Average — CMS composite of the measures below.
The next survey window likely opens around March 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 Healthcare Center during CMS and state inspections, most recent first.
Incomplete and inaccurate documentation was found for two residents. One resident’s neuro checks after a fall were not completed for the full ordered 72-hour period, and another resident’s record included a PA progress note dated after the resident had already been transferred to the hospital. The record also showed late-entry documentation for a post-fall evaluation and an IDT note that was entered days after the events, and the DON verified the documentation was not completed timely.
Incomplete informed consents for psychotropic medications: Multiple residents received psychotropic meds including quetiapine, mirtazapine, lorazepam, valproic acid, and zolpidem tartrate, but the consent forms did not document the indication for use or the manifested behaviors tied to the orders. Records showed the meds were ordered for conditions such as psychosis, depression with poor oral intake, anxiety with physical restlessness, agitation, and insomnia, and RNs, the MDS Coordinator, the Administrator, and the DON verified the omissions.
Respiratory care was not provided as ordered for two residents. One resident’s Yankauer suction tubing was found in the bedside drawer and was not labeled, and an LVN stated she could not verify when it had last been changed. Another resident receiving continuous O2 via nasal cannula was observed with the cannula not properly positioned while the oxygen concentrator was sounding an alarm and displaying a warning symbol; staff verified the issue and replaced the concentrator.
Failure to document required HR checks before giving antihypertensive meds. Three residents had orders for BP meds with hold parameters for SBP and HR, but the MARs showed the meds were given repeatedly without documented HR monitoring before administration. RN verified the findings, and the Administrator and DON were informed.
Kitchen sanitation and food protection deficiencies were observed during survey. Surveyors found heavily marred cutting boards, brownish particles inside the oven, and an unlabeled vegetable oil spread container in the walk-in refrigerator. They also observed red duct tape placed too far inward, allowing two family members without hairnets into the milk-prep area while a Dietary Aide poured milk into open cups; one cup contained a black particle. In addition, a Maintenance Supervisor entered the kitchen without a beard restraint, and a portable fan was blowing toward clean plate lids.
Infection control failures were identified when a staff member’s personal vest was stored in the clean linen area, residents’ personal clothing was transported on a partially covered rack and left exposed, and a laundry aide entered and exited EBP rooms without hand hygiene. The facility also lacked a documented Legionella risk assessment for its water system, and a CNA changed the linen of a resident on EBP without wearing gloves or a gown, despite the resident’s PEG tube-related EBP order and posted precautions.
Call Light Not Within Resident's Reach: A resident was observed seated in a wheelchair with the call light hanging on the opposite side of the bed and out of reach. The resident, who had impaired ROM and needed staff help with ADLs, was seen searching for the call light with the right hand and could not reach it until an Activity Assistant placed it within reach. The facility policy stated call lights should be accessible and within reach.
Failure to Provide Advance Directive Information and Follow-Up: A resident with decision-making capacity stated a desire for help formulating an advance directive, but the medical record did not show that written information was provided or that social services followed up to assist with completion. The SSD confirmed there was no documentation of the required follow-up, and the FM reported receiving no paperwork or information.
Inaccurate meal intake monitoring was found for two residents receiving mirtazapine for depression with poor oral intake. The MAR entries made by licensed nurses did not match CNA task records for documented meal percentages, and RN 2 verified the discrepancies for both residents. The Administrator and DON were informed of the findings.
Failure to Notify Ombudsman of Resident Transfer: A resident was transferred to an acute care hospital for further evaluation due to poor oral intake and generalized weakness, but the facility did not document sending the required transfer/discharge notice to the State LTC Ombudsman. RN verified there was no fax transmittal or other record showing the notification, and the DON confirmed the omission despite the facility's notification system.
A resident had a physician order for an LAL mattress for skin management, but the care plan did not include any problem, goal, or intervention for the mattress with bolster. LVN, RN, and the DON all verified that no care plan had been developed for this equipment.
Care plans were not revised for three residents when their care changed. One resident’s Foley catheter had been discontinued, but the care plan still listed the catheter. Two other residents had APP mattress settings adjusted for comfort, but their care plans were not updated to reflect the changes or include monitoring of effectiveness. Staff, including the DON, confirmed the omissions.
A resident with impaired decision-making capacity and anticoagulation-related bruising risk had right eye redness with discharge and new purplish discoloration on both upper extremities, but the findings were not documented as monitored or reported to the MD and responsible party. Staff observed the eye issue, and an LVN later acknowledged the physician was not notified right away; the IP stated the eye condition was not normal and required immediate reporting.
Improper Use of LAL Mattress for Pressure Injury Care: A resident with an order for an LAL mattress for skin management was observed lying on the mattress with a foam topper placed on top of it. The resident said the topper had been added by family with staff assistance, and an LVN confirmed it was in place and stated it defeated the therapeutic purpose of the LAL mattress. Another LVN stated the mattress would not function effectively with an added topper and noted the resident had a sacrococcyx pressure injury.
A resident received celecoxib for pain when the MAR documented a pain score of 2, but the record did not show any nonpharmacological interventions were offered or provided before the medication was administered. The facility P&P stated that nonpharmacological pain interventions may be used alone or with meds, and an RN confirmed there was no documentation of such interventions before the pain med was given.
A facility failed to ensure nursing staff were competent in recognizing changes in condition and using equipment. An LPN did not report a resident’s right eye redness with discharge to the physician or RP, despite CNA notification and the resident’s significant cognitive impairment. In another case, a treatment nurse used a newly purchased APP mattress but could not explain the settings and had not received training or competency validation before the device was used on a resident.
Improper Storage of Internal and External Medications: Surveyors found internal oral meds, including alendronate sodium and pantoprazole DR, stored in the same storage cube as external rivastigmine transdermal patches in Medication Cart A. LVN and RN staff verified the mixed storage and stated internal and external medications should be stored separately because they are administered by different routes and mixing them could cause medication errors or contamination.
Unsafe storage of food brought in by families or visitors was identified when the walk-in refrigerator used for kitchen items had no designated space for outside food, and an open box of pasteurized eggs and other prep items were stored there. Staff gave conflicting accounts of how outside food was handled: one CNA said families were told to take it home, while an LVN said residents had to eat it immediately or it was discarded after two hours because there was no designated refrigerator.
