Inspection visit
Health inspection
9 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 9 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a
review of Resident 42's admission Record, it indicated Resident 42 was admitted to the facility on [DATE],
with diagnoses that included brain disorder, urinary tract infection (an infection in any part of the kidneys,
bladder or urethra), and dementia (mental disorder when a person loses the ability to think, remember,
learn, make decisions, and solve problems).
During a dining observation, on October 25, 2022, at 1:00 PM, in Resident 42's room, Resident 42 was in
bed while being fed by CNA 5. CNA 5 raised Resident 42's bed in the highest position and was standing at
the bedside feeding her. CNA 5 was not on eye level with Resident 42. Resident 42 became agitated and
started to refuse to eat.
During a concurrent interview and record review with Director of Nursing (DON), on October 26, 2022, at
11:00 AM, the DON reviewed the facility's policy and procedure titled Assistance with Meals revised March
2022, and stated it was the policy of the facility for all staff to sit eye level when feeding residents. The DON
acknowledged CNA 5 did not follow the facility policy and procedure.
During record review of facility's policy and procedure titled Assistance with Meals, revised March 2022,
indicated Residents shall receive assistance with meals in a manner that meets the individual needs of
each resident . Dining Room Residents . 3. Residents who cannot feed themselves will be fed with attention
to safety, comfort, and dignity, for example: a. not standing over residents while assisting them with meals;
b. keeping interactions with other staff to a minimum while assisting resident with meals; c. avoiding the use
of labels when referring to residents (e.g., feeders) .Residents Requiring Full Assistance .2. Residents who
cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. not standing
over residents while assisting them with meals; b. keeping interactions with other staff to a minimum while
assisting resident with meals.
Based on observation, interview, and record review, the facility failed to ensure resident's right to dignified
existence, self-determination and communication was exercised for two of 34 sampled residents (Residents
75 and 42) when:
1. For Resident 75, the facility failed to provide the means for Resident 75 to be able to communicate her
individualized care needs and preferences accurately and thoroughly with the facility.
2. For Resident 42, the facility failed to ensure Resident 42 was fed in a dignified manner when a Certified
Nursing Assistant (CNA 5) stood over while feeding her.
These failures resulted in Residents 75, and 42's rights to be violated, which had the potential to
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 17
Event ID:
056024
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056024
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/28/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Highland Palms Healthcare Center
7534 Palm Ave
Highland, CA 92346
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0550
cause psychosocial harm leading to low self-esteem, feeling irritated, sad, and anxious.
Level of Harm - Minimal harm
or potential for actual harm
Findings:
Residents Affected - Few
1. During a review of Resident 75's clinical record, the admission Record (contains demographic and
medical information) indicated Resident 75 was admitted to the facility on [DATE], with diagnoses that
included muscle wasting and atrophy (loss of muscle tissue), type 2 diabetes mellitus (an impairment in the
way the body uses sugar), dementia (difficulty remembering, think or make decisions because of poor
blood flow to the brain) and major depressive disorder (feelings of sadness, emptiness or hopelessness).
Further review indicated Resident 75's preferred language was Vietnamese.
During a review of Resident 75's Care Plan titled At risk for Altered Communication R/T: Language barrier,
last reviewed on October 28, 2022, it indicated the following interventions .Face the resident when speaking
. If needed use: (e.g. short, direct phrases, gesture, communication board, flash card etc) when speaking to
resident Observe for signs and symptoms of pain/discomfort to the best of their ability whenever necessary.
A written question could be utilized .
During a concurrent observation and interview, with the Registered Nurse Supervisor (RNS 1) and
Resident 75, on October 28, 2022, at 8:30 AM, in Resident 75's room, RNS 1 stated the staff used
Resident 75's family as a language translator when they are available, and utilize Google translate when
they were not available. When RNS 1 was asked if the facility had a language translation service available,
RNS 1 referred to the Director of Nursing (DON) and stated he had not used a language translation service
at the facility.
During further observation and interview, at Resident 75's bedside area, RNS 1 was using his cellphone to
communicate with Resident 75. Resident 75 was responding to the translated language from RNS 1's
cellphone, but RNS 1 was unable to understand Resident 75's response.
During an interview with the DON, on October 28, 2022, at 9:54 AM, the DON stated the facility missed the
opportunity to provide a way to accurately communicate with Resident 75.
During an interview with the Social Services Director (SSD), on October 28, 2022, at 2:16 PM, the SSD
stated the facility communicated with Resident 75 using communication board, which Resident 75 did not
like, and Google translate. The SSD acknowledged that a language translation service would help in
communicating with Resident 75.
