Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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.
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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 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 | — | 0 | 0 |
| Rowntree Gardens | 1.9 mi | — | 20 | 0 |
| Park Anaheim Healthcare Center | 3.7 mi | — | 28 | 0 |
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