Highland Palms Healthcare Center

for Pre-admission Screening and Resident Review (PASARR- a screening assessment to ensure

[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.During a record review on April 28, 2026, at 8 :44 AM, facility's electronic documents titled PASARR, dated December 20, 2025, was reviewed.

The PASARR indicated, Resident 51 level 1 screening for serious mental illness (SMI- major mental disorder) and Intellectual disability (a person's cognitive function and adaptive skills are affected), developmental disability, or related conditions (ID/DD/RC) was negative and Resident 51 does not require a level 2 screening for mental health evaluation.During a review of Resident 51's admission Record(AR), the AR indicated, Resident 51 was admitted on [DATE] with diagnoses which included, schizophrenia (a serious mental disorder where individuals interpret reality abnormally which leads to symptoms as disorganized thinking) and bipolar disorder (a mental health condition where intense, alternating mood swings between extreme highs and low).

During an interview on April 28, 2026, at 11:30 AM, with RN1, the RN1 stated he was the person responsible in the facility who completes the PASARR for all the admitting residents. RN1 verified and acknowledged that level 1 screening was incorrect as he wrote no for question regarding resident's diagnosis of serious mental illness. RN 1 further stated, incorrect level I screening delays the residents' care and need for level II screening.During a concurrent interview and record review on April 29,2026, at 3:30 PM, with Director of Nursing (DON), the facility's policies and procedures (P&P) titled, admission Criteria PASARR, dated March 2019, was reviewed.

The P&P indicated, .9.

All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-admission Screening and Resident Review (PASARR) process. a.

The facility conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if the individual meets the criteria for an MD, ID or RD. b. If the level I screen indicates that the individual may meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. (I) The admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID or RD.

The DON verified and acknowledged that PASARR was documented incorrectly.

The DON stated that the policy was not followed as RN did not complete the level 1 screening.

056024 04/30/2026

Highland Palms Healthcare Center 7534 Palm Ave Highland, CA 92346

During a further review, of the TAR indicated a treatment order for APP Mattress.

Set to Resident's weight Check to ensure proper placement and function.

Every shift for mattress check.

Start date December 13, 2025 at 07:00 AM.

There was no documented evidence that the treatment was completed during evening shift on the following date: i.

April 9, 2026, evening shiftA total of one (1) occurrence of missing documentation was identified and confirmed with the TN 1.

The TN 1, stated the treatment should have been documented as completed.

During a concurrent interview and record review on April 30, 2026, at 11:57 AM with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled Physician Orders, Accepting, transcribing, and implementing (noting) was reviewed.

The P&P indicated, All physician orders are to be complete and clearly defined to ensure accurate implementation. the DON stated the policy was not followed by the staff because care was not recorded as completed in the Treatment Administration Record.

056024 04/30/2026

Highland Palms Healthcare Center 7534 Palm Ave Highland, CA 92346

Based on observation, interview, and record review, the facility failed to ensure medications were

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.

The License Vocational Nurse (LVN 1) was observed down the hallway administering medications, leaving the cart unsecured, and unattended.During a concurrent observation and interview on April 29, 2026, at 6:02 AM, with the facility Consultant 1, (C1), C1 walked by Medication cart 1 and noted the lock was found dislodged from its secured position, resulting in the cart being left unsecured and accessible.

The C1 manually pushed the lock back to secure the cart.

The C1, confirmed the Medication cart 1, had been left unlocked and unattended. C1 stated the Medication cart should not be left unlocked because it can be accessible to anyone, including residents and visitors.

During an interview on April 29, 2026, at 6:22 AM, with LVN 1, LVN 1 acknowledged that leaving the Medication cart 1 unattended and unlocked is not a safe practice. LVN 1 further stated the cart may have been left open after medication administration, approximately at 5:25 AM.During a concurrent interview and record review on April 30, 2026, at 10:01 AM, with the Director of Nursing (DON), in his office, the facility's policy and procedure (P&P) titled, Storage of Medications dated Revised April 2007 was reviewed.

The P&P indicated, . 7.

Compartments containing drugs and biological shall be locked when not in use, and trays or carts sued to transport such items shall not be left unattended if open or otherwise potentially available to others.

The DON stated that medication carts are required to remain locked at all times when not in used to avoid unauthorized access.

serve food in accordance with professional standards.

when the walk-in refrigerator had a wet box containing cold cut meat sitting on top of a thawing roast

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.During a follow up interview with DS on April 27, 2026, at 3:20 PM, DS stated, the box contains individually rapid cold cuts. DS stated, the cold cut should have been taken out of the box and placed on a pan.During a concurrent interview and record review on April 27, 2026, at 4:39 PM, with Administrator (Admin), the facility's policy and procedure (P&P) titled Thawing of Meats, dated 2023, was reviewed.

The P&P indicated, . a.

Use a drip pan under food being thawed so drippings do not contaminate other food.

The Admin stated, the cold cut should have been taken out of the box and placed on a drip pan.

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 TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

056024 04/30/2026

Highland Palms Healthcare Center 7534 Palm Ave Highland, CA 92346

During a concurrent interview and record review on April 29, 2026, at 1:30 PM, with the DON, the

indicated, .Purpose: The purpose of this procedure is to provide guidelines for aseptic administration set changes in order to prevent infections associated with contaminated IV therapy equipment.

Preparation: Assemble equipment and supplies as needed.

Assess equipment for sterile condition. Do not use if not sterile.

General Guidelines : 1.

Adhere to Standard-ANTI when connecting, changing and accessing administration set injection ports.

The DON acknowledged that RN 1 did not follow the process correctly. DON stated, it is not acceptable to carry a medication in his scrub pants pocket to be administered for a resident, it is a concern for infection. DON further stated, the policy was not followed.

During a concurrent interview and record review on April 30,2026, at 12:45 PM, with Admin, the facility's P&P tilted IPCP, dated October 2018 was reviewed.

The P&P indicated, An infection prevention and control program (IPCP) is established and maintained to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

The Admin stated, RN should have done that, it is a concern for infection control.

056024 04/30/2026

Highland Palms Healthcare Center 7534 Palm Ave Highland, CA 92346