During a review of the facility's policy and procedure titled Resident Rights, revised December 2016,
indicated .Federal and state laws guarantee certain basic rights to all residents of this facility. These rights
include the resident's right to: A dignified existence . Self-determination . Communication with and access to
people and services, both inside and outside the facility . Communicate with outside agencies (e.g., local,
state, or federal officials, state and federal surveyors, state long-term care ombudsman, protection or
advocacy organizations, etc.) regarding any matter .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056024
If continuation sheet
Page 2 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056024
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/28/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Highland Palms Healthcare Center
7534 Palm Ave
Highland, CA 92346
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0640
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure the Minimum Data Set (MDS- a facility assessment
tool) assessment was completed in accordance with the Centers of Medicare and Medicaid Services
(CMS) federal completion timeframes, for two residents reviewed for resident assessment (Residents 2 and
90).
Residents Affected - Few
These failures had the potential to result in inadequate monitoring of Residents 2 and 90's progress and
decline, and the lack of resident specific information to CMS for payment and quality measure monitoring.
Findings:
1. A review of Resident 90's clinical record, the admission Record (contains demographic and medical
information) indicated Resident 90 was admitted to the facility on [DATE], with diagnoses that included
malignant neoplasm of larynx (cancer of the throat), adult failure to thrive (general state of decline that is
characterized by profound weight loss, diminished appetite, poor nutrition, and lack of physical activity), and
cerebral infarction (damage to the brain from interruption of its blood supply).
During a concurrent interview and record review with the MDS Nurse (MDS 1), on October 26, 2022, at
2:30 PM, the MDS 1 reviewed Resident 90's clinical record and stated the Significant Change in Status
Assessment (SCSA- a comprehensive Minimum Data Set assessment) dated July 8, 2022, was not
completed within 14 days. She further stated it was completed on August 9, 2022. (It was 18 days overdue).
2. During a review of Resident 2's clinical record, the admission Record indicated, Resident 2 was admitted
to the facility on [DATE], with diagnoses that included hypertensive heart disease (high blood pressure),
diabetes mellitus (a condition that result in too much sugar in the blood), and cerebral infarction (damage to
the brain from interruption of its blood supply).
During a concurrent interview and record review with the MDS Nurse 1 (MDS 1), on October 27, 2022, at
9:36 AM, the MDS 1 reviewed Resident 2's clinical record and stated the Quarterly MDS assessment dated
[DATE], was also not completed within 14 days. She further stated it was completed on June 27, 2022. (It
was 5 days overdue).
During a concurrent interview and record review of the facility's policy and procedure titled, Clinical Policy
and Procedure Manual- Resident Assessment Instrument: Minimum Data Set, dated July 2015, with the
MDS 1, on October 27, 2022, at 12:30 PM, the MDS 1 stated these assessments should have been
completed within 14 days from the Assessment Reference Date (ARD). She also stated assessment should
be completed in a timely manner for payment and care planning. The MDS 1 further stated they did not
follow our policy and procedure and Resident Assessment Instrument (RAI) Guidelines.
During a review of the facility's policy and procedure titled, Clinical Policy and Procedure Manual- Resident
Assessment Instrument: Minimum Data Set, dated (effective) July 2015, it indicated, POLICY: It is the policy
of this facility to utilize the most current RAI (Resident Assessment Instrument) Manual as the policy and
procedure for the completion of the MDS (Minimum Data Set) 3.0 Assessments. All persons completing
sections of the MDS are responsible for following all protocols and instructions in the RAI Manual regarding
completion and submission of Assessments and Tracking Records. In
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056024
If continuation sheet
Page 3 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056024
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/28/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Highland Palms Healthcare Center
7534 Palm Ave
Highland, CA 92346
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0640
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
conjunction with the facility Administrator, the lead Coordinator of the MDS Department has overall
responsibility for ensuring the timely completion of the MDS by all members of the Interdisciplinary Team
(IDT) .
During a review of CMS RAI Version 3.0 Manual, dated October 2019, page 5-2, it indicated .For all
non-admission OBRA and PPS assessments, the MDS Completion Date (Z0500B) must be no later than
14 days after Assessment Reference Date (ARD) (A2300).
Event ID:
Facility ID:
056024
If continuation sheet
Page 4 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056024
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/28/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Highland Palms Healthcare Center
7534 Palm Ave
Highland, CA 92346
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0646
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Notify the appropriate authorities when residents with MD or ID services has a significant change in
condition.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, and record review, the facility failed to ensure the Pre-admission Screening and Resident Review
(PASRR- a federal requirement to help ensure individuals who have a mental disorder or intellectual
disabilities are not inappropriately placed in nursing homes for long term care) was re-evaluated after a
Significant Change in Status Assessment (SCSA- a comprehensive Minimum Data Set [MDS] - a facility
assessment tool) assessment done for a resident that must be completed when a resident meets the
significant change guidelines for either improvement or decline), for three residents reviewed for PASRR
(Residents 6, 32 and 90).
These failures had the potential for Residents 6, 32, and 90 not to receive the care and services most
appropriate for their needs.
