Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mission Palms Post Acute during CMS and state inspections, most recent first.
A resident with dementia and significant cognitive impairment was observed by a CNA being subjected to aggressive behavior by a visiting friend during feeding, including flicking the resident’s nose and yelling at the CNA when redirected. The CNA reported the incident to an RN, who in turn reported it to the DON, and the resident’s daughter requested that it be reported to the case worker. The DON and Administrator/Abuse Coordinator acknowledged awareness of the allegation but, after interviewing the resident, decided not to treat it as abuse and did not report it to outside agencies or document it as an abuse allegation or grievance. Review of logs and records showed no documentation of required reporting or interventions toward the visitor, despite facility policy mandating immediate removal of the visitor, reporting to law enforcement and state/federal agencies, and a comprehensive investigation for any visitor-related abuse allegation.
A resident with dementia, severe to moderate cognitive impairment, and multiple comorbidities had a care plan addressing impaired cognition and communication. A CNA observed the resident’s friend assisting with feeding and flicking the resident’s nose in an aggressive manner, then yelling at the CNA when redirected. The CNA reported the incident to an RN, who reported it to the DON; the DON and the Administrator/Abuse Coordinator decided not to treat the event as abuse and did not report it to state or federal agencies or law enforcement, despite facility policy requiring reporting of such allegations involving visitors. No documentation of reporting or a grievance related to the incident was found in the record or grievance log.
A resident with multiple comorbidities and moderate to severe cognitive impairment was observed by a CNA being flicked on the nose in an aggressive manner by a visiting friend while being assisted with feeding. The CNA intervened, and the visitor became confrontational and yelled at the CNA, who then reported the incident to an RN. The RN documented the event and notified the resident’s daughter, but no abuse allegation was reported, and no formal abuse investigation was documented in the record or grievance log. The DON and Administrator/Abuse Coordinator acknowledged awareness of the incident and decided it did not meet criteria for abuse or neglect, despite facility policy requiring thorough investigation of all abuse allegations, including interviews with the reporter, resident, witnesses, and alleged perpetrator and review of the medical record and circumstances.
Inaccurate Cognitive Assessment Documentation: A resident admitted with a fracture, muscle weakness, and DM2 had documentation showing he was alert and oriented x4/x3 in multiple nursing and provider notes, yet his admission MDS recorded a BIMS score of 00 indicating severe cognitive impairment. Interviews with the resident, his roommate, CNA, RN, MDS Coordinator, SS staff, and DON showed the resident was generally able to converse, follow topics, and tell staff what was going on, while the facility could not explain the mismatch between the BIMS and the rest of the clinical record.
A resident with diabetes and vascular disease did not receive consistent monitoring and documentation of negative pressure wound therapy (NPWT) as ordered. When the wound vac was removed due to a broken seal and peri-wound maceration, required wound care and dressing changes were not completed or documented for several days. Staff interviews confirmed lapses in monitoring and documentation, contrary to physician orders and facility policy.
Nurses and nurse aides lacked the appropriate competencies to provide care that maximizes each resident's well-being, resulting in care that did not fully support residents' highest practicable physical, mental, and psychosocial well-being.
A resident with complex medical conditions received continuous oxygen therapy without a documented physician order for an extended period. Nursing staff initiated and adjusted oxygen therapy in response to low oxygen saturation, but the required physician order was not present in the clinical record, and the care plan did not reflect oxygen therapy during this time.
Failure to Report and Investigate Visitor-Related Abuse Allegation per Facility Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse and neglect policies regarding reporting an allegation of abuse by a visitor to the appropriate agencies. A resident with multiple diagnoses, including vascular dementia, cognitive communication deficit, and severe to moderate cognitive impairment as evidenced by BIMS scores of 7 and 9, was observed by a CNA to be subjected to aggressive behavior by a visiting family friend while being assisted with feeding. The CNA reported that the visitor flicked the resident’s nose in an aggressive manner and, when redirected, turned and yelled at the CNA. The resident’s daughter was notified and requested that the matter be reported to the resident’s case worker. The RN on duty documented the CNA’s report in the electronic health record and stated in interview that she reported the incident to the DON. The DON stated that he went to the facility, interviewed the resident, and discussed the matter with the Abuse Coordinator/Administrator. Both the DON and the Abuse Coordinator acknowledged awareness of the allegation and stated that, based on the resident’s report that she felt safe with staff and the visiting friend, they decided not to treat the event as abuse or neglect and did not report it to outside authorities. There was no documentation in the electronic health record that an allegation of abuse was reported on or after the date of the incident, and no related entry was found in the grievance log. Review of the visitor log confirmed that the alleged perpetrator and her husband visited the resident on the date of the incident, but there was no documentation of any intervention related to the visitor’s behavior or any action taken in response to the allegation. The facility’s written policy on abuse prevention and prohibition required that when an allegation of abuse, neglect, misappropriation, or exploitation involves a visitor, the visitor is to be immediately escorted from the building and the allegation reported to local law enforcement and appropriate state and federal agencies within required timeframes. The policy also required a thorough investigation including interviews with the reporter, the resident, witnesses (including the alleged perpetrator), review of the medical record, and interviews with relevant staff. The documented and reported actions by facility staff did not include required reporting to external agencies or the full investigative steps outlined in the policy.
