Citations (last 4 years)
Citations (over 4 years)
13.8 citations/year
Citations are regulatory findings recorded during state inspections.
245% worse than California average
California average: 4 citations/yearCitations per year
24
18
12
6
0
Inspection Report
Complaint Investigation
Citations: 1
Date: Mar 19, 2025
Visit Reason
The inspection was conducted in response to a complaint alleging that a CNA forced a resident to walk without using a wheelchair or walking aids on specific dates.
Complaint Details
The complaint was substantiated. Family Member 2 alleged CNA 2 forced Resident 1 to walk without using a wheelchair or walking aids on 3/13 and 3/14/25. Interviews with CNA 2 and Family Member 1 confirmed the resident was unstable and almost fell while ambulating. The resident was not cleared to ambulate by physical therapy.
Findings
The facility failed to ensure that 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 the resident was unstable while ambulating and was not cleared to ambulate by physical therapy.
Citations (1)
F 0689: The facility failed to ensure Resident 1 was provided with two-person assistance for transfers, contrary to the care plan. This failure had the potential to place the resident at risk for serious injuries.
Report Facts
Date of complaint receipt: Mar 17, 2025
Date of medical record review initiation: Mar 18, 2025
Date of Fall Risk Screen: Mar 7, 2025
Date of care plan problem: Mar 8, 2025
Date of Nurse Weekly Progress Note: Mar 12, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA | CNA 2 interviewed regarding assistance to Resident 1 | |
| Director of Nursing | DON interviewed and acknowledged findings |
Inspection Report
Routine
Citations: 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.
Citations (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
Citations: 1
Date: Aug 27, 2024
Visit Reason
The inspection was conducted following a complaint alleging physical abuse of a resident by a facility staff member.
Complaint Details
The complaint was substantiated. Resident 1 reported being slapped by a male CNA on 8/21/24, resulting in a slight redness on the right cheek. Interviews with staff and the resident confirmed the incident. The CNA admitted to the physical abuse and was terminated.
Findings
The facility failed to protect a resident from physical abuse by a CNA who slapped the resident on the face, causing redness. The CNA admitted to the action and was terminated; the resident expressed fear and planned to transfer due to feeling unsafe.
Citations (1)
F 0600: The facility failed to protect residents from all types of abuse, including physical abuse. One resident was slapped by a CNA, resulting in redness and psychological distress.
Report Facts
Residents Affected: 1
Dates of incident and investigation: Incident occurred on 2024-08-21; investigation and interviews conducted through 2024-08-27.
Disciplinary actions: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 1 | Certified Nursing Assistant | Admitted to slapping Resident 1 and was terminated for physical abuse. |
| RN 1 | Registered Nurse | Conducted assessments and interviews related to the abuse incident. |
| DSD | Director of Staff Development | Conducted interviews and verified CNA 1's admission and termination. |
| Administrator | Facility Administrator | Conducted telephone interview with CNA 1 and confirmed inappropriate behavior. |
Inspection Report
Complaint Investigation
Citations: 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.
Citations (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
Annual Inspection
Citations: 2
Date: Jan 24, 2024
Visit Reason
The inspection was conducted as a routine annual survey to assess compliance with regulatory requirements and facility policies.
Findings
The facility failed to ensure the call light was within reach for one resident, potentially impacting timely care. Additionally, the facility did not promptly assess or notify the physician and responsible party regarding a significant change in condition for another resident, risking inadequate care.
Citations (2)
F 0558: The facility failed to ensure the call light was within reach for Resident 2, which could prevent timely communication with staff.
F 0684: The facility failed to promptly assess and notify the physician and responsible party of a change in condition for Resident 1, risking inadequate care and adverse complications.
Report Facts
Date of survey completion: Jan 24, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 2 | Interviewed regarding call light placement for Resident 2 | |
| RN 1 | Interviewed regarding call light placement for Resident 2 | |
| Administrator | Interviewed and verified findings | |
| DON | Interviewed and verified findings | |
| LVN 1 | Interviewed regarding failure to promptly assess and notify for Resident 1 | |
| RN 2 | Interviewed regarding facility's COC protocol and Resident 1's transfer |
Inspection Report
Routine
Citations: 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.
Citations (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
Citations: 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.
Citations (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 |
Inspection Report
Citations: 12
Date: Dec 6, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, dietary services, infection control, and hospice coordination at Mission Palms Healthcare Center.
Findings
The facility was found deficient in multiple areas including failure to maintain advance directives in medical records, failure to follow physician orders for resident care and safety, inaccurate monitoring of psychotropic medication effects, improper dietary practices, inadequate food safety and storage, lack of coordination with hospice services, and failure to implement an effective antibiotic stewardship program.
Citations (12)
F 0578: The facility failed to maintain copies of residents' advance directives in medical records for three residents, risking that their healthcare decisions may not be honored.
F 0684: The facility failed to apply a physician-ordered knee immobilizer to a resident post-surgery, risking improper knee extension maintenance.
F 0686: The facility failed to ensure heel protectors were applied as ordered to a resident with pressure ulcers, risking delayed healing.
F 0689: The facility failed to implement a physician-ordered sensor pad alarm for a resident at risk of falls, instead using a less effective Tab alarm.
F 0693: The facility failed to ensure a resident received the full prescribed amount of enteral feeding and did not notify the physician of the shortfall.
F 0755: The facility failed to properly supervise administration of an inhaler medication, resulting in incorrect inhalation technique and swallowing of rinse water.
F 0758: The facility failed to ensure four residents were free from unnecessary psychotropic medications and failed to accurately monitor related behaviors and orthostatic blood pressure.
F 0803: The facility failed to follow physicians' diet orders for multiple residents, including serving prohibited fruits and not preparing portion sizes in advance.
F 0804: The facility failed to maintain the nutritive value of pureed food by preparing it more than two hours before meal service and holding it in a heated oven.
F 0812: The facility failed to store employee food properly, maintain kitchen equipment and utensils in good repair, and separate chemical products from food items.
F 0849: The facility failed to designate an interdisciplinary team member responsible for coordinating hospice care with hospice agencies for two residents.
F 0881: The facility failed to implement an effective Antibiotic Stewardship Program and did not address inappropriate antibiotic use in infection control meetings.
Report Facts
Residents sampled: 18
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 16
Residents affected: 21
Residents affected: 2
Antibiotic use incidents: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LVN 1 | Licensed Vocational Nurse | Observed improperly supervising inhaler administration to Resident 35 |
| RN 1 | Registered Nurse | Verified orthostatic blood pressure monitoring deficiencies for Resident 42 and Resident 11 |
| RN 2 | Registered Nurse | Interviewed regarding sensor pad alarm use for Resident 37 |
| DSS | Dietary Services Supervisor | Verified dietary violations and food storage issues |
| RD | Registered Dietitian | Verified dietary portion size and food preparation timing issues |
| IP | Infection Preventionist | Discussed antibiotic stewardship program deficiencies |
| DSD | Director of Staff Development | Discussed antibiotic stewardship program deficiencies |
| SSD | Social Services Director | Verified missing advance directives and hospice coordination issues |
| DON | Director of Nursing | Verified hospice coordination and dietary documentation issues |
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