Highland Palms Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that call light (a device that allows residents to communicate with nursing staff when they need assistance) was within resident's reach for one (1) of the five (5) sampled residents (Resident 1), when Resident 1's call light was found to be wrapped around the bedrail and out of Resident 1's reach. This failure had the potential to result in Residents 1's needs not being addressed when needed help, placing him at risk of injury. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a sanitary kitchen when the walk-in refrigerator had a wet box containing cold cut meat sitting on top of a thawing roast beef inside the container. This failure had the potential to cause food borne illness (illnesses contracted from eating contaminated food or beverages) to 91 of 91 medically compromised residents who received food from the kitchen. During a concurrent observation and interview on April 27, 2026, at 9:08 AM, with the Dietary Supervisor (DS), in the kitchen, the walk-in refrigerator was inspected. There was a wet box thawing inside a plastic container. When DS lifted the wet box, a thawed roast beef under was observed. DS opened the contents of the wet box and stated the box contained cold meat. and it was sitting on top of the thawing roast beef. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control and prevention practices for two of four sampled residents (Resident 36 and 122) when:1. Resident 122's foley catheter bag (a drainage unit attached to an indwelling catheter to collect urine) was on the floor, while Resident 122 was in the dining room. 2. One Registered Nurse 1 (RN 1) carried pre-prepared Intravenous medication (IV- into the vein) in his scrub pocket before administering it through a peripherally inserted central catheter (PICC line - a very long thin flexible tube inserted into the large vein in the upper arm and threaded to a vessel just above the heart) to one vulnerable resident (Resident 36). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a complete and accurate clinical records (documentation used to show that ordered treatments and care were provided) for one of eight sampled residents (Resident 10) reviewed for treatment orders when monitoring and care for indwelling urinary catheter (a tube inserted into the bladder to drain urine that requires routine care and monitoring) and APP mattress (a special air mattress used to prevent skin breakdown that requires routine monitoring to ensure proper function) were not documented for multiple days from March 2026 through April, 2026. This failures had the potential to result in unverified treatment orders, lack of continuity for care, and increase for adverse outcomes, including infection, skin breakdown, and decline in residents conditions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Electronic Health Records (EHR- medical records kept on a computer system) was kept secure for one of five sampled residents (Resident 132), when a Licensed Vocational Nurse (LVN 1) left Resident 132's health information on the computer screen unattended and visible to the public in the hallway. This failure had the potential to place Resident 132's confidential information at risk of disclosure to unauthorized individuals. During a concurrent observation and interview on April 29, 2026, at 09:25 AM, with the LVN 2, the LVN 2 logged into the computer on top of the medication cart, checked Resident 132's EHR, and prepared the medication. LVN 2 then proceeded to go inside room [ROOM NUMBER] without logging off the computer, and administered the medications. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure its policy and procedure (P&P) for Pre-admission Screening and Resident Review (PASARR- a screening assessment to ensure individuals who are identified to have a significant mental illness [SMI] or intellectual/developmental [I/DD] disability are appropriately placed in nursing homes for long term care) was followed for one out of six residents (Resident 51) when Registered Nurse 1 (RN 1) assessed and documented the level 1 PASARR incorrectly. This failure had the potential to result in Resident 51's condition not being identified prior to admission and the needs for treatment and services not being accurately assessed, placing Resident 51 at risk for unmet mental health needs. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were secured to prevent unauthorized access when one of four medication carts (Medication cart 1), was unattended and unlocked in a common area accessible to residents, staff, and visitors. This failure had the potential to result in medications being accessible, diverted, or used inappropriately by unauthorized individuals. During an observation on April 29, 2026 at 5:59 AM, medication cart 1, was observed unattended and unlocked. The cart was parked directly in front of the Nurses' Station I near the main entrance of the building, an area accessible to residents, staff, and visitors. The medication cart contained eight drawers. On the top of the cart, there was a binder labeled Station I Narcotic & Antibiotic Record. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of sexual abuse involving one of four sampled residents (Resident 1). This failure prevented the California Department of Public Health (CDPH) from ensuring the facility was taking appropriate actions to protect residents from abuse, which could jeopardize the safety and well-being of residents within the facility.