Failure to Report Allegation of Visitor Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of abuse to the state agency involving a resident with severe cognitive impairment. The resident had multiple diagnoses, including a femoral neck fracture, generalized muscle weakness, dysphagia, difficulty walking, cognitive communication deficit, protein-calorie malnutrition, epilepsy, chronic kidney disease, vascular dementia, depression, and hypertension. Her care plan addressed impaired cognitive function and thought processes related to dementia, with interventions focused on communication at her level of understanding. MDS assessments showed BIMS scores of 7 and 9, indicating severe to moderate cognitive impairment, which affected her decision-making and ability to assess personal safety. On one evening, a CNA observed the resident’s friend assisting with feeding and flicking the resident’s nose in an aggressive manner. The CNA instructed the visitor to stop, after which the visitor approached and yelled at the CNA. The CNA reported the incident to an RN, who documented the event and stated she reported it to the DON. The DON stated he went to the facility, interviewed the resident, and, after discussing the situation with the Abuse Coordinator/Administrator, concluded there were no aspects of abuse or neglect and did not report the allegation to the appropriate authorities. The Abuse Coordinator confirmed awareness of the allegation and agreed with the decision not to report. Review of the electronic health record and grievance log showed no evidence that the allegation was reported or that a grievance was filed, despite a facility policy requiring immediate removal of visitors involved in such allegations and reporting to law enforcement and applicable federal or state agencies within required timeframes.
Failure to Investigate and Report Allegation of Visitor Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse involving a resident when staff observed a visitor flicking the resident on the nose in an aggressive manner while assisting with feeding. The resident had multiple medical conditions, including a femur fracture, generalized muscle weakness, dysphagia, difficulty walking, cognitive communication deficit, protein-calorie malnutrition, epilepsy, chronic kidney disease, vascular dementia, depression, and hypertension. Care plans and MDS assessments documented moderate to severe cognitive impairment, which could affect the resident’s decision-making and ability to assess personal safety. On the date of the incident, a CNA observed the resident’s friend flicking the resident’s nose and intervened by instructing the visitor not to continue the behavior. The visitor then became confrontational and yelled at the CNA. The CNA reported the incident to an RN, who documented the event in the electronic health record and notified the resident’s daughter, who requested that the matter be reported to the resident’s case worker. However, there was no documentation in the electronic health record or the facility’s grievance log that an allegation of abuse was reported or that a formal abuse investigation was initiated. Interviews with staff confirmed that the CNA reported the incident to the RN, and the RN reported it to the DON. The DON stated that he went to the facility, spoke with the resident, and, after discussing the situation with the Abuse Coordinator/Administrator, decided the incident did not meet criteria for abuse or neglect and did not report it to the state agency. The Abuse Coordinator confirmed awareness of the allegation and the decision not to report. This response did not follow the facility’s abuse prevention policy, which required that all allegations of abuse and neglect be thoroughly investigated, including interviews with the reporter, the resident, witnesses, and the alleged perpetrator, as well as review of the medical record and relevant circumstances.