A resident receiving hospice services had mismatched hospice visit frequencies between the physician orders and the hospice plan of care, and the chart lacked hospice aide visit notes for April. The SSD said LPNs/RNs were responsible for checking orders and hospice visit notes, but the record showed no documentation that the facility reconciled the discrepancy or followed up with the hospice provider about the missing notes.
Glucometer Not Calibrated or Quality Checked The facility failed to ensure a glucometer in Medication Cart A was calibrated and had QC testing documented, despite a P&P requiring nightly control solution testing. The QC log for the cart was blank for the shift in question, and an LVN verified that the 11-7 nurses were responsible for calibration and QC checks for residents requiring blood glucose monitoring.
Hot Water Temperatures in Kitchen Sinks Exceeded Safe Levels: The facility failed to keep hot water at safe levels at a kitchen handwash sink and the two-compartment manual dishwashing sink. Staff observed the water felt abnormally hot, steam was visible, and both sinks measured 151.9 degrees Fahrenheit. The DSS confirmed the findings, and staff reported the water was often very hot.
A resident with a high fall risk and a care plan requiring two-person assistance for transfers was assisted to the bathroom by only one CNA, with a family member present. The resident was unstable and nearly fell during the transfer, and it was later confirmed that the resident was not cleared to ambulate. The DON acknowledged these findings.
The facility failed to provide appropriate respiratory care for six residents, with incorrect oxygen administration and failure to adhere to infection control protocols. Residents received incorrect oxygen rates, and a nebulizer set-up was not changed weekly as required. Staff acknowledged these deficiencies during interviews.
The facility failed to maintain sanitary conditions in the kitchen, with improper hand hygiene and glove use by staff, unclean equipment, and inadequate calibration of thermometers. Personal belongings were improperly stored, and utensils were not air-dried as required. These deficiencies were confirmed through observations and interviews with staff.
The facility failed to maintain effective infection control, with issues such as improper disposal of gowns, inaccurate infection logs, and unsanitary storage of a resident's nasal cannula. Medication carts were not cleaned properly, and a resident with an ESBL infection was not placed under required precautions. Staff acknowledged these deficiencies, indicating lapses in infection control protocols.
A facility failed to complete the McGeer's Criteria for Infection Surveillance Checklist for a resident on antibiotics, risking unnecessary use and resistance. The IP also failed to identify many HAIs in infection logs and incorrectly documented residents with confusion as asymptomatic.
A resident with moderate cognitive impairment was found with several medications at her bedside, which she self-administered without proper assessment or physician's orders. Facility policy requires an assessment for self-administration and secure storage of medications, which was not followed in this case.
Two residents experienced falls, and their post-fall neurological assessments were inaccurately documented, with no interventions recorded for sluggish pupil reactions. The facility's policies for neurological assessments and falls management were not followed, leading to potential delays in care. The deficiencies were acknowledged by the facility's staff and administration.
A facility failed to implement and document necessary fall risk interventions for a resident identified as high risk for falls. The care plan included conducting rounds every two hours, placing a star sticker on the resident's room, and applying a colored arm band, but these were not consistently followed. Interviews with an LVN and the DON confirmed the lack of documentation and the absence of required interventions, putting the resident at risk for further falls and injuries.
A facility failed to adhere to a resident's physician-ordered fluid restriction of 1000 ml per day, resulting in the resident's fluid intake consistently exceeding the prescribed limits. The Intake and Output Records were inaccurate, and staff interviews revealed a lack of understanding and communication regarding the fluid restriction. There was no evidence that the physician was notified or that the resident was monitored for fluid overload.
Two residents in a facility were administered the anticoagulant apixaban without proper monitoring for bleeding signs, as required by the facility's policy. Resident 39, with a care plan for high bleeding risk, lacked documented assessments for bleeding symptoms. Similarly, Resident 84, with acute embolism and thrombosis, was not monitored for bleeding until weeks after starting the medication. Interviews revealed a lack of in-service training for staff on monitoring anticoagulant therapy, and the facility's administration acknowledged these deficiencies.
A facility failed to ensure a resident was free from unnecessary psychotropic medication by inaccurately monitoring meal intake and not completing a monthly behavior summary for mirtazapine use. Discrepancies in documentation between licensed nurses and CNAs were noted, and the medication was administered despite meal intake often being below the required threshold.
The facility failed to ensure safe medication storage, with an unlocked medication cart left unattended and improper storage of medications. A resident had vitamin A&D ointment at their bedside without a physician's order, and eye and rectal medications were stored together in a cart. Staff acknowledged these storage issues.
The facility did not adhere to menu guidelines for pureed diets, resulting in discrepancies in meal preparation. Pureed mixed vegetables lacked cauliflower and tofu present in the regular version, and pureed beef was served without the required sauce. These deviations were confirmed by the DSS, potentially affecting the nutritional adequacy for residents on pureed diets.
The facility failed to ensure safe handling and storage of food brought by family members or visitors, as their policies lacked guidelines for such practices. Interviews revealed that while residents could request kitchen storage for outside food, there was no separate refrigerator, and overnight storage was not permitted. This oversight posed a potential risk of foodborne illnesses to residents.
A resident was physically abused by a CNA who slapped them on the face, resulting in redness on the cheek. The incident was confirmed through interviews and document reviews, revealing the CNA's admission of the act as a reflexive response to being kicked and hit by the resident. The facility's policies on abuse prevention and resident rights were not upheld, leading to the CNA's termination.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two sampled residents. For one resident, the neurological assessment flowsheet initiated after a bed alarm event and fall to the floor mat showed the scheduled assessments were documented through the 1500-2300 shift on 5/12/26, but the record did not show assessments continuing through the full 72-hour monitoring period ending 5/13/26 at 0400 hours. The DON verified that the neurological assessments were not conducted for the full 72 hours. For another resident, the closed record showed the resident was transferred to the acute care hospital after a fall on 5/6/26, yet a Physician Progress Note was documented on 5/13/26 as if the resident had been assessed by the PA while the resident was no longer in the facility. The record also contained a post-fall evaluation entered as a late entry on 5/15/26, although the DON stated the evaluation had been conducted on the morning of 5/5/26 and was not documented in the EHR until 5/15/26. In addition, an IDT note dated 5/12/26 was created as a late entry on 5/15/26, three days after the IDT meeting, and the DON verified it was not completed timely.
