Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0684
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview and record review for one of three sampled residents (Resident 1), the facility failed to
follow their policy and procedure for:
Residents Affected - Few
a. Change of Condition for weight loss.
b. To notify responsible party (RP) of left foot discoloration.
This failure resulted in Resident 1 having unplanned weight loss and (RP) uniformed and unaware in foot
discoloration changes.
Findings:
During review of Residents 1's admission Record (general demographics), the document indicated
Resident 1 was admitted to the facility on originally on October 30, 2021 and readmit August 20, 2023, with
diagnoses to include: metabolic encephalopathy (chemical imbalance in the blood/brain), hemiplegia and
hemiparesis following cerebral infarction (muscle weakness or paralysis on one part of body due to stroke),
pyelonephritis (kidney infection), vitamin B12 deficiency (can lead to reduction on red blood cells).
During a concurrent interview and record review of Resident 1's Medical Record with the Director of
Nursing (DON), reviewed are as follows:
1. Cognitive patterns Section C, Brief Interview for Mental Status dated August 31, 2023, score 10. History
and Physical dated November 09, 2022, decision making, fluctuating.
2. Weights October 01, 2023= 142 Lbs. (pounds), October 08, 2023=138 Lbs., October 22, 2023=125 Lbs.,
November 03, 2023= 119 Lbs. From October to November approximately a 16.19% weight loss.
3. Facility cannot provide documentation of a Change in Condition due to weight loss starting in October
2023 and continuing November 2023 and on.
4. Nurse Progress Notes dated November 21, 2023, at 20:28 .Patient family at beside concerned about
patients decrease in weight. Doctor contacted and ordered Dietician consult and asked if family would
consider PEG tube feeding (percutaneous endoscopic gastrostomy, feeding tube through stomach).
Daughter will discuss with family members and let facility know about PEG tube feeding.
5. Careplan Weight Loss: Resident has an actual significant weight loss of 5 lbs. in 7 days. Date initiated
December 13, 2023, Revision on December 13, 2023. Will have no significant weight change of
(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 2
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
02/22/2024
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 0684
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
5 % or more per month. Activities to promote intake. Administer medications as ordered, appetite stimulants
as ordered, monitor for side effects, and notify physician if observed. House supplements as ordered. Labs
as ordered. Report results to physician. Monitor vital signs per protocol. Report significant abnormalities to
physician, RD to evaluate as indicated.
6. Progress Note: Skin/Wound Note dated January 06, 2024, at 10:08: New skin assessment completed
with the following .Purple discoloration to left foot (Related To poor discoloration History of heart disease.
Patient's legs and foot noted to be cold to touch .doctor notified, orders carried out . (NO FAMILY
NOTIFICATION New Skin assessment and finding).
During an interview with the Director of Nursing (DON), the (DON) stated, Sometime in November Resident
1 started losing a lot of weight. We had Registered Dietician (RD) do interventions when the ideal body is
not met is when we did are Change of Condition (COC) and G-tube (feeding tube) interventions. Family
was notified and documented December 13, 2023. We were waiting for the resident's family to make
decision on feeding tube, the responsible party wanted to discuss with her family. She didn't think she was
going to make it through the procedure. There is no COC on Oct to November 2023 regarding weight loss
but there is RD notes regarding weight loss. I don't have a COC regarding the weight loss, it should have
been done after the significant weight loss. We did not notify the daughter of the discoloration of her foot.
The resident was refusing to have the skin assessment. The discoloration was due to arterial disease, that
was part of disease process and was inevitable. We should have notified the daughter of this, and we did
not.
During a review of the facility's policy and procedure titled, Change in a Resident's Condition or Status
revised February 2021, the policy and procedure indicated, Our facility promptly notifies the resident, his or
her attending physician, and the resident representative of changes in the resident's medical/mental
condition and/or status . 1.The nurse will notify the resident's attending physician or physician on call when
there has been a(an): d. significant change in the resident's physical/emotional/mental condition; 2. A
significant change of condition is a major decline or improvement in the resident's status that: a. will not
normally resolve itself without intervention by staff or by implementing standard disease-related clinical
interventions (is not self-limiting ); c. requires interdisciplinary review and/or revision to the care plan; and
.3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and
gather relevant and pertinent information for the provider, including (for example) information prompted by
the Interact SBAR Communication Form. 4. Unless otherwise instructed by the resident, a nurse will notify
the resident's representative when: b. there is a significant change in the resident's physical, mental, or
psychosocial status.
During a review of the facility's policy and procedure titled, Weight Assessment and Intervention revised
March 2022, the policy and procedure indicated, Resident weights are monitored for undesirable or
unintended weight loss or gain. Care Planning 1. Care planning for weight loss or impaired nutrition is a
multidisciplinary effort and includes the physician, nursing staff, the dietitian, the consultant pharmacist, and
the resident or resident's legal surrogate.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
056024
If continuation sheet
Page 2 of 2
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
1 citation 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.
F684 - Quality of care
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
FAQ · About this visit
Common questions about this visit
What happened during the February 22, 2024 survey of Highland Palms Healthcare Center?
This was a inspection survey of Highland Palms Healthcare Center on February 22, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Highland Palms Healthcare Center on February 22, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate treatment and care according to orders, resident’s preferences and goals."
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.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.