Health inspection·March 19, 2025

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 interview and medical record review, the facility failed to ensure one of two sampled residents (Resident 1) remain free from the accident hazards. * The facility failed to ensure Resident 1 was provided with two-person assistance for transfers. This failure had the potential to place the resident at risk for serious injuries. Findings: Medical record review for Resident 1 was initiated on 3/18/25. Resident 1 was admitted to the facility on [DATE]. Review of Resident 1's Fall Risk Screen dated 3/7/25, showed Resident 1 was at high risk for falls and had a history of falls. Review of Resident 1's plan of care showed a care plan problem dated 3/8/25, addressing the resident's altered skin integrity. The interventions included to provide two-person assistance with transfers and positioning. Review of Resident 1's Nurse Weekly Progress Note dated 3/12/25, showed Resident 1 was dependent on the facility's staff for ADL care and required extensive assistance for transfers. On 3/17/25 at 0919 hours, CDPH, L&C Program received a complaint from Family Member 2. Family member 2 alleged CNA 2 forced Resident 1 to walk without using a wheelchair or walking aids on 3/13 and 3/14/25. On 3/18/25 at 1509 hours, an interview was conducted with CNA 2. CNA 2 was asked how she assisted Resident 1 to the bathroom on 3/13/25. CNA 2 stated she held Resident 1's arm while she ambulated to the bathroom. CNA 2 stated Family Member 1 was present and assisted her with taking the resident to the bathroom. On 3/19/25 at 1128 hours, an interview was conducted with Family Member 1. Family Member 1 stated on 3/13/25 at around 1700 hours, Resident 1 wanted to use the bathroom. CNA 2 came and assisted Resident 1 to use the bathroom. Family Member 1 stated CNA 2 held Resident 1's left arm as the resident ambulated to the bathroom. Family Member 1stated Resident 1 was unstable while ambulating with CNA 2 and almost fell. Family Member 1 stated she called the PT the next day and was told Resident 1 was not cleared to ambulate. (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: 056271 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 056271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Palms Healthcare Center 240 Hospital Circle Westminster, CA 92683 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)