Mission Park Healthcare Center

Based on observation, interview, record review, and facility policy review, the facility failed to ensure an incident report was completed and a post-fall assessment and investigation was completed after 1 (Resident #1) of 1 sampled resident reviewed for accidents sustained a fall. Findings included: A facility policy titled, Fall Risk Assessment, dated 10/01/2023, indicated C. An episode where a resident lost his/her balance and would have fallen, if not for staff intervention or the if the resident caught themselves, is considered a fall. D. A fall without injury is still a fall. A facility policy titled, Fall Management Program, dated 10/01/2023, indicated IV. Post-Fall A. Following a resident's fall, the licensed nurse will complete an incident report and a Post-Fall Assessment & Investigation within 24 hours or as soon as practicable. B. The Licensed Nurse will review the circumstances of the fall, review the plan of care, implement new interventions as appropriate, and revise the plan as indicated. An admission Record indicated the facility admitted Resident #103 on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and facility policy review, the facility failed to ensure pain medication was available for administration for 1 (Resident #267) of 3 sampled residents reviewed for pain management. Findings included: A facility policy titled, Ordering and Receiving Controlled Medications, dated 01/2020, indicated, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances, and medications classified as controlled substances by stated law, are subject to special ordering, receipt, and record keeping requirements in the nursing care center in accordance with federal and state laws and regulations. The nursing care center obtains and keeps current and on file any permits require by state agencies. The policy specified, If only one refill remains or only a partial fill quantity remains, the pharmacy will simultaneously dispense the remaining fill, and, if necessary proactively seek out a new, complete prescription form the prescriber for a new…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure resident ' s representative (RR) was invited and included in the formulation of a person-centered baseline care plan (CP -implementation of care plan goals and interventions) that was to be done within 48 hours of resident ' s admission when the facility discussed the initial plan of care to one of two cognitively impaired (problems with ability to think, learn and remember) sampled residents (Resident 1). This failure resulted in RR being uninformed and was not given at the opportunity to participate in making decisions for Resident 1 ' s initial plan of care, treatment, and healthcare goals that could affect Resident 1 ' s care and quality of life. Findings: During a review of the facility ' s policy and procedure (P&P), titled, Care Planning, dated 10/2023, the P&P indicated, in part, I. The facility will develop a person-centered Baseline Care Plan for each resident within 48 hours of admission .A. The facility will invite the resident, if capable, and their family to the care planning meetings and use its best…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to provide resident or the resident ' s representative (RR) a summary of the baseline care plan (initial plan of care) for one of two sampled residents ' (Resident 1). This failure resulted in RR to have no knowledge of the initial care plan goals and interventions being provided to Resident 1. Findings: During a review of the facility ' s policy and procedure (P&P) titled, Care Planning, dated 10/2023, the P&P indicated, in part . I. The facility will develop a person-centered Baseline Care Plan for each resident within 48 hours of admission .Once the Baseline Care Plan is completed, the Facility must provide the resident and /or the resident ' s representative with a written summary of the Baseline Care Plan that includes: A. Initial goals based on admission orders. B. Physician ' s orders. C. Dietary orders. D. Therapy Services. E. Social services. F. PASARR recommendations, if applicable .The medical record must contain evidence that the summary was given to the resident and/or resident ' s representative. During a review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to keep one of three residents (Resident 1) free from abuse when the resident was the victim of sexual abuse by Resident 2. This failure resulted in psychosocial harm to Resident 1 and had the potential to result in harm to other female residents. Findings: During a review of Resident 1's Medical Record, the Medical Record indicated, Resident 1 had diagnoses that included, anxiety disorder (persistent and excessive worry and fear) and aftercare following joint replacement surgery. Further review shows, Resident 1 had decision making capacity. During an interview on 4/2/2024 at 9:55 a.m. with Resident 1, Resident 1 explained that when she