Inaccurate Cognitive Assessment Documentation
Penalty
Summary
The facility failed to ensure that Resident #108’s assessments accurately reflected his status. Resident #108 was admitted with diagnoses including a right humerus fracture, muscle weakness, and type 2 diabetes. An admission assessment completed on February 4, 2026 documented that he was alert and oriented to person, place, time, and situation, and the admission note also stated that he arrived alert and oriented x4. However, the admission MDS dated the same period recorded a BIMS score of 00, indicating severe cognitive impairment. Additional clinical documentation continued to describe the resident as cognitively intact. A NP/PA progress note on February 5, 2026 stated that he was alert and oriented x3, and a daily skilled note on February 6, 2026 also described him as alert and oriented x3 and noted no active symptoms or treatments affecting consciousness, cognition, sleep, mood, or behavior. The chart did not contain progress notes describing cognitive status, confusion, or inability to participate in assessments due to altered level of consciousness. The care plan initiated on February 4 and revised on February 10 addressed risk for impaired cognitive function/dementia or impaired thought process related to new admission, with interventions such as identifying oneself, facing the resident when speaking, making eye contact, and reducing distractions. During interviews, Resident #108 was observed to be able to stay on topic and did not show signs of confusion. His roommate reported having conversations with him on a variety of topics and not seeing confusion. CNA #123 and RN #196 both described him as alert, able to follow conversations, and able to tell staff what was going on. The MDS Coordinator and Social Services staff explained that the BIMS was completed as a snapshot of cognition, but the Social Services staff member stated he scored a 00 because the resident was not able to be engaged when assessed. The DON reviewed the record and stated he had no reasonable explanation for why the BIMS was 00 when several progress notes indicated the resident was alert and oriented.
Failure to Monitor and Document Wound Vac Therapy
Penalty
Summary
The facility failed to ensure appropriate monitoring and documentation of negative pressure wound therapy (NPWT) for a resident with a history of Parkinson's disease, type 2 diabetes mellitus, and peripheral vascular disease, who was at risk for pressure ulcers and had existing wounds on the left lateral foot and ankle. Physician orders required wound vac monitoring every shift for functioning and placement, with specific instructions to follow if the wound vac malfunctioned or was off for more than two hours, including cleansing the wound and changing the dressing every 12 hours until the wound vac was replaced. However, review of clinical records revealed that wound vac monitoring was not documented as completed for the overnight shift on one occasion, and when the wound vac was removed due to a broken seal and peri-wound maceration, the required wound cleansing and dressing changes were not completed on multiple subsequent days. The resident reported discomfort and worsening of the wound after the wound vac was applied, and interviews with staff confirmed that the wound vac was removed due to a leak in the seal. The Director of Nursing stated that it was expected for nurses to monitor the wound vac every shift and notify the physician of any issues, but acknowledged that monitoring was not documented as completed. Facility policy required that all wound treatments be administered and documented as per physician orders. The failure to monitor and document wound vac therapy and to perform required wound care when the vac was off constituted the deficiency.
Lack of Staff Competency in Resident Care
Penalty
Summary
Nurses and nurse aides did not demonstrate the necessary competencies to provide care that maximizes each resident's well-being. The deficiency was identified due to a lack of evidence that staff possessed or applied the required skills and knowledge to meet the individualized needs of all residents. This failure resulted in care that did not fully support the highest practicable physical, mental, and psychosocial well-being of residents, as required.
Oxygen Therapy Administered Without Physician Order
Penalty
Summary
A deficiency was identified when a resident with multiple diagnoses, including cirrhosis of the liver, ascites, type 2 diabetes mellitus, and depression, received oxygen therapy without a physician's order. Clinical record review showed that although the resident had orders to monitor temperature and oxygen saturation, there was no documented physician order for oxygen therapy from admission until several months later. Nursing notes indicated the resident was on continuous oxygen at 2 liters, with documented episodes of low oxygen saturation and subsequent increases in oxygen flow, but these interventions were not supported by a physician's order in the medical record. The care plan also did not reflect oxygen therapy during this period. Interviews with nursing staff revealed that it was common practice to initiate oxygen therapy or adjust oxygen flow in response to low oxygen saturation, and then notify the charge nurse and physician to obtain an order. However, in this case, the facility was unable to provide evidence of a standing or timely physician order for oxygen therapy during the period in question. Facility policy required that oxygen therapy be administered as ordered by a physician or as an emergency measure until an order could be obtained, but documentation did not show that an order was obtained in a timely manner.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mesa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mi Casa Nursing Center | 0.6 mi | ★★★★★ | 4 | 0 |
| Springdale Village Post Acute | 1.2 mi | ★★★★★ | 1 | 0 |
| Desert Blossom Health & Rehab Center | 1.2 mi | ★★★★★ | 1 | 0 |
| Advanced Healthcare Of Mesa | 1.2 mi | ★★★★★ | 3 | 0 |
| Alta Mesa Health And Rehabilitation | 1.4 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.