Mission Palms Post Acute: Wound Care Monitoring Failure - AZ
The patient, identified in the inspection report as Resident 4, said staff placed the wound vac on his left foot in mid-August 2025. He had it on for about five days when he started feeling pain. He told staff, they removed the device and wrapped the foot. By the time federal inspectors arrived on August 25, the wound vac was gone, and Resident 4 was left with the belief that the device had done more damage than good.
A wound vacuum, used to promote healing in open wounds, works by applying continuous negative pressure to draw out fluid and encourage tissue growth. When the seal breaks, that pressure is lost. The device stops working as intended, and depending on how long the leak goes undetected, the wound underneath can deteriorate.
Staff knew this. The Licensed Practical Nurse on the floor, identified as Staff 128, told inspectors that the wound vac had been removed the prior week because of a leak in the seal. She described the monitoring routine clearly: check the device each shift for seal integrity, document it in the medication administration record, and if there's a leak, stop the vac and notify the physician immediately. That was the protocol. Nurses were supposed to catch a failing seal before a patient spent hours in pain wondering why his foot felt worse.
The Director of Nursing, identified as Staff 193, confirmed during his interview at 4:02 p.m. on August 25 that he expected floor nurses to check the wound vac every 12 hours. He also confirmed that the overnight nurse did not sign off on monitoring the wound vac the night of August 17, 2025.
One shift. One missed check. One unsigned line in the chart.
The Director of Nursing did not dispute the lapse. His expectation was every shift, he said. The overnight of August 17 did not meet that expectation. What he did not say, and what the inspection report does not answer, is how long the seal had been failing before anyone caught it, or whether the missed overnight check was the moment the leak went undetected long enough to matter.
Resident 4's account suggests it mattered. He described pain. He described worsening wounds. He was the one who told staff something was wrong, not the other way around.
The facility's own wound management policy, last reviewed in September 2024, states that a resident with a pressure ulcer receives the treatment and services necessary to promote healing, prevent infection, and prevent new avoidable sores from developing. It also states that all wound treatments must be documented in the resident's clinical record at the time they are given. The overnight nurse's failure to sign off was not just a paperwork gap. It was the absence of the documentation that would have shown the wound vac was being watched.
Inspectors cited the deficiency under F0686, which covers pressure ulcer treatment and prevention. The level of harm was listed as minimal harm or potential for actual harm. Few residents were noted as affected.
Resident 4 had a different accounting of the harm. He felt it in his foot for five days before he said something.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mission Palms Post Acute from 2025-08-25 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 3, 2026 · Our methodology
MISSION PALMS POST ACUTE in MESA, AZ was cited for violations during a health inspection on August 25, 2025.
The patient, identified in the inspection report as Resident 4, said staff placed the wound vac on his left foot in mid-August 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.