Inspection Reports for
Mission Palms Post Acute

The facility failed to ensure appropriate monitoring and care of negative pressure wound therapy (wound vac) for one resident, resulting in potential worsening of wounds due to inadequate monitoring and incomplete wound care documentation.

The facility failed to ensure that hospitality aides possessed the qualifications or certifications to provide direct care to residents. Hospitality aides were performing tasks such as taking vitals, which they were not trained or authorized to do, posing a risk of inadequate care and potential medical errors.

The facility failed to ensure that oxygen therapy was properly ordered by a physician for one resident requiring oxygen treatment. Oxygen therapy was administered without a physician's order from admission until September 12, 2022, posing potential risk to the resident.

The complaint investigation found that the facility did not report an allegation of sexual abuse made by Resident #2. The resident initially alleged abuse but later denied the statements. The facility's Director of Nursing stated they investigate immediately before reporting and did not report because they did not know what the patient was alleging.

The facility failed to report an allegation of sexual abuse made by Resident #2 to the State Agency. Interviews and documentation revealed that the resident made statements alleging sexual assault, but the facility staff did not report the allegation, and the resident later denied making the statements during follow-up.

The facility was found deficient in multiple areas including failure to protect resident privacy during medication administration, inadequate environmental safety leading to a resident fall and fracture, improper catheter care resulting in urinary tract infections, administration of pain medication outside prescribed parameters, failure to provide dental services, and lapses in infection prevention practices such as hand hygiene during food handling.

The facility was found deficient in multiple areas including resident privacy during medication administration, environmental safety hazards leading to resident falls, catheter care and prevention of urinary tract infections, medication administration outside prescribed parameters, dental care provision, and infection prevention practices related to hand hygiene during food handling.

The complaint investigation found that on May 4, 2023, a licensed practical nurse administered insulin to the wrong resident due to distraction. The nurse immediately reported the error, and the resident's blood sugar levels were monitored without adverse effects. The nurse was counseled on minimizing distractions during medication administration. No further disciplinary actions were taken.

The facility failed to ensure that one resident was not administered an unnecessary medication, specifically 50 units of Glargine insulin without a physician order. The medication error was acknowledged by the responsible licensed practical nurse, who was counseled to minimize distractions during medication administration.

The complaint alleged that a temporary nurse aide verbally abused resident #92 using racial slurs and inappropriate language. The facility investigation was inconclusive, but interviews with residents and staff confirmed verbal abuse occurred. The temporary nurse aide was terminated.

The facility failed to prevent verbal abuse of resident #92 by a temporary nurse aide. Additionally, the facility failed to provide restorative nursing services as ordered for resident #57, resulting in inconsistent care.

The facility was found deficient in multiple areas including failure to ensure residents' dignity by knocking before entering rooms, lack of resident participation in care planning and discharge, unsafe hot water temperatures, failure to provide therapeutic diets as ordered, improper midline catheter care, and failure to implement an antibiotic stewardship program.