Inspectors wroteBased on interview and record review, the facility failed to investigate an allegation of sexual abuse involving one of four sampled residents (Resident 1). This failure had the potential for the facility to not identify the concern or any potential harm, allowing ongoing or future abuse to continue which could jeopardize the health and safety of highly vulnerable residents living in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to document a change of condition for one of six sampled residents (Resident 42) when Resident 42 had new physician orders on October 30, 2024, for moisture associated skin damage (MASD-describes a range of skin conditions that occur when the skin is exposed to moisture for a prolonged period of time). This failure had the potential to result in delayed care and treatment for Resident 42 and cause harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive care plan (an individualized plan for the medical care of a resident) for smoking for one of one resident (Resident 70) investigated for smoking. This failure resulted in the facility to not have a plan of care regarding Resident 70's smoking privileges and facility interventions to ensure a safe smoking environment. This had the potential to increase the risk of accidents or injuries associated with fire hazards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow physician orders in accordance with the facility's policy and procedure for one of six sampled residents (Resident 44) when Resident 44's enteral feeding (nutrition feeding through a tube into the stomach) was found running at 65 mL/hr (ml-milliliters - a unit of measurement, hr-hour, amount given in an hour) instead of 60 mL/hr, on October 31, 2024 as specified by physician order. This failure had the potential to result in Resident 44 receiving extra calories than ordered by the physician and excessive weight gain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one resident (Resident 73) investigated for respiratory care, received services as specified by the physician's orders when Resident 73's tracheostomy (a surgically created hole in the windpipe [trachea] that provides an alternative airway for breathing) was not monitored for redness, discharge, and discoloration every shift. This failure had the potential for Resident 73 to experience a delay in the staff identification and subsequent treatment of possible complications with his tracheostomy (such as infection) which would affect the resident's overall health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility's policies and procedures for destruction, final disposition, and disposal for medications were followed when six medication tablets were found on top of the medication waste receptacle, available for use on [DATE]. This failure had the potential for the misuse of expired and discarded medications that could harm residents when administered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired medications were removed from one of the two facility's medication supply rooms when one expired intravenous (IV-a method of delivering fluids, nutrients, medications, or blood directly into a vein using a needle or tube) antibiotic (medicine that treats bacterial infections by killing bacteria or preventing them from growing and multiplying) was found in the medication fridge, readily available for use on October 30, 2024. This failure had the potential for the IV antibiotic to have decreased efficacy (ability to produce a desired result) and sub-therapeutic (less than optimal) effects when administered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices when Certified Nursing Assistant 1 did not don (put on) a gown upon entering the room of a resident (Resident 391) who was on contact precautions (a set of measures to prevent the spread of infectious agents through direct or indirect contact with a patient or their environment) on October 29, 2024. This failure had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi, or parasite) to 91 medically compromised residents and staff in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were properly stored in accordance with facility ' s policies and procedures and standards of practice when one of three residents, Resident 3 was observed to have these medications stored at his bedside unlocked: 1. One opened bottle of Genvoya (used to treat infections). 2. An injection pen of Ozempic (used to treat diabetes). This failure had the potential to place Resident 3 ' s health at risk for drug abuse and ingestion of unsanitary drugs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of four sampled residents (Resident 1) received treatment and care in accordance with professional standards of practice. This failure had the potential to delay and promote wound healing for Resident 1 when one staff did not cover the surgical site (a cut in the skin made by a doctor) during surgery) with dry dressing per physician ' s order.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a comprehensive person-centered care plan for one of four sample residents (Resident 1) who had used and tested positive for an illicit drug (a drug that is not allowed by the law). This failure had the potential to place Resident 1's overall health and safety at risk.

Inspectors wroteBased on interview and record review for one of three sampled residents (Resident 1), the facility failed to follow their policy and procedure for: 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.

Inspectors wroteBased on interview and record review, the facility failed to report for one of three sampled residents (Resident 1) per there policy and procedure to the state agency and the local ombudsman for an alleged physical abuse by staff member towards (Resident 1). This failure has the potential to put (Resident 1) health, safety, and well-being at risk.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a sanitary kitchen in accordance with professional standards for food service safety when: 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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 cause psychosocial harm leading to low self-esteem, feeling irritated, sad, and anxious.

Inspectors wroteBased 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). 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. 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.

Inspectors wroteBased 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: 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.