Mission Palms Healthcare Center

In the surveyor’s words

From the most serious findings on record at Mission Palms Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF600Aug 27, 2024

  Based on interview, medical record review, facility document review, and facility P&P review, the facility failed to protect the resident's rights to be free from the physical abuse by the facility staff for one of three sampled residents (Resident 1). * Resident 1 was slapped on the face by CNA 1 and sustained a redness to the right cheek. This failure had violated the resident's rights to be free from the abuse and negatively affected the resident's psychological well-being. Findings: Review of the facility's P&P titled Abuse Prevention Program revised on 12/1/22, showed the facility should promote an environment free from any form of resident abuse, neglect, misappropriation of resident property, exploitation and/or mistreatment. […]

• No harm, potential for more than minimal, widespreadF761Mar 23, 2023

  Based on observation, interview, and facility P&P review, the facility failed to ensure the proper administration, storage, and disposal of the medications in a safe manner as evidenced by the following: * The facility failed to ensure the medications were not left unattended. * The facility failed to ensure the discontinued medications were properly stored and disposed. * The facility failed to ensure the expired lemon glycerin swab sticks and used sterile wound dressing supplies were disposed from the treatment cart. These failures had the potential to cause unsafe handling and storage of the residents' medications. Findings: 1. […]

• No harm, potential for more than minimal, patternF552Apr 24, 2026

  Based on interview, medical record review, and facility P&P review, the facility failed to ensure five of five final sampled residents reviewed for unnecessary medications (Residents 2, 4, 11, 75, and 95) and one final sampled resident (Resident 13) reviewed for informed consents were provided the right to self-determination regarding the use of psychotropic medications and treatments. * The facility failed to ensure the informed consents for the quetiapine (antipsychotic) and mirtazapine (antidepressant) medications included the indication of use and manifested behavior for Resident 2. * The facility failed to ensure the informed consent for the quetiapine medication included the indication for the use and manifested behavior for Resident 4. […]

• No harm, potential for more than minimal, patternF695Apr 24, 2026

  Based on observation, interview, medical record review, and facility P&P review, the facility failed to ensure the respiratory care and services were provided in accordance with the professional standards for two of three final sampled residents (Residents 57 and 83) reviewed for respiratory care. * The facility failed to ensure Resident 57's nasal cannula was placed properly positioned and the oxygen concentrator was functioning properly. * The facility failed to ensure Resident 83's Yankauer suction tubing was labeled. These failures had the potential to result in the residents not receiving appropriate respiratory care and increased risks of the infection.Findings: 1. Medical record review for Resident 83 was initiated on 4/21/26. […]

• No harm, potential for more than minimal, patternF757Apr 24, 2026

  Based on interview and medical record review, the facility failed to ensure the residents were free from unnecessary medications for one of five sampled residents reviewed for unnecessary medications (Resident 11) and two of 19 final sampled residents (Residents 13 and 57). * The facility failed to ensure Resident 57's heart rate was monitored prior to administering the amlodipine (blood pressure medication) and lisinopril (blood pressure medication), as prescribed by the physician. * The facility failed to ensure Resident 13's heart rate was monitored prior to administering the diltiazem (blood pressure medication) and hydralazine (blood pressure medication), as prescribed by the physician. […]