Incomplete informed consents for psychotropic medications
Penalty
Summary
The facility failed to ensure that informed consents for psychotropic medications included the indication for use and the manifested behaviors for multiple residents reviewed during the survey. The deficiency involved residents receiving quetiapine, mirtazapine, lorazepam, valproic acid, and zolpidem tartrate, with the consent forms not documenting the reason each medication was prescribed or the behavior being treated. For one resident, physician orders showed quetiapine for psychosis manifested by paranoid delusion and mirtazapine for depression manifested by poor oral intake, but the informed consent forms for both medications did not include the reason for use or the related behavior manifestation. Another resident had an order for mirtazapine for depression manifested by poor oral intake, and the consent form likewise did not include the indication or behavior manifestation. A third resident had an order for lorazepam via GT for anxiety manifested by physical restlessness causing distress, but the consent form did not show the reason for use or the behavior manifestation. Additional records showed a resident with quetiapine ordered for psychosis as manifested by striking out during care, but the consent form did not include the indication or behavior manifestation. Another resident with chronic dementia with agitation received Seroquel for psychosis manifested by striking out and valproic acid as a mood stabilizer for sudden yelling out loud and attention seeking, yet both informed consents failed to include the indication for use and manifested behavior. A final resident had orders for quetiapine for psychosis manifested by visual hallucinations and zolpidem tartrate for insomnia manifested by inability to sleep, and both consent forms lacked the reason for use and behavior manifestation. During interviews, RN 1, RN 2, the MDS Coordinator, the Administrator, and the DON verified the missing information on the consent forms.
Respiratory Care Equipment and Oxygen Delivery Issues
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for two sampled residents. For Resident 83, the medical record showed an order to suction secretions as needed for excessive secretions. During observation, the Yankauer suction tubing was found open, connected to the suction machine, and stored inside the original packaging in the resident’s partially open bedside drawer. Although the tubing was initially observed labeled, the LVN later verified that it was not labeled and stated she could not verify when it had last been changed; she also stated it should have been labeled. For Resident 57, the medical record showed an order for oxygen at 2 liters per minute via nasal cannula continuously for shortness of breath to maintain oxygen saturation above 95%. During multiple observations, the resident was receiving oxygen while an audible alarm sounded from the oxygen concentrator, and the display panel showed a general warning symbol and a phone icon. Later, the nasal cannula was observed not properly positioned in the resident’s nostrils while the concentrator continued to alarm. An LVN verified the cannula was not properly positioned and observed it being placed correctly, and an RN replaced the oxygen concentrator.
Failure to Document Required Heart Rate Checks Before Antihypertensive Administration
Penalty
Summary
The facility failed to ensure that residents' drug regimens were free from unnecessary medications by not documenting required heart rate checks before administering ordered antihypertensive medications. For Resident 57, the physician ordered amlodipine 10 mg in the morning and lisinopril 20 mg daily, both with instructions to hold if systolic blood pressure was less than 110 mmHg and heart rate was less than 60 beats per minute. The MAR showed both medications were administered from 4/1/26 through 4/22/26 at 0900, but there was no documented evidence that licensed nurses monitored the resident's heart rate before giving the medications. For Resident 13, the physician ordered diltiazem 60 mg via GT every eight hours and hydralazine 100 mg via GT every eight hours, each with hold parameters for systolic blood pressure less than 110 mmHg and heart rate less than 60 beats per minute. The MAR showed these medications were administered from 4/1/26 through 4/22/26 at 0600, 1400, and 2200, but there was no documented evidence of heart rate monitoring before administration. For Resident 11, the physician ordered amlodipine besylate 2.5 mg daily with the same hold parameters, and the MAR showed administration from 4/1/26 through 4/22/26 at 0900 without documented heart rate monitoring. RN 2 verified the findings for all three residents, and the Administrator and DON were informed and acknowledged the findings.
Kitchen Sanitation and Food Protection Deficiencies
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and food storage areas during survey observations and interviews. On an initial tour of the kitchen, surveyors observed two heavily marred cutting boards with white discoloration, brownish particles inside the oven, and a vegetable oil spread container in the walk-in refrigerator that was not labeled with an open date. The surveyor and DSS verified these findings, including that the oven should have been clean and the plastic container should have been labeled with an open date. During a later kitchen observation, red duct tape marking the milk-serving preparation area was positioned too far inward, allowing two family members without hairnets to enter the area while Dietary Aide 2 was pouring milk into open plastic cups. One cup of milk was observed uncovered with a black particle floating on top, and Dietary Aide 2 verified that the milk was to be served to residents and that the particle was present. In a separate observation, the Maintenance Supervisor was seen walking past the kitchen refrigerators with a chin beard and without a beard restraint. Surveyors also observed a portable fan blowing air toward a rack of clean, dry plate lids, with particles on the fan grill.
Infection Control Failures in Linen Handling, Water Risk Assessment, and EBP Practices
Penalty
Summary
The facility failed to maintain infection control practices when a staff member’s personal item was found in the clean linen sorting area. During observation in the laundry room, a black vest was hanging on a clothing hook in the clean linen area and was touching clean sorting gowns. Laundry Aide 1 confirmed the gowns were clean and stated the vest belonged to a staff member who was not present to remove it. The Housekeeping Supervisor later verified the vest should not have been in the clean linen area and stated staff had an employee lounge where personal items could be stored. The facility also did not complete a documented facility-wide risk assessment for Legionella and other opportunistic waterborne pathogens. The facility had a Legionella: Water Management Program policy and a water system flow diagram showing the receiving water, cold-water distribution, heating components, hot-water distribution, and sanitary sewer system, but the records reviewed did not show a comprehensive risk assessment identifying where pathogens could grow and spread within the water system. The IP and Maintenance Supervisor were unable to produce documentation of such an assessment, the Maintenance Supervisor verified the facility did not have documentation showing how hazardous areas within the water system were identified, and the IP Consultant also verified that no risk assessment had been completed other than the waterflow map. The Administrator and DON were informed and acknowledged these findings. The facility further failed to protect residents’ clean personal clothing from dust and contamination during transport and failed to ensure hand hygiene and PPE use during EBP care. Multiple residents’ personal clothing items were observed hanging on a partially covered mobile rack being pushed through the hallway and later parked near the nurses’ station, leaving the clothing visibly exposed. Laundry Aide 2 verified the rack was only partially covered and stated it was left uncovered for easier viewing of labels and room numbers. Laundry Aide 2 was also observed entering and leaving two rooms on EBP without performing hand hygiene, despite orange precaution signs posted outside the rooms instructing staff to clean their hands when entering and leaving. The facility also failed to ensure CNA 3 wore PPE when changing the linen for a resident on EBP. Resident 13 had a physician’s order for EBP due to the presence of a PEG tube. During observation, CNA 3 was seen changing the resident’s bed linen without gloves or a gown, even though an EBP sign outside the room indicated gloves and a gown were required for high-contact care activities such as changing linen. CNA 3 confirmed she did not wear PPE because the resident was not in the room. The IP later stated staff must perform hand hygiene when entering and leaving EBP rooms and that CNAs should wear gown and gloves when changing linen for residents on EBP.