was in the hallway, Resident 2 approached her and asked about the cast on her leg. Resident 1 stated, I said it's a cast and it's very heavy. He asked if he could touch it, and I said yes, and he reached down and touched it and within a second, he reached up and grabbed my right breast, and I said no you can't do that! He said please let me touch you, and I said no you can't do…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and record review, the facility failed to report sexual abuse within two hours per regulation and their abuse policy and procedure when one of three residents (Resident 3) was the victim of sexual abuse by Resident 2. This failure had the potential to result in further harm to Resident 3 and harm to other female residents. Findings: During a review of the facility'ss policy and procedure (P&P) titled, Abuse Prevention and Prohibition Program, dated October 1, 2023, the P&P indicated, IX. Special Considerations for Reporting Suspected Incidents of Criminal Sexual Abuse A. Anyone who suspects that criminal sexual abuse has been committed against a resident must immediately report this information to Administrator and to the Director of Nursing Services. i. The Facility will treat allegations as criminal sexual abuse wherein the Facility determines that the resident does not have the decision-making capacity to consent to the sexual act. B. The Director of Nursing Services or designee will immediately report this information to the Attending Physician. C. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, and interview, the facility failed to adhere to their medication administration policy and procedures, for two of two sampled Residents (Resident 1 and Resident 2). This facility failure had the potential for both residents to experience negative outcomes. Findings: During a review of Resident 1 ' s Order Summary Report undated, indicated in part, Resident 1 had an order for Metoprolol Tartrate (a medication used to treat high blood pressure, referred to as hypertension). The order read Metoprolol Tartrate Oral Tablet 25 MG (milligrams) Give 25 mg by mouth one time a day for HTN (Hypertension > high blood presure) Hold if SBP (systolic blood pressure) less than 110 and HR (heart rate) less than 55 (55 heart beats per minute). During a concurrent record review, and interview, on 4/9/24 at 2:52 p.m., with Licensed Nurse LN 2, and the Director of Nursing (DON), Resident 1 ' s Medication Administration Record (MAR) indicated, from 12/23 through 1/24, Resident 1 received the medication Metoprolol Tartrate on 12/22/23, 12/25/23, 12/26/23, 12/27/23, 12/28/23,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to follow a physician's order for treatment and care as ordered for one of two sampled residents (Resident 1). This failure had the potential to result in increased swelling and complications to Resident 1's affected elbow. Findings: During a review of Resident 1's admission physician office note dated 09/08/2023, Resident 1 was admitted to the facility for 10 days for respite care (provides short-term relief for primary caregivers). During a review of Resident 1's nurses notes dated 09/08/23, this indicated Resident 1 was alert to self only with episodes of confusion with redirection from staff. During a review of Resident 1's physician office visit note dated 09/08/23, Resident 1 had left elbow bursitis (a painful swelling, usually around your joints) and to compress Resident 1's elbow with an ACE Bandage (a stretchable bandage that provides a gentle pressure that helps reduce swelling) or compression sleeve (applies a therapeutic compression to the elbow joint to improve blood flow and promote healing of elbow injuries).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure a person centered careplan was developed and implemented for one of two residents (Resident 1) per the facility's policy and procedure regarding a physician order (PO) to monitor and record Intake and Output (Intake refers to the number of fluids the client ingests, and output refers to the amount of fluids that leave the body) every shift for Foley catheter ( FC- rubberized tube inserted into the bladder for urine passage) use. This failure has the potential to not have a plan in place on how to care and direct staff in managing the resident's bodily input and output which can either result to urine retention detrimental to the resident's overall health. Findings: During a review of Resident 1's medical record titled face sheet(a document that gives a patient's information at a quick glance) indicated, an admission date of 11/1/23 with diagnoses that included Hypotension (Low blood pressure) Heart Failure (occurs when the heart muscle doesn't pump blood as well as it should) Chronic Kidney Disease ( condition in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to provide adequate supervision for one of two sampled residents (Resident 1), when Resident 1 eloped (a situation in which a resident with