Findings:
1. During a review of Resident 90's clinical record, the admission Record (contains demographic and
medical information) indicated Resident 90 was admitted to the facility on [DATE], with diagnoses that
included malignant neoplasm of larynx (cancer of the throat), adult failure to thrive (general state of decline
that is characterized by profound weight loss, diminished appetite, poor nutrition, and lack of physical
activity), and cerebral infarction (damage to the brain from interruption of its blood supply).
A concurrent interview and record review of Resident 90's MDS dated [DATE], was conducted with the
MDS Nurse 1 (MDS 1) on October 26, 2022, at 9:53 AM. She stated Resident 90's SCSA was done
because he was admitted to hospice (providing care for the sick or terminally ill).
During further interview and review of Resident 90's clinical record with MDS 1, she stated Resident 90's
most current PASRR was dated June 22, 2022, when the resident was admitted to the facility.
2. During a review of Resident 32's clinical record, the admission Record indicated Resident 32 was initially
admitted to the facility on [DATE], with diagnoses that included respiratory failure (condition in which the
lungs fail to function properly making it hard to breath), cerebral infarction (damage to the brain from
interruption of its blood supply), and heart failure (a condition in which the heart does not pump blood
adequately).
A concurrent interview and record review of Resident 32's MDS, dated [DATE], was conducted with the
MDS Nurse (MDS 1) on October 26, 2022, at 9:54 AM. She stated Resident 32's SCSA was done because
she was discharged from hospice services.
During further interview and review of Resident 32's clinical record with MDS 1, she stated Resident 32's
most current PASRR on file was dated December 15, 2020.
3. During a review of Resident 6's clinical record, the admission Record indicated Resident 6 was admitted
to the facility on [DATE], with diagnoses that included major depressive disorder (mental disorder
characterized by depressed mood or loss of interest in activities), dementia (a group of conditions affecting
memory and judgement), and epileptic seizure (disorder involving the brain causing changes in behavior,
movements, and levels of consciousness).
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056024
If continuation sheet
Page 5 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056024
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/28/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Highland Palms Healthcare Center
7534 Palm Ave
Highland, CA 92346
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0646
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
A concurrent interview and record review of Resident 6's MDS, dated [DATE], was conducted with the MDS
1 on October 26, 2022, at 10:12 AM. She stated Resident 6's SCSA was done because she was placed on
hospice. She further stated the latest PASSR on file was dated July 18, 2020.
During an interview with the Registered Nurse Supervisor (RNS 1), on October 26, 2022, at 10:47 AM, he
stated the RN was responsible in completing the PASRR on admission, but he was not aware or told to
re-evaluate and update PASRRs.
During an interview with the Director of Nursing (DON), on October 26, 2022, at 11:36 AM, he stated the
PASRR were not re-evaluated after the completion of the SCSA for Resident 90, 32 and 6. He further
stated the PASRR should be done on admission and when there is a SCSA. He stated the facility did not
follow the PASRR Guidelines.
A review of the Department of Health Care Services Guide to Completing the PASRR Level I Screening,
dated May 2018, indicated Select Resident Review (RR) (Status Change) if the individual has already been
admitted to your facility and you are updating the existing PASRR on file for either of the following reasons:
A. The individual's stay has exceeded the 30-day exempted hospital discharge 1. The Resident Review
Level I Screening should be submitted by the 40th calendar day after admission for such cases. B. There is
a significant change in an individual's physical or mental condition. According to the MDS 3.0 manual a
significant change is a decline or improvement in an individual's status that: 1. Will not normally resolve
itself without intervention by staff or by implementing standard disease-related clinical interventions, is not
self-limiting (for declines only) and 2. Impacts more than one area of the individual's health status and 3.
Requires interdisciplinary review and/or revision of the care plan.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056024
If continuation sheet
Page 6 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056024
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/28/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Highland Palms Healthcare Center
7534 Palm Ave
Highland, CA 92346
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure an individualized comprehensive care
plan (specific interventions to provide effective and person-centered care to meet the resident's needs) was
initiated for one of three residents (Resident 10) reviewed for pain management.
This failure had the potential for Resident 10 to have unidentified care concerns related to pain
management, placing his health and safety at risk.
Findings:
During a concurrent observation and interview, on October 25, 2022, at 10:34 AM, with Resident 10,
Resident 10 was lying in her bed watching television. Resident 10 was alert, oriented and able to make
needs known. She also stated she has rheumatoid arthritis (disorder affecting many joints causing painful
swelling) and was receiving pain medications to manage her pain level.
During a review of Resident 10's clinical record, the admission Record (contains demographic and medical
information) indicated Resident 10 was admitted to the facility on [DATE], with diagnoses that included
rheumatoid arthritis, opioid (a medication used to treat moderate to severe pain) dependence, and anemia
(condition in which the body does not have enough healthy red blood cells resulting to reduced oxygen flow
to the body).