Call Light Not Within Resident's Reach
Penalty
Summary
The facility failed to provide a reasonable accommodation for Resident 108 by not ensuring the resident's call light was within reach. During observation, Resident 108 was seated in a wheelchair on the right side of the bed, while the call light button was hanging on the bed on the left side and was not reachable from the resident's position. The resident was observed searching for the call light with the right hand and was unable to reach it. The Activity Assistant verified that the call light was not within reach and placed it within the resident's reach. Resident 108 stated she was unable to move the left arm and required staff assistance for activities of daily living. The resident also reported using the call light button to request staff assistance. Record review showed impaired ROM in both lower extremities and impaired ROM in the left upper extremity. The H&P noted the resident was able to make medical decisions and needs known. The facility's policy stated call lights should be accessible and within reach of residents, including when in bed or other sleeping accommodations.
Failure to Provide Advance Directive Information and Follow-Up
Penalty
Summary
The facility failed to provide written information and follow-up assistance regarding the formulation of an advance directive for Resident 95. Resident 95 was admitted to the facility and, according to the H&P dated 3/28/26, had the capacity to understand and make decisions. The Advance Directives Acknowledgment dated 3/29/26 showed the resident had capacity and wanted assistance to formulate an advance directive. Review of the medical record did not show documented evidence that the facility provided written information or followed up to assist the resident in completing an advance directive. During interview and concurrent record review, the SSD stated the admission nurse completed the acknowledgment form and social services was responsible for follow-up, including providing written information, documenting what was provided, and following up within 1-2 weeks. The SSD stated it had been three weeks since admission and was unsure whether follow-up had occurred, but confirmed there was no documentation showing information was provided or assistance was offered. The resident's FM stated she did not receive any paperwork or information regarding how to formulate an advance directive for Resident 95.
Inaccurate Meal Intake Monitoring for Mirtazapine Use
Penalty
Summary
The facility failed to ensure two sampled residents were free from unnecessary psychotropic medication by not accurately monitoring meal intake related to mirtazapine use. The facility's policy stated that the effects of psychotropic medications on a resident's physical, mental, and psychosocial well-being were to be evaluated on an ongoing basis in accordance with nurse assessments and medication monitoring parameters. Resident 11 had an order for mirtazapine 15 mg at bedtime for depression manifested by poor oral intake less than 76%, along with an order to monitor and record meal percentages for breakfast, lunch, and dinner for mirtazapine use. Review of the April 2026 MAR showed mirtazapine was administered daily, but the MAR documented meal intake that did not match CNA documentation for dinner on 4/8 and 4/16 and for lunch on 4/19. RN 2 stated the licensed nurses documented meal intake in the MAR based on information from CNAs, and verified the MAR entries did not match the CNA task records. Resident 2 had orders to monitor oral intake less than 76% and refusal of meals during mealtime for mirtazapine use, and to administer mirtazapine 15 mg at bedtime for depression manifested by poor oral intake less than 76%. The April 2026 MAR showed mirtazapine was administered daily, but the documented meal intake in the MAR did not match CNA documentation for dinner on 4/8 and 4/10 and for lunch on 4/19. RN 2 again verified that the meal intake documentation entered by licensed nurses did not match the CNA task documentation. On 4/23/26, the Administrator and DON were informed and acknowledged the findings.
Failure to Notify Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to provide a copy of the transfer/discharge notification to the Office of the State Long-Term Care Ombudsman for Resident 105 when the resident was transferred to an acute care hospital. Facility policy titled "Transfer or Discharge Notice" stated that the resident and/or representative would be notified in writing of the reason for transfer or discharge, the effective date, the destination, appeal rights, bed-hold policy, and the Ombudsman contact information, and that a copy of the notice would be sent to the Ombudsman. Resident 105 was admitted to the facility and later transferred to the acute care hospital for further evaluation due to poor oral intake and generalized weakness. Review of the medical record showed the physician order for transfer, but there was no documented evidence that the Ombudsman was notified of the transfer. During interviews, RN 1 stated the documentation should have been in a binder with other fax transmittals, but verified that no record showed the Ombudsman was notified. The DON also verified the finding and stated the facility had a system in place to notify the Ombudsman but missed that one.
Failure to Care Plan for LAL Mattress With Bolster
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for Resident 5. Review of the facility policy on Comprehensive Assessments and the Care Delivery Process showed that comprehensive assessments are used to develop, review, and revise the resident's comprehensive care plan. Medical record review showed Resident 5 had a physician's order dated 4/3/26 for a low air loss (LAL) mattress in bed every shift for skin management. Review of Resident 5's plan of care did not show any care plan problem, goal, or intervention addressing the use of the LAL mattress with bolster. During an interview and concurrent record review, LVN 2 verified that no care plan had been developed for this equipment. RN 2 also verified there was no care plan developed for Resident 5's use of the LAL mattress with bolster, and the DON confirmed the same.
Care Plans Not Updated for Changed Interventions
Penalty
Summary
The facility failed to revise the comprehensive, person-centered care plan for three sampled residents when their conditions or interventions changed. Review of facility policy showed that care plans are to be revised as resident information and conditions change, and that they should reflect identified problem areas, risk factors, and resident wishes. Surveyors found that Resident 5’s care plan still reflected an indwelling Foley catheter even after the physician order to discontinue the catheter was carried out, and staff confirmed the catheter had been removed but the care plan had not been updated. Surveyors also found that the care plans for Residents 11 and 87 were not revised to reflect adjustments made to their APP mattress settings for comfort. Both residents were observed in bed with APP mattresses in use, and staff confirmed the settings were adjusted based on comfort. The care plans continued to list APP mattress use for skin management, but did not include the setting changes or monitoring/evaluation of their effectiveness. The Administrator and DON were informed of these findings.
