Mission Palms Post Acute

In the surveyor’s words

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

• No harm, potential for more than minimal, patternF553Apr 2, 2021

  Based on clinical record review, resident and staff interviews, and review of policy, the facility failed to ensure one resident (#15) was provided opportunities for participation in his care and discharge planning process. The deficient practice could result in residents' not being provided the opportunity to participate in the planning care process. Findings include: Resident #15 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . In a review of the comprehensive care plans from September 2019 through October 1, 2020, there was no evidence of a care plan that included the resident's discharge plan or desire to remain in the facility. […]

• No harm, potential for more than minimal, patternF689Apr 2, 2021

  Based on observations, staff interviews, review of facility documentation and facility policy, the facility failed to ensure the environment was free from accident hazards by failing to ensure safe water temperatures were maintained in multiple resident bathrooms (residents #s 56, 12, 92, 47, 65, 15, 443, 16). The deficient practice could result in hazardous temperatures and put residents at risk for [CONDITION(S)]. Findings include: On March 30, 2021 between 9:00 am and 11:30 am, the hot water temperatures in multiple resident bathrooms was found to be over 120 degrees Fahrenheit (F). […]

• No harm, potential for more than minimal, isolatedF607Aug 20, 2026

  Based on clinical records, staff interviews, review of facility documentation, policies and procedures, and the State Agency (SA) database, the facility failed to implement its policy regarding reporting allegations of abuse to appropriate agencies for one of two sampled resident (#12). The deficient practice could result in abuse continuing and not being prevented. The universe was 154.Findings include:Resident #12 was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, fracture of the shaft of the left femur subsequent encounter for closed fracture with routine healing, chronic pain syndrome, generalized anxiety disorder, and major depressive disorder.A comprehensive care plan focus… […]

• No harm, potential for more than minimal, isolatedF609Aug 20, 2026

  Based on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to ensure that an allegation of physical abuse for one of two sampled resident (#12) was reported to all applicable state agencies. The deficient practice could result in further allegations of abuse not being reported and investigated by the appropriate state agencies. The universe was 154. Findings include:Resident #12 was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, fracture of the shaft of the left femur, chronic pain syndrome, generalized anxiety disorder, and major depressive disorder.A comprehensive care plan focus area for psychotropic medication use was… […]

• No harm, potential for more than minimal, isolatedF610Aug 20, 2026

  Based on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to complete a thorough investigation regarding allegation of physical abuse for one of two sampled resident (#12). The deficient practice could result in abuse continuing and not being prevented. The universe was 154.Findings include:Resident #12 was admitted to the facility on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, fracture of the shaft of the left femur, chronic pain syndrome, generalized anxiety disorder, and major depressive disorder.A comprehensive care plan focus area for psychotropic medication use was initiated on January 16, 2025, and revised on August 13, 2026, to manage the… […]