During a review of Resident 10's current physician's orders, dated October 27, 2022, it indicated Resident
10 had an order to receive the following pain medication:
i. Ibuprofen Tablet 600 MG [Milligrams- unit of measure for dose] Give 600 mg by mouth three times a day
for pain management
ii. Norco Tablet 10-325 MG Give 1 tablet by mouth every 6 hours as needed for moderate pain
iii. Oxycodone HCl Tablet 15 MG Give 1 tablet by mouth every 6 hours for Pain Management
During a concurrent interview and record review, with the Minimum Data Set Nurse (MDS 2), on October
27, 2022, at 2:07 PM, (about three months after Resident 10's admission to the facility), the MDS 2
reviewed Resident 10's clinical record and could not find documented evidence of a care plan having been
developed for pain management. She stated Resident 10 should have had a pain management care plan
upon admission to address resident's concerns about pain. She further stated care plan should be made
known and communicated to other members of the health care team.
During a review of the facility's policy and procedure titled, Care Plans, Comprehensive Person-Centered,
revised December 2016, it indicated, A comprehensive, person-centered care plan that includes
measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is
developed and implemented for each resident .12. The comprehensive, person-centered care plan is
developed within seven (7) days of the completion of the required comprehensive assessment (MDS).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056024
If continuation sheet
Page 7 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056024
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/28/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Highland Palms Healthcare Center
7534 Palm Ave
Highland, CA 92346
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0689
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to
prevent accidents.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure a safe environment for two of four
residents reviewed for accidents (Residents 56 and 77) when Residents 56 and 77's smoking care plan
were not implemented by the staff.
These failures had the potential for Residents 56 and 77's safety needs to be unmet, which could place
them at risk for accidents and life-threatening injuries.
Findings:
1. During a review of Resident 56's admission Record (demographic information), it indicated Resident 56
was admitted to the facility on [DATE] with diagnoses that included hypertensive heart disease (heart
problems that occur because of high blood pressure that is present over a long time), atrophy of the kidney
(condition in which one or both kidneys shrink to a smaller size, thus hindering normal function), and
dementia (mental disorder in which a person loses the ability to think, remember, learn, make decisions,
and solve problems).
During review of Resident 56's Comprehensive Care Plan, dated October 1, 2022, through October 31,
2022, under the section for Smoking, it indicated an intervention for Resident 56 to have his clothes
checked for cigarette burns when he returns from smoking.
During an observation, at the smoking patio, on October 26, 2022, at 10:00 AM, Resident 56 was smoking
a cigarette. He extinguished his cigarette in the ashtray. From the smoking patio, he entered the facility from
the courtyard. As he passed the nursing station to go back to his room, the staff did not check his clothing
for cigarette burns.
2. During a review of Resident 77's admission Record, it indicated Resident 77 was admitted to the facility
on [DATE], with diagnoses that included acute embolism and thrombosis of unspecified deep veins of right
lower extremity (the condition results from a blood clot that forms in the legs or another part of the body,
and Methicillin Resistant Staphylococcus Aureus Infection as the cause of diseases classified elsewhere
(group of Gram-positive bacteria that are distinct from other strains of the bacteria).
During review of Resident 77's Comprehensive Care Plan, dated October 1, 2022, through October 31,
2022, under the section for Smoking, it indicated an intervention for Resident 77 to have his clothes
checked for cigarette burns when he returns from smoking.
During an observation, at the smoking patio, on October 26, 2022, at 10:30 AM, Resident 77 was smoking
a cigarette. He extinguished his cigarette in the ashtray. From the smoking patio, he entered the facility from
the courtyard. As he passed the nursing station to go back to his room, the staff did not check his clothing
for cigarette burns.
During a concurrent interview and record review, with the Director of Nursing, on October 26, 2022, at 1:25
PM, the DON reviewed Residents 56 and 77's smoking care plan and acknowledged the staff had to check
residents' clothes for cigarette burns after they return from smoking. The DON stated the staff were not
implementing this intervention for Residents 56 and 77.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056024
If continuation sheet
Page 8 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056024
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/28/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Highland Palms Healthcare Center
7534 Palm Ave
Highland, CA 92346
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0697
Provide safe, appropriate pain management for a resident who requires such services.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure the provision of pain management
before, during, and after wound care treatment was implemented for one of four residents (Resident 63)
reviewed for wound care.
Residents Affected - Few
This failure had the potential for Resident 63 to experience excessive unrelieved and/or uncontrolled pain
associated with the wound care treatment, due to absence of pain management intervention by facility staff
providing the wound care treatment.
Findings:
During a review of Resident 63's clinical record, the document titled admission Record, (contains
demographic and medical information) indicated Resident 63 was admitted to the facility on [DATE], with
diagnoses that included hemiplegia/hemiparesis (caused by a brain injury resulting in varying degree of
weakness on one side of the body), and pressure ulcer (a wound caused by unrelieved pressure and
restricted blood flow) of sacral (a spine located at the back within the hip) region.
During a review of Resident 63's physician's order titled, Order Summary Report, dated August 25, 2022,
indicated, Acetaminophen (pain medication) tablet 325 milligrams (mg-unit of measure) 2 tablets every 6
hours via GT as needed for pain.