Failure to Report New Eye Redness and Bruising
Penalty
Summary
The facility failed to identify and notify the physician and the resident’s representative of a resident’s right eye redness with discharge, and failed to ensure dark purplish discoloration on the right dorsal hand and light purplish discoloration on the left posterior lower arm were monitored and reported. The resident had no capacity to understand and make decisions, was dependent on staff for activities of daily living, and was at high risk for bruising and bleeding related to anticoagulation. The care plan included reporting new areas of bruising to the physician and responsible party/surrogate decision maker, but the medical record contained no documentation that these findings were reported or monitored. On observation, the resident was seen lying in bed with dried eye discharge and redness at the corner of the right eye, along with the purplish discolorations on both upper extremities. A CNA stated she noticed right eye redness with discharge and notified the assigned LVN, and later noticed the eye was more red and again notified the LVN. The LVN acknowledged she did not notify the physician right away and only did so after it was raised during the investigation. The IP stated that eye discharge with redness is not normal and must be reported immediately, and another LVN confirmed the purplish discolorations were new findings that should have been reported to the physician and responsible party.
Improper Use of LAL Mattress for Pressure Injury Care
Penalty
Summary
The facility failed to ensure the necessary care and services were provided to prevent the development of pressure injuries for one of three final sampled residents reviewed for pressure injuries. Resident 9 was admitted to the facility and had an H&P examination dated 3/11/26 showing the resident had the capacity to understand and make decisions. The resident also had a physician order dated 3/11/26 for a low air loss (LAL) mattress for skin management every shift. During observation on 4/21/26, Resident 9 was found lying on an LAL mattress with a foam mattress topper placed on top of it. The resident stated the foam topper had been added about 10 days earlier, that his son purchased it, and that facility staff helped place it on top of the LAL mattress. LVN 1 verified the topper was in place and stated it should not be placed on top of the LAL mattress because it defeated the therapeutic purpose of the mattress. LVN 2 also verified the topper was present, stated she had not noticed it during treatment the day before, and stated the LAL mattress would not function effectively if another mattress topper was placed on top of it. LVN 2 further stated Resident 9 had a pressure injury on the sacrococcyx. The Administrator and DON were later informed of the findings and acknowledged that the LAL mattress should not have an additional mattress topper placed on top of it.
Failure to Provide Nonpharmacological Pain Interventions Before Pain Medication
Penalty
Summary
The facility failed to ensure appropriate pain management was provided for one resident reviewed for pain management. The facility's Pain Assessment and Management policy stated that nonpharmacological interventions may be appropriate alone or with medications and listed examples such as repositioning, massage, relaxation, music, and diversions. Resident 4 had a physician's order dated 3/31/26 for celecoxib 200 mg by mouth daily for pain management, and the MAR showed the medication was administered on 4/1/26 at 0730 hours when the resident's pain level was documented as 2 on a 0 to 10 scale. Review of the medical record did not show that nonpharmacological interventions were offered or provided when the resident reported pain at the time the medication was given. During a concurrent interview and record review on 4/23/26, RN 1 verified the pain score and medication administration but was unable to provide documentation of any nonpharmacological interventions before the pain medication was administered. RN 1 stated that nonpharmacological interventions should be provided when a resident reports pain prior to administering pain medication. The Administrator and DON were informed of and acknowledged the findings on 4/24/26.
Nursing Competency and Change-in-Condition Monitoring Failures
Penalty
Summary
The facility failed to ensure nursing staff demonstrated competency in identifying changes in condition and providing care for two residents. For one resident, the record showed severe cognitive impairment, no capacity to understand or make decisions, and dependence on staff for activities of daily living. Staff observed dried eye discharge and redness in the corner of the right eye, but the nurse did not notify the physician or the responsible party when the eye redness and discharge were noted. The nurse later stated she believed the eye discharge and redness were normal for the resident and therefore did not report it, even though the eye appeared more red on the day of the observation. Interviews and record review showed that a CNA had noticed the right eye redness with discharge and told the assigned nurse, and later told the nurse again when the eye appeared more red. The nurse confirmed she was notified but did not notify the physician right away. The infection preventionist stated that eye discharge with redness was not normal in any resident and needed to be reported to the physician and responsible party right away. The resident was later prescribed antibiotic eye drops for the eye redness. The facility also failed to ensure a treatment nurse was trained and competent in using a newly purchased APP machine for another resident. That resident had a physician order for an APP mattress for skin management and was observed in bed with the APP mattress attached and set at different numerical levels, including 180 and 280. The treatment nurse stated she was responsible for monitoring the APP machines but could not explain what the numerical settings meant or how they related to pressure or comfort. She also stated the facility had recently purchased the equipment and that she had not received training or in-service education on the new APP machine, and no documented competency validation or training was provided before the device was used on residents.
Improper Storage of Internal and External Medications
Penalty
Summary
The facility failed to provide proper medication storage for one of three medication carts inspected, Medication Cart A. During a review of the facility policy titled Storage of Medications, it was noted that drugs for external use were to be clearly marked and stored separately from other medications. On 4/22/26 at 1400 hours, surveyors inspected Medication Cart A with LVN 3 and found one box of alendronate sodium 7 mg tablets and 11 individually packaged pantoprazole DR 40 mg suspensions, both oral/internal medications, stored in the same storage cube as 12 individually packaged rivastigmine transdermal system 4.5 mg patches, which are external medications. LVN 3 verified the medications were stored together and stated that internal and external medications should not be stored in the same storage cube because they are administered by different routes and mixing them could cause medication errors or contamination. At 1415 hours, RN 1 also verified that internal and external medications were stored together in the first drawer of Medication Cart A and stated they must be stored separately to prevent contamination and potential medication errors. On 4/24/26 at 1104 hours, the Administrator and DON were informed and acknowledged the findings.
Unsafe Storage of Food Brought in by Families or Visitors
Penalty
Summary
The facility failed to ensure safe food handling of food brought in for residents from outside sources. Review of the facility policy titled "Use and Storage of Food Brought in by Family or Visitors" showed that outside food was to be stored in a way that facilitated safety, with storage in a designated unit and a recommendation that the food be consumed within three days of preparation. During observation, the DSS showed the walk-in refrigerator used for food storage and identified that it contained an open box of pasteurized eggs and other kitchen food items used for meal preparation, with no dedicated space for outside food. The DSS acknowledged that this could result in cross-contamination. Interviews showed inconsistent staff knowledge about the handling of outside food. CNA 3 stated that families and residents were instructed to take outside food back home. LVN 5 stated that the facility did store outside food, but residents were required to eat it immediately or it had to be discarded after two hours because there was no refrigerator designated for storing outside food. The Administrator, DON, and DSS were informed of these findings.