impaired cognition or poor safety awareness or judgment successfully leaves the facility undetected or unsupervised by staff) across a street, on two separate occasions. This facility failure had the potential for Resident 1 to suffer negative outcomes. Findings: During a review of Resident 1's admission Record undated, indicated in part, Resident 1 was admitted to the facility on [DATE], with diagnoses including dementia, history of falling, mild cognitive impairment, muscle weakness and other abnormalities of gait and mobility. During a review of Resident 1's care plan, undated, indicated in part Resident 1 was a High Elopement Risk related to Cognitive impairment, exit seeking behaviors, ability to move around independently in wheelchair. Resident 1's care plan further indicated Resident 1 had actual elopement from…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to implement one of two sample residents' (Resident 1's) care plan. This facility failure resulted in Resident 1 crying, verbalizing feeling depressed, expressing suicidal ideations, and delayed psychiatry services for possible medication regime adjustments. Findings: During a review of the facility's policy and procedure (P&P) titled, Comprehensive Plan of Care, dated 12/16, the P&P indicated, The comprehensive care plan must describe services that are provided to the resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. During a review of Resident 1's care plan titled, [Name] has a psychosocial well-being problem r/t suicidal ideation, initiated on 7/11/23, the care plan indicated in the Interventions part, Consult with . Psych services, Other: During a concurrent observation and interview, on 7/19/23, at 2:30 p.m., with Resident 1, in the facility, the resident started crying…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to notify the Physician of a change of condition (COC) for one of two sampled residents (Resident 1), when resident expressed suicidal ideations, continued exhibiting symptoms of depression, i.e., continuously crying, as per standards of practice and their policy and procedure (P&P). This facility failure resulted in resident suffering psychologically as evidence by crying, verbalizing feeling depressed, expressing suicidal ideations and a delay in psychiatry services for possible medication regime adjustments. Findings: According to the Standards of Competent Performance, California Code of Regulations, Title 16, Section 1443.5 (5): A registered nurse (RN) shall be considered to be competent when he/she consistently demonstrates the ability to transfer scientific knowledge from social, biological and physical sciences in applying the nursing process, as follows: · evaluate the effectiveness of the care plan through observation of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure an accurate system for monitoring the effectiveness of nutrition interventions in order to have the ability to identify and evaluate when to revise as necessary, and for comparison of nutrition intake to the assessed daily nutrition needs, per facility policy and procedure, for one of 14 sampled residents (Resident 53). This failure had the potential to result in inaccurate nutrition assessment and potential delay in identifying and evaluating the necessity of an alternative nutrition approach. Findings: During a review of the facility's policy and procedure (P&P) titled, Nutrition Assessment, dated January 2022, the P&P indicated, The resident will be seen in a timely manner, assessed and a plan put in place to identify and address nutritional concerns. Procedure 3. Comprehensive Nutrition Assessment d. Determine calorie, protein and fluids needs, compare to food/fluid intake . During a concurrent observation and interview on 01/19/22, at 11:40 a.m., inside Resident 53's room, Resident 53 was eating…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to ensure a completed Minimum Data Set (MDS, an assessment tool) were transmitted timely per regulation for one sampled resident (Resident 6) and four un-sampled residents (Residents 4, 5, 7 and 36). This failure resulted in the facility's non-compliance with the regulatory requirements and with the potential for records unaccountability of resident's whereabouts and current conditions. Findings: A review of facility MDS transmittal records was condcuted on 5/2/19 and the following were noted. -Resident 4 was discharged on 11/17/18 and the MDS assessment for discharge was completed on 11/29/18. -Resident 5 was discharged on 12/3/18 and the MDS assessment was completed on 12/17/18. -Resident 6's quarterly assessment was completed on 3/18/19. -Resident 7 was discharged on 1/29/19 and MDS assessment was completed on 2/1/19. -Resident 36's significant change of condition assessment was completed on 3/28/19. On 5/2/19 all five assessments were found not transmitted to the federal database and pass the 14 days requirement for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.