During a review of Resident 63's Care Plan titled, Pain, dated September 17, 2022, it indicated, .Assess
level of pain, frequently, site and factors that trigger the pain .Consider pre-medicating for pain PRN (as
needed) to optimize participation .
An observation of Licensed Vocatiuonal Nurse's (LVN 1) wound care treatment for Resident 63 and a
concurrent interview was conducted on October 26, 2022, at 9:07 AM, in Resident 63's room. LVN 1 stated
she did not assess Resident 63's pain level prior to the wound care treatment. After the wound care
treatment, Resident 63 was repositioned on her back by Certified Nursing Assistant (CNA 1).
During further observation and interview, Resident 63 was noted to have facial grimacing (wrinkled nose,
squeezed eyes, and twisted mouth) and flushed face (reddening of skin). Resident 63 was non-verbal. LVN
1 was asked to look at Resident 63's face and appearance after wound care treatment. LVN 1 stated she
should have given Resident 63 pain medication before treatment. LVN 1 further stated Resident 63 has a
pain medication order as needed.
During a concurrent interview and review of Resident 63's clinical record with the Director of Nursing
(DON), on October 28, 2022, at 9:15 AM, the DON stated LVN 1 should have pre-medicated Resident 63
for pain before providing the wound care treatment. The DON further stated LVN 1 should have assessed
Resident 63's pain level using non-verbal expressions of pain before, during, and after the wound care
treatment. The DON further stated it was important for the pain scale to be assessed by the licensed nurse,
so the licensed nurse can provide the appropriate pain medication for the residents.
A review of the facility's policy and procedure (P&P) titled, Pain Assessment and Management, revised
March 2022, indicated .to help the staff identify pain in the resident, and to develop interventions that are
consistent with the resident's goals and needs and that address the underlying causes of pain, recognizing
signs of pain for physiological and behavioral (non-verbal) signs of pain
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056024
If continuation sheet
Page 9 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056024
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/28/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Highland Palms Healthcare Center
7534 Palm Ave
Highland, CA 92346
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0697
Level of Harm - Minimal harm
or potential for actual harm
.verbal expressions such as groaning, crying, screaming, facial expressions such as grimacing, frowning,
clenching of the jaw .Review the resident's clinical record to identify conditions or situations that may
predispose the resident to pain, including skin/wound conditions .pressure, venous or arterial ulcers; and
identify any situations or interventions where an increase in the resident's pain may be anticipated
treatments such as wound care or dressing changes .
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056024
If continuation sheet
Page 10 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056024
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/28/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Highland Palms Healthcare Center
7534 Palm Ave
Highland, CA 92346
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview, and record review, the facility failed to maintain a sanitary kitchen in
accordance with professional standards for food service safety when:
Residents Affected - Many
1. Plastic food storage containers were stacked and stored wet, which prevented them from drying and had
the potential to allow an environment where microorganisms can begin to grow.
2. The floor, under the stainless-steel counter, had food crumbs and loose trash, which had the potential for
microorganism growth that could unintentionally be transferred to the food.
3. There were food crumbs found on the bottom shelf of reach-in freezer near the three-compartment sink,
which had the potential for microorganism growth that could be transferred to the food.
4. There was food, black grime, and trash build-up found behind, and underneath the stove. This had the
potential for microorganism growth that could inadvertently be transferred to food.
5. Ice machine had brown substance on the ice chute, which had the potential for microorganism growth
that could contaminate the ice.
These failures had the potential to cause foodborne illness in a highly susceptible population of 91
residents who received food from the kitchen.
Findings:
1. During an observation and concurrent interview, with the Dietary Services Supervisor (DSS), on October
25, 2022, at 8:41 AM, in the kitchen, plastic food storage containers were stacked and stored wet. DSS
stated these containers should have been air dried before storing.
During an interview with the Registered Dietitian (RD), on October 27, 2022, at 1:10 PM, she stated her
expectation was that food storage containers should be dry before stacking and storing.
During a review of the facility's policy and procedure (P&P) titled Dish Washing, dated 2018, it indicated
.dishes are to be air dried in racks before stacking and storing .
During a review of the FDA (Federal Food Code), dated 2017, it indicated 4-901.11 Equipment and
Utensils, Air-Drying Required. After cleaning and sanitizing, equipment, and utensils: (A) Shall be air-dried .
2. During an observation and concurrent interview, with the DSS, on October 25, 2022, at 8:11 AM, in the
kitchen, there was food crumbs and loose trash under the stainless-steel counter. The DSS stated the food
crumbs and loose trash should have been cleaned up.
During an interview with the RD, on October 27, 2022, at 1:10 PM, she stated her expectation was that the
kitchen floor should be clean under all the equipment.