Hospice Orders and Visit Documentation Not Kept Consistent
Penalty
Summary
The facility failed to ensure coordination and consistency between the facility and Hospice Provider A for Resident 13, who was receiving hospice services. The deficiency involved the facility not transcribing the current frequencies of hospice staff visits from the hospice plan of care into the resident’s physician’s orders, and not maintaining hospice aide visit notes in the resident’s medical record. Resident 13 was readmitted to the facility and had orders for hospice services under Hospice Provider A, including RN care manager, social worker, spiritual counselor, and CHHA visits. The hospice IDG comprehensive assessment and plan of care update showed multiple changes in visit frequencies for skilled nursing, social work, CHHA, and chaplain services during the benefit period. However, the resident’s order summary did not reflect the updated frequencies shown in the hospice plan of care. Review of the resident’s hospice binder and medical record did not show hospice aide visit notes for April 2026. The record also did not show documented evidence that the facility reconciled or clarified the physician’s order and hospice plan of care to ensure consistency in the frequency of hospice staff visits, or that it verified whether hospice aide visits occurred as scheduled. The SSD stated she was the facility’s hospice coordinator and that licensed nurses were responsible for checking physician orders and hospice staff visit notes, while RN 2 confirmed the mismatch between the order and the hospice plan of care and could not provide documentation of follow-up regarding the missing hospice aide visit notes.
Glucometer Not Calibrated or Quality Checked
Penalty
Summary
The facility failed to ensure essential equipment was maintained in safe and operating condition for one of three glucometers inspected. The glucometer in Medication Cart A, serial number 1040-4515600, was not documented as calibrated and had no documented quality control testing on 4/21/26. The facility’s P&P for Assure glucometer quality control testing stated that control solution testing is to be performed every night to verify the meter and test strips are working correctly as a system and that testing is being performed correctly. Review of the Quality Control Record for Medication Cart A for 4/2026 showed the log was blank for 4/21/26. During an inspection of Medication Cart A, LVN 3 verified the findings and stated the 11-7 shift nurses calibrated the glucometer and performed the quality control testing, and that glucometers and quality control testing were checked nightly to ensure accurate blood glucose readings for residents requiring blood glucose monitoring. The Administrator and DON were later informed and verified the findings.
Hot Water Temperatures in Kitchen Sinks Exceeded Safe Levels
Penalty
Summary
The facility failed to ensure a safe and comfortable environment for staff, vendors, and visitors by not maintaining safe hot water temperatures at one kitchen handwash sink and the two-compartment manual dishwashing sink. The report states that the kitchen sinks had "Caution - Hot Water" signage posted, and the DSS confirmed that the signs were used to warn individuals that the sink water was hot. The DSS also stated that the facility did not maintain a temperature log to monitor hot water temperatures at the kitchen sinks. During observation, the hot water from the kitchen handwash sink near the DSS's office felt abnormally hot to the touch, and steam was visibly rising from the water. When the DSS checked the temperatures of both the kitchen handwash sink and the two-compartment manual dishwashing sink, both measured 151.9 degrees Fahrenheit. Dietary Aide 1 stated the water was often very hot, and the DSS verified these findings.
Failure to Provide Required Two-Person Assistance During Transfer
Penalty
Summary
A deficiency occurred when a resident, identified as high risk for falls and dependent on staff for activities of daily living (ADL) care, was not provided with the required two-person assistance for transfers as outlined in their care plan. The resident's care plan specifically indicated the need for two-person assistance with transfers and positioning due to altered skin integrity and a history of falls. Despite these documented needs, the resident was assisted to the bathroom by only one certified nursing assistant (CNA), with a family member present, rather than the required two staff members. Interviews and medical record reviews confirmed that the CNA held the resident's arm while ambulating to the bathroom, and the family member reported that the resident was unstable and nearly fell during the transfer. Further, the family member contacted physical therapy and was informed that the resident was not cleared to ambulate. The Director of Nursing (DON) acknowledged these findings during a review of the incident.
Inadequate Respiratory Care and Infection Control
Penalty
Summary
The facility failed to provide appropriate respiratory care for six residents, as evidenced by incorrect oxygen administration and failure to adhere to infection control protocols. Residents 11, 32, 37, 44, and 685 were not receiving the correct rate of oxygen as per their physician's orders. For instance, Resident 44 was observed using an oxygen concentrator set at 2.5 liters per minute, contrary to the physician's order of two liters per minute as needed for shortness of breath. Similarly, Resident 32 was receiving oxygen at three liters per minute, while the order specified two liters per minute as needed. Resident 37 was also receiving oxygen at three liters per minute, despite a physician's order for two liters per minute to maintain oxygen saturation above 92%. Resident 685 was found to be receiving less than one liter per minute, contrary to the order for two liters per minute continuously. Additionally, there was no physician's order for oxygen saturation monitoring for Resident 685, and documentation of oxygen saturation results was inconsistent. Resident 11 was observed receiving oxygen at three and four liters per minute on different occasions, while the order specified two liters per minute continuously. Furthermore, the facility failed to change Resident 28's nebulizer set-up weekly as per the facility's policy and procedure. The nebulizer mask and tubing were observed inside a set-up bag dated beyond the seven-day change requirement. This oversight in infection control practices could potentially affect the respiratory health and well-being of the residents. The facility's Director of Nursing and other staff members acknowledged these findings during interviews.
Sanitation and Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as evidenced by multiple observations of improper hand hygiene and glove use by Dietary Aide 1. The aide was seen not washing hands between glove changes and using bare hands to handle clean items after touching dirty areas. This was confirmed during an interview with Dietary Aide 1, who acknowledged the findings. The facility's policies on glove use and handwashing were not adhered to, increasing the risk of contamination. Additionally, the facility did not ensure that kitchen equipment and utensils were kept in a clean and sanitary condition. Observations revealed rusty steel racks stored with clean utensils, a microwave with a cracked and rusty interior, and a plate warmer with dirt and rust on its hinges. These conditions were verified by the Dietary Services Supervisor (DSS) and were in violation of the USDA Food Code, which requires equipment to be clean and free from debris. The facility also failed to properly calibrate kitchen thermometers and maintain sanitizing solutions. Thermometers were not calibrated according to the manufacturer's instructions, and there was no documentation of sanitizer solution test results. Furthermore, personal belongings were improperly stored in the kitchen area, and utensils were not air-dried as required, with staff using paper towels to dry them instead. These practices were confirmed through observations and interviews with kitchen staff, indicating a lack of adherence to established sanitation protocols.
