic medication assessment requirements | |
| Pharmacy Consultant | Interviewed regarding medication disposal procedures | |
| Dietary Aide 1 | Interviewed regarding food temperature checks | |
| Dietary Aide 2 | Observed and interviewed regarding hand hygiene and glove use | |
| DSS | Dietary Services Supervisor | Interviewed regarding kitchen sanitation and food preparation |
Inspection Report
Annual Inspection
Deficiencies: 12
Date: Dec 6, 2019
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements and evaluate the quality of care and services provided at Mission Palms Healthcare Center.
Findings
The facility was found deficient in multiple areas including failure to maintain residents' advance directives in medical records, failure to follow physician orders for treatment and care (e.g., knee immobilizer, pressure ulcer care, fall prevention alarms), inaccurate medication administration and monitoring of psychotropic medications, failure to follow dietary orders and menu preparation, improper food storage and sanitation practices, lack of coordination with hospice services, and failure to implement an effective Antibiotic Stewardship Program.
Deficiencies (12)
Failed to maintain copies of residents' advance directives in medical records for three residents.
Failed to apply left knee immobilizer as ordered for a resident post total knee arthroplasty.
Failed to provide appropriate pressure ulcer care and ensure heel protectors were applied as ordered.
Failed to implement fall prevention interventions including use of sensor pad alarm as ordered.
Failed to ensure accurate administration of enteral feeding per physician's order.
Failed to properly supervise administration of inhaler medication, resulting in improper technique.
Failed to ensure residents were free from unnecessary psychotropic medications and failed to monitor orthostatic blood pressure as ordered.
Failed to follow physicians' dietary orders for no concentrated sweets diets and failed to prepare portion sizes in advance.
Failed to ensure nutritive value of pureed food was conserved when held in heated oven for more than two hours prior to meal service.
Failed to store food and employee personal items properly, maintain kitchen equipment and utensils in good repair, and separate chemical products from food items.
Failed to designate an interdisciplinary team member responsible for coordinating hospice care with hospice agencies for two residents.
Failed to implement an Antibiotic Stewardship Program and address inappropriate antibiotic use in infection control meetings.
Report Facts
Residents sampled: 18
Residents affected: 21
Increase in antibiotic use incidents: 300
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Observed improperly supervising inhaler administration and verified inaccurate medication administration |
| RN 1 | Registered Nurse | Verified orthostatic blood pressure monitoring was not performed as ordered |
| RN 2 | Registered Nurse | Interviewed regarding fall prevention alarm use and confirmed use of incorrect alarm |
| LVN 3 | Licensed Vocational Nurse | Verified orthostatic blood pressure monitoring was not performed for Resident 19 |
| DSS | Dietary Services Supervisor | Verified dietary deficiencies including improper food served and storage issues |
| RD | Registered Dietitian | Verified dietary portion size and food preparation deficiencies |
| IP | Infection Preventionist | Verified failure to implement Antibiotic Stewardship Program |
| DSD | Director of Staff Development | Verified failure to implement Antibiotic Stewardship Program |
| SSD | Social Services Director | Verified missing advance directives and hospice coordination issues |
| DON | Director of Nursing | Verified hospice coordination issues and other findings |
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