During a review of the FDA (Federal Food Code), dated 2017, it indicated 4-602.13 Nonfood-Contact
Surfaces. The presence of food debris or dirt on nonfood contact surfaces may provide a suitable
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056024
If continuation sheet
Page 11 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056024
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/28/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Highland Palms Healthcare Center
7534 Palm Ave
Highland, CA 92346
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
environment for the growth of microorganisms which employees may inadvertently transfer to food. If these
areas are not kept clean, they may also provide harborage for insects, rodents, and other pests .
3. During an observation and concurrent interview, with the DSS on October 25, 2022, at 8:37 AM, in the
kitchen, there was food crumbs on the bottom shelf of reach-in freezer near the three-compartment sink.
The DSS stated there should not be any crumbs and it should have been cleaned up.
During an interview with the RD, on October 27, 2022, at 1:10 PM, she stated her expectation was that
reach-in freezer should be clean.
During a review of the facility's policy and procedure (P&P) titled Procedure for Refrigerated Storage, dated
2018, it indicated .Refrigeration equipment should be routinely cleaned .
During a review of the FDA (Federal Food Code), dated 2017, it indicated 4-602.13 Nonfood-Contact
Surfaces. The presence of food debris or dirt on nonfood contact surfaces may provide a suitable
environment for the growth of microorganisms which employees may inadvertently transfer to food.
4. During an observation and concurrent interview with the DSS, on October 25, 2022, at 8:50 AM, in the
kitchen, there was food, black grime, and trash build-up behind and underneath the stove. The DSS stated
it has been like that for a long time but that the area should be kept clean.
During an interview with the RD, on October 27, 2022, at 1:10 PM, she stated her expectation was that the
floors should be clean under all the equipment.
During a review of the FDA (Federal Food Code), dated 2017, it indicated 4-202.16 Nonfood-Contact
Surfaces. Hard-to-clean areas could result in the attraction and harborage of insects and rodents and allow
the growth of foodborne pathogenic microorganisms.
5. During an observation and concurrent interview with Maintenance Supervisor (MS), on October 25,
2022, at 8:50 AM, in the kitchen, the ice machine had brown substance on the ice chute. The MS stated it
should have been cleaned.
During an interview with the RD, on October 27, 2022, at 1:10 PM, she stated her expectation was that the
ice machine should be kept clean.
During a review of the facility's policy and procedure (P&P) titled Ice Machine Cleaning Procedures, dated
2018, it indicated .Clean inside of ice machine with a sanitizing agent per the manufacturer's instructions .
During a review of the FDA (Federal Food Code), dated 2017, indicated 4-601.11 Equipment, Food-Contact
Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) Equipment food contact surfaces and utensils shall
be clean to sight and touch.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056024
If continuation sheet
Page 12 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056024
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/28/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Highland Palms Healthcare Center
7534 Palm Ave
Highland, CA 92346
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, and record review, the facility failed to ensure the Physician Orders for Life-Sustaining Treatment
(POLST- written medical orders that addresses a limited number of critical medical decisions) were filled
out completely for six of nine residents (Residents 22, 34, 56, 58, 71, 77, and 85) reviewed for advance
directives (legal document that states a person's wishes about receiving medical care if that person is no
longer able to make medical decisions).
This failure had the potential to result in a delay of treatment for Residents 22, 34, 56, 58, 71, 77, and 85 as
related to advance directives, or for life sustaining measures to be rendered against what the resident
wanted.
Findings:
1. A review of Resident 22's admission Record (contains demographic information) indicated Resident 22
was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease
(a group of lung diseases that block airflow and make it difficult to breathe), acute respiratory failure with
hypoxia (results from acute or chronic impairment of gas exchange between the lungs and the blood), and
dementia (a mental disorder in which a person loses the ability to think, remember, learn, make decisions,
and solve problems).
During a concurrent interview and record review, with the Director of Nursing (DON), on October 28, 2022,
at 2:00 PM, the DON reviewed Resident 22's POLST, dated February 1, 2021, which indicated Section D Information and Signatures, was unanswered. The DON stated Section D was blank and should have been
completed.
2. During a review of Resident 34's admission Record, it indicated Resident 34 was admitted to the facility
on [DATE], with diagnoses that included cellulitis of right lower leg (a common potentially serious bacterial
skin infection), and hypertensive heart disease with heart failure (heart problems with occur because of
high blood pressure that is present over a long time).
During a concurrent interview and record review, with the DON, on October 28, 2022, at 2:15 PM, the DON
reviewed Resident 34's POLST, dated on February 1, 2021, which indicated Section C - Artificially
Administered Nutrition and Section D - Information and Signatures were unanswered. The DON verified
that Sections C and D were blank and should have been completed.
3. During a review of Resident 56's admission Record, it indicated Resident 56 was admitted to the facility
on [DATE] with diagnoses that included hypertensive heart disease, kidney atrophy (a condition in which
one or both kidneys shrink to a smaller size, thus hindering normal function), and dementia.
During a concurrent interview and record review with the DON, on October 28, 2022, at 2:25 PM, the DON
reviewed Resident 56's POLST, dated September 3, 2022, which indicated Section D - Information and
Signatures, was unanswered. The DON stated Section D was blank and should have been completed.