Infection Control Deficiencies in Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies. Room A, designated for Enhanced Barrier Precautions, lacked a receptacle for disposing of used gowns, leading to improper disposal practices by staff. The infection surveillance logs were inaccurately maintained, with numerous healthcare-associated infections (HAIs) not correctly identified or documented. The mapping of infections also failed to accurately reflect all HAIs, and there was confusion regarding the categorization of infections, particularly those not meeting McGeer's criteria. Resident 44's nasal cannula was found on the floor without proper storage, posing a risk of infection. Despite having a physician's order for oxygen administration, the nasal cannula was not stored in a sanitary manner, and staff were observed attempting to reuse it without proper cleaning. Additionally, medication carts were observed with hardened medication residue, indicating a lack of proper cleaning and maintenance, which is crucial for infection prevention. Resident 688, diagnosed with an ESBL-resistant urinary tract infection, was not placed under Enhanced Barrier Precautions as per the physician's order. There was no signage indicating the need for such precautions, and staff were unaware of the resident's status. The facility's infection preventionist and other staff members acknowledged these deficiencies, indicating a lack of adherence to established infection control protocols.
Failure to Complete Infection Surveillance Checklist and Identify HAIs
Penalty
Summary
The facility failed to ensure the completion of the McGeer's Criteria for Infection Surveillance Checklist for a resident who was administered antibiotics. During an interview and medical record review, it was verified that the resident received two different antibiotics, azithromycin and cefepime, with an increased dose of cefepime, without the necessary follow-up using the McGeer's Criteria. This oversight posed a risk of unnecessary antibiotic use, potentially leading to adverse reactions and antibiotic resistance. Additionally, the facility's infection control program was found lacking in identifying and tracking healthcare-associated infections (HAIs). The Infection Preventionist (IP) categorized infections into community-acquired, HAIs, and those not meeting McGeer's criteria, but failed to identify a significant number of HAIs in the facility's infection surveillance logs for December 2024 and January 2025. Furthermore, residents with increased confusion were incorrectly documented as asymptomatic, and the IP was unable to explain this discrepancy.
Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 389, was safe to self-administer medications found at her bedside. During an initial tour, it was observed that Resident 389 had several medications, including ibuprofen, Advil, alpha-chymotrypsin, arthritis relief pain ointment, and dry eye relief eye drops, on her bedside table. Resident 389 stated she self-administered these medications for various ailments, but there was no assessment conducted to determine her capability to do so safely. The facility's policy requires that residents be assessed for their ability to self-administer medications, and that medications be stored securely if self-administration is permitted. Further review of Resident 389's medical records revealed that she had moderate cognitive impairment and impairments in both upper extremities. There were no physician's orders for the medications found at her bedside, nor was there any documentation indicating that she had been assessed for self-administration. Interviews with facility staff confirmed that Resident 389 had not been evaluated for self-administration, and that the medications should not have been at her bedside without proper authorization and assessment. This oversight had the potential to lead to inaccurate medication administration and adverse reactions, impacting Resident 389's well-being.
Inaccurate Neurological Assessments Post-Fall
Penalty
Summary
The facility failed to provide necessary care and services to maintain the highest practicable well-being for two residents, specifically in the area of post-fall neurological assessments. Resident 685 experienced an unwitnessed fall, resulting in a bump and skin discoloration on the forehead. The neurological assessment conducted post-fall showed a sluggish reaction in the right pupil, but no interventions were documented to address this finding. Additionally, a section of the assessment was left blank, indicating incomplete documentation. These issues were acknowledged by the facility's RN and administration during interviews. Resident 7 also experienced a fall, and the subsequent neurological assessment contained inaccuracies. The assessment documented the right pupil size with a letter instead of a number, and the left pupil size was similarly documented incorrectly. Despite the sluggish reaction noted in the right pupil, no interventions were recorded to address this issue. The LVN responsible for the assessment and the RN reviewing it both verified these findings, and the DON confirmed the inaccuracies in the documentation. The facility's policies and procedures for neurological assessments and falls management were not adhered to, as evidenced by the incomplete and inaccurate documentation for both residents. The lack of proper documentation and follow-up interventions had the potential to delay necessary care for the residents involved. The facility's administration acknowledged these deficiencies during interviews with surveyors.
Failure to Implement Fall Risk Interventions
Penalty
Summary
The facility failed to implement necessary care plan interventions for a resident identified as high risk for falls. The resident's care plan included interventions such as conducting facility rounds every two hours, placing a star sticker on the resident's room, and applying a colored arm band to alert staff of the fall risk. However, the facility did not consistently document the required fall risk monitoring, with multiple instances of missing documentation on the Fall Risk Monitoring Table. Additionally, the resident did not have the star sticker or colored arm band as specified in the care plan. Interviews with the LVN and DON confirmed the lack of documentation and the absence of the required interventions. The LVN acknowledged that the post-fall monitoring should be completed and documented every two hours for three months, and the DON verified the missing documentation on the Fall Risk Monitoring Table. The resident, who had a fall in the restroom due to the wheelchair's brakes not being locked, was at risk for further falls and injuries due to the facility's failure to implement and document the care plan interventions.
Failure to Maintain Fluid Restriction for Resident
Penalty
Summary
The facility failed to maintain acceptable parameters for fluid intake for a resident who was under a physician-ordered fluid restriction of 1000 ml per day. The nursing and dietary departments were responsible for providing specific amounts of fluid throughout the day. However, the resident's fluid intake consistently exceeded the prescribed limits, with daily totals ranging from 910 ml to 1260 ml, as documented by the CNAs. The facility's Intake and Output Records did not accurately reflect the resident's total daily fluid intake, and there was a discrepancy between the fluid restriction breakdown printed on the resident's records and the physician's order. Interviews with facility staff revealed a lack of understanding and communication regarding the resident's fluid restriction. A CNA incorrectly believed the resident's fluid limit from meals was 1500 ml per day, and the LVN confirmed that the documentation did not match the physician's order. Additionally, there was no documented evidence that the physician was notified of the resident's non-compliance or that the resident was monitored for fluid overload. This failure had the potential to negatively impact the resident's well-being.
