Mission Palms Post Acute: Wound Care Monitoring Lapse - AZ
The wound vac had been reapplied after a seal leak the week before. A staff member told inspectors that nurses are supposed to check the device every shift, mark the medication administration record after each check, and call the physician immediately if the seal breaks again. Nobody did that the night of August 17.
The Director of Nursing confirmed it himself. In an interview on August 25, he told inspectors that his expectation is clear: wound vacs get monitored every 12 hours, and if there is any problem with the seal, the physician gets called. He acknowledged the overnight nurse had not signed off on monitoring that night.
A seal failure on a wound vac is not a minor paperwork problem. When the device loses its seal, it stops working. For a resident already managing a pressure ulcer serious enough to require a vacuum-assisted closure device, hours without proper negative pressure can stall healing and open the door to infection.
The facility's own wound management policy, last reviewed in September 2024, states that residents with pressure ulcers receive treatment to promote healing, prevent infection, and prevent new sores from developing, and that all wound treatments must be documented in the clinical record at the time they are given.
The documentation gap means there is no way to know whether the wound vac was working through the night, or whether the resident's wound went unmonitored while staff moved through other tasks and the device sat unexamined in the dark.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
MISSION PALMS POST ACUTE in MESA, AZ was cited for violations during a health inspection on August 25, 2025.
The wound vac had been reapplied after a seal leak the week before.
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.