4. During a review of Resident 58's admission Record, it indicated Resident 58 was admitted to the facility
on [DATE], with diagnoses that includes gastrostomy status (artificial opening to stomach),
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056024
If continuation sheet
Page 13 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056024
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/28/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Highland Palms Healthcare Center
7534 Palm Ave
Highland, CA 92346
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
dysphagia (difficulty or discomfort in swallowing), and cerebral palsy (congenital disorder of movement,
muscle tone, or posture).
During a concurrent interview and record review with the DON, on October 28, 2022, at 2:45 PM, the DON
reviewed Resident 58's POLST, dated September 1, 2022, which indicated Section C - Artificially
Administered Nutrition and Section D - Information and Signatures, were unanswered. The DON stated
Section C and D were blank and should have been completed.
5. During a review of Resident 71's admission Record, it indicated Resident 71 was admitted to the facility
on [DATE], with diagnoses that include abnormal posture (rigid body movements and chronic abnormal
positions of the body), muscle wasting and atrophy (decrease in size and wasting of muscle tissue), and
acute osteomyelitis left ankle (new infection in bone).
During a concurrent interview and record review with the DON, on October 28, 2022, at 2:55 PM, the DON
reviewed Resident 71's POLST, dated September 22, 2022, which indicated Section D - Information and
Signatures, was unanswered. The DON stated Section D was blank and should have been completed.
6. During a review of Resident 77's admission Record, it indicated Resident 77 was admitted to the facility
on [DATE], with diagnoses that included acute embolism and thrombosis of deep veins of right lower
extremity (the condition results from a blood clot that forms in the legs or another part of the body), and
Methicillin Resistant Staphylococcus Aureus Infection (group of Gram-positive bacteria that are distinct from
other strains of the bacteria).
During a concurrent interview and record review with the DON, on October 28, 2022, at 3:05 PM, the DON
reviewed Resident 77's POLST, dated September 23, 2022, which indicated Section D - Information and
Signatures, was unanswered. The DON stated Section D was blank and should have been completed.
During a concurrent interview and record review with the DON, on October 28, 2022, at 3:20 PM, the DON
reviewed the facility's policy and procedure (P&P) titled, Advance Directives, revised September 2022,
which indicated, The resident has the right to formulate an advance directive, including the right to accept
or refuse medical or surgical treatment. Advance Directives are honored in accordance with state law and
facility policy. Under the section titled, Definitions, the policy indicated, .h. Physician Orders for
Life-Sustaining Treatment (or POLST) paradigm form - a form designed to improve patient care by creating
a portable medical order form that records patients' treatment wishes so that emergency personnel know
what treatments the patient wants in the event of a medical emergency, taking the patients current medical
condition into consideration .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056024
If continuation sheet
Page 14 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056024
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/28/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Highland Palms Healthcare Center
7534 Palm Ave
Highland, CA 92346
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to implement infection control and prevention
measures to help prevent and manage transmission of diseases and infections when:
Residents Affected - Few
1. Resident 25's used nebulizer (a device producing a fine spray of liquid) masks and tubing were not
properly stored per facility's policy.
2. Resident 10's used nebulizer masks and tubing were not properly stored per facility's policy.
3. A Licensed Vocational Nurse (LVN 6) failed to perform handwashing or hand hygiene during medication
administration for Residents 42 and 85.
These failures had the potential for cross contamination (physical movement or transfer of harmful bacteria
from one person, object or place to another) and spread of infection which can adversely affect the health
and wellbeing of 91 medically compromised residents.
Findings:
1. During a review of Resident 25's clinical record, the admission Record (contains demographic and
medical information) indicated Resident 25 was re-admitted on [DATE], with diagnoses that included
chronic obstructive pulmonary disease (a condition involving narrowing of the airways and difficulty or
discomfort in breathing), hypertension (high blood pressure), and muscle weakness.
During a concurrent observation and interview with Certified Nursing Assistant (CNA 2), on October 25,
2022, at 10:05 AM, inside Resident 25's room, a nebulizer mask and tubing were seen on top of the
bedside table with a comb, TV remote, and pieces of papers next to it. CNA 2 acknowledged the finding and
stated it was unacceptable. CNA 2 further stated it was hygiene and infection control issues.
During a concurrent interview and record review of the facility's policy and procedure titled Prevention of
Infection Respiratory Equipment revised November 2011, with the Infection Preventionist Nurse (IPN), on
October 28, 2022, at 9:52 AM, the IPN stated the nebulizer mask should be kept inside the plastic bag
when not in use for infection control purposes. The IPN further stated the facility's policy and procedure was
not followed in these instances.
During a review of the facility's policy and procedure (P&P), titled, Prevention of Infection Respiratory
Equipment, revised November 2011, the P&P indicated, Purpose: The purpose of this procedure is to guide
prevention of infection associated with respiratory therapy task and equipment among residents and staff.
Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: 1. Obtain
equipment .4. Store the circuit in a plastic bag, marked with a date and resident's name and replace tubing
and plastic bag once a week.
2. During a review of Resident 10's clinical record, the admission Record indicated, Resident 10 was
admitted on [DATE], with diagnoses that included anemia (condition in which the body does not have
enough healthy red blood cells resulting to reduced oxygen flow to the body), shortness of breath, and
muscle weakness.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056024
If continuation sheet
Page 15 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056024
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/28/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Highland Palms Healthcare Center
7534 Palm Ave
Highland, CA 92346
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During an observation on October 25, 2022, at 10:28 AM, inside Resident 10's room, her nebulizer mask
and tubing were hanging by the nebulizer machine on top of the bedside table.
During a follow up observation and concurrent interview with CNA 3, on October 25, 2022, at 10:32 AM, in
Resident 10's room, CNA 3 acknowledged Resident 10's nebulizer mask and tubing were hanging by the
nebulizer on top of the bedside table. CNA 3 stated it should be kept inside the plastic bag for infection
control reasons.
During an interview with Licensed Vocational Nurse (LVN 2), on October 27, 2022, at 12:46 PM, LVN 1
stated the nebulizer mask should be kept in a plastic bag at the bedside when not in use. She further stated
it should not be left hanging outside the bag to minimize contamination.
During a concurrent interview and record review of the facility's policy and procedure titled Prevention of
Infection Respiratory Equipment revised November 2011, with the Infection Preventionist Nurse (IPN), on
October 28, 2022, at 9:52 AM, the IPN stated the nebulizer mask should be kept inside the plastic bag
when not in use for infection control purposes. The IPN further stated the facility's policy and procedure was
not followed in these instances.
During a review of the facility's policy and procedure (P&P), titled, Prevention of Infection Respiratory
Equipment, revised November 2011, the P&P indicated, Purpose: The purpose of this procedure is to guide
prevention of infection associated with respiratory therapy task and equipment among residents and staff.
Infection Control Considerations Related to Medication Nebulizers/Continuous Aerosol: 1. Obtain
equipment .4. Store the circuit in a plastic bag, marked with a date and resident's name and replace tubing
and plastic bag once a week.
3. During a review of Resident 42's clinical record, the admission Record indicated Resident 42 was
admitted to the facility on [DATE], with diagnoses that included disorder of brain (a non- cancerous or
cancerous disorder that affects the brain), urinary tract infection (an infection in any part of the kidneys,
bladder or urethra), and dementia (mental disorder when a person loses the ability to think, remember,
learn, make decisions, and solve problems).
During a medication administration observation, on October 25, 2022, at 12:05 PM, LVN 4 administered
medications to Resident 85, and headed straight to Resident 42's room without performing handwashing or
hand hygiene. LVN 4 assisted CNA 4 in providing care to Resident 85. LVN 4 then entered the Biohazard
Room to dispose trash and returned back to Resident 42's room.
During a subsequent interview with LVN 4 and CNA 4, on October 25, 2022, at 12:30 PM, LVN 4 and CNA
4 acknowledged that proper handwashing or hand hygiene should have been used between Residents 85
and 42.
During an interview with the IPN, on October 28, 2022, at 9:30 AM, the IPN stated the staff were expected
to practice proper handwashing and hand hygiene when providing care to the residents.
During record review of the facility's policy and procedure titled, Infection Control, revised October 2018,
indicated This facility's infection control policies and practices are intended to facilitate maintaining a safe,
sanitary and comfortable environment and to help prevent and manage transmission of diseases and
infections . Policy Interpretation and Implementation . 2 .c. Establish guidelines for implementing Isolation
Precautions, including Standard and Transmission-Based Precautions.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056024
If continuation sheet
Page 16 of 17
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
056024
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
10/28/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Highland Palms Healthcare Center
7534 Palm Ave
Highland, CA 92346
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
During record review of the facility's policy and procedure titled, Handwashing/Hand Hygiene, revised
August 2019, .7. Use an alcohol-based rub containing at least 62% alcohol; or alternatively, soap
(antimicrobial or non-antimicrobial) and water for the following situations: .b. Before and after direct contact
with residents, c. Before preparing or handling medications g. Before handling clean or soiled dressings,
gauze pads, etc.k. After handling used dressings, contaminated equipment, etc .p. Before and after
assisting a resident with meals.
Event ID:
Facility ID:
056024
If continuation sheet
Page 17 of 17
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
9 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F640 - Automated data processing requirement-
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
F646 - A nursing facility must notify the state mental health authority or state
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F697 - Pain Management
Provide safe, appropriate pain management for a resident who requires such services.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the October 28, 2022 survey of Highland Palms Healthcare Center?
This was a inspection survey of Highland Palms Healthcare Center on October 28, 2022. The surveyor cited 9 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Highland Palms Healthcare Center on October 28, 2022?
Yes, 9 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.