Failure to Monitor Anticoagulant Therapy
Penalty
Summary
The facility failed to adequately monitor two residents, identified as Residents 39 and 84, who were administered the anticoagulant medication apixaban (Eliquis) without proper monitoring for signs and symptoms of bleeding. This oversight was identified through interviews, medical record reviews, and a review of the facility's policies and procedures. The facility's policy on anticoagulation therapy required staff to assess for adverse drug reactions and signs of bleeding, but this was not documented for the residents in question. Resident 39, who was readmitted to the facility and had a care plan addressing the high risk of bleeding due to anticoagulation therapy, did not have documented evidence of monitoring for bleeding signs. Despite receiving apixaban as prescribed, there was no record of assessments for bleeding symptoms such as bruising, gum bleeding, or hematuria. An interview with RN 3 confirmed the lack of documentation and emphasized the importance of monitoring due to the potential for fatal injury. Similarly, Resident 84, who had a diagnosis of acute embolism and thrombosis, was administered Eliquis without a physician's order for monitoring bleeding signs until several weeks after starting the medication. The resident's care plan included interventions for monitoring bleeding, but there was no evidence of such monitoring until a later date. Interviews with LVN 4 and the DSD revealed a lack of in-service training for licensed nurses on monitoring anticoagulant medication, and the facility's administration acknowledged these findings.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medication, specifically mirtazapine, which was prescribed for depression manifested by poor oral intake. The resident's meal intake was supposed to be monitored and recorded as part of the treatment plan. However, there were discrepancies between the meal intake documentation by licensed nurses and CNAs, indicating inaccurate monitoring. The resident's meal intake often fell below the threshold of 76%, which was the criterion for administering mirtazapine, yet the medication was consistently administered. Additionally, the facility did not complete the monthly behavior summary related to the use of mirtazapine for the resident. This lack of documentation and monitoring could lead to the unnecessary use of the psychotropic medication, potentially affecting the resident's well-being. An interview with an RN confirmed these findings, highlighting the facility's failure to adhere to proper monitoring and documentation protocols for the resident's medication and meal intake.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to ensure the safe storage of medications and supplies, as evidenced by several observations. Medication Cart F was found unlocked and unattended in the hallway, with staff, residents, and visitors passing by. The cart contained syringes with needles, sterile gauze, alcohol prep pads, specimen vials, and bleach wipes stored with tuberculin syringes. The Infection Preventionist (IP) admitted to leaving the cart unlocked after removing isolation signage. Additionally, a packet of vitamin A&D ointment was found on a resident's bedside table without a physician's order, and the resident was unaware of its presence. The ointment was reportedly used by CNAs for the resident's dry skin. Furthermore, the facility's medication storage practices were found to be inadequate. Eye medication (cyclosporine ophthalmic emulsion) was stored together with rectal medication (bisacodyl suppository) in the same drawer of Medication Cart A. This was confirmed by LVN 5, who acknowledged that these medications should not be stored together. The Director of Nursing (DON) also confirmed that the storage of these medications together was inappropriate.
Menu Deviations in Pureed Diets
Penalty
Summary
The facility failed to ensure that the menus were followed, which resulted in discrepancies in the preparation and serving of pureed diets. Specifically, the pureed mixed vegetables did not match the regular mixed vegetables, as the pureed version was prepared with broccoli, zucchini, and carrots, while the regular version included cauliflower and slices of fried tofu, but no zucchini. Additionally, the pureed beef was not served with a ladle of sauce as required by the recipe. These deviations were confirmed by the Dietary Services Supervisor (DSS) during observations of food preparation and trayline assembly. The facility's policy requires that any deviations from posted menus be recorded and archived, but this was not adhered to, potentially impacting the nutritional adequacy of meals for residents on pureed diets.
Deficiency in Safe Food Handling and Storage
Penalty
Summary
The facility failed to ensure the safe handling and storage of food brought in by family members or visitors for residents. This deficiency was identified through observations, interviews, and a review of facility policies and procedures (P&P). The facility's P&P on foods brought by residents, family members, and visitors did not include guidelines for safe food handling and storage in the reach-in refrigerator. Interviews with RN 3 and the Dietary Services Supervisor (DSS) revealed that while residents and their families could request the kitchen to store food items from outside sources, there was no separate refrigerator for these items, and the facility did not allow overnight storage. The DSS and Registered Dietitian (RD 1) confirmed that the facility's P&P lacked specific instructions for the safe handling and storage of food from outside sources. The absence of these guidelines posed a potential risk of foodborne illnesses to the medically vulnerable resident population. The facility's failure to incorporate safe food handling practices into their P&P, as required by CMS guidelines, was a significant oversight that could impact resident health and safety.
Resident Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from physical abuse by a staff member, specifically a Certified Nursing Assistant (CNA). The incident involved a resident who reported being slapped on the face by the CNA, resulting in redness on the right cheek. This incident was confirmed through interviews with the resident, staff, and a review of medical records and facility documents. The resident expressed fear and a desire to leave the facility due to feeling unsafe. The facility's policies and procedures, including the Abuse Prevention Program and Resident Rights, were reviewed and indicated that residents should be free from abuse and treated with respect and dignity. Despite these policies, the CNA admitted to slapping the resident, claiming it was a reflexive action after being kicked and hit by the resident. The CNA's behavior was acknowledged as physical abuse and deemed unacceptable by the facility's administration. The CNA involved had a history of disciplinary actions for inappropriate behavior, including using vulgar language and not following instructions. Following the incident, the CNA was terminated from employment. The facility conducted an investigation, which included interviews with the CNA and other staff members, confirming the occurrence of the abuse.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 4,693 citations issued within 25 miles in the last 12 months — including the 15 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Westminster
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Extended Care Hospital Of Westminster | 0.6 mi | ★★★★★ | 1 | 0 |
| Stanley Healthcare Center | 1.2 mi | ★★★★★ | 22 | 0 |
| Garden Grove Post Acute | 1.9 mi | ★★★★★ | 4 | 0 |
| Rowntree Gardens | 1.9 mi | ★★★★★ | 20 | 0 |
| Park Anaheim Healthcare Center | 3.7 mi | ★★★★★ | 28 | 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 July 2026) and official state health department websites.