F 0622
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Not transfer or discharge a resident without an adequate reason; and must provide documentation and
convey specific information when a resident is transferred or discharged.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews and record review, the facility failed to ensure the code status (a legal document or instruction
that outlines a patient's wishes regarding medical care, particularly if they experience a cardiac or
respiratory arrest) and presence of medical device was communicated accurately to the receiving facility
when the resident was transferred to the acute hospital, for one of three residents sampled (Resident A).
This failure had the potential to result in Resident A not to receive the correct code status during the
resident's hospital stay, and could have a delay in care and treatment when the presence of medical device
was not initially communicated to the receiving facility.
Findings:
On [DATE], at 9:30 a.m., an unannounced visit to the facility was conducted to investigate for a complaint of
resident rights and quality of care.
On [DATE], at 10 a.m., a review of Resident A's medical record was conducted. Resident A was admitted to
the facility on [DATE], with diagnoses which included respiratory failure, tracheostomy (a surgical procedure
where an opening is created in the neck to insert a tube into the trachea, allowing air to enter the lungs and
bypass the mouth, nose, and throat), and aphasia (a language disorder resulting from brain damage).
Resident A's POLST (Physician Orders for Life-Sustaining Treatment - a portable medical order that helps
people with serious illnesses make and communicate their choices about medical treatments they do or do
not want to receive during serious illness), dated [DATE], indicated, .attempt resuscitation/CPR
(cardio-pulmonary resuscitation-a method used to revive the heart and lungs, to sustain life) .full treatment .
Resident A's Hospital Transfer Form, dated [DATE], at 12:35 p.m., indicated .Code status .DNR (do not
resuscitate) .02 at 1% . The document did not include the type and size of the tracheostomy tube.
Resident A's Respiratory Therapy (RT) Notes, dated [DATE], at 1:16 p.m., indicated .O2 (oxygen) 98% .
trach (tracheostomy tube) secured and intact .removed off vent (ventilator-a medical device that helps a
person breathe when they are unable to do so on their own) per husband's request and placed on T-bar (a
medical device, placed on a tracheostomy tube, to help with breathing and allows for the delivery of
oxygen) tolerated well .husband refused for downsized trach from Shiley (a type of tracheostomy tube that
is flexible) 7 cuffed (an option on a tracheostomy tube) to Shiley 6.5 cuffless
(continued on next page)
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
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
055542
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
055542
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
04/16/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Mission Care Center
8487 Magnolia Avenue
Riverside, CA 92504
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0622
even after husband requesting to downsize trach .
Level of Harm - Minimal harm
or potential for actual harm
A review of Resident A's Social Service Notes, dated [DATE], at 12:10 p.m., indicated . [family member]
.was able to sign the new POLST for FULL code .he wants her (Resident A) out to the acute hospital. He
wants to admit her (Resident A) to the hospital and hold her there until he can take her home .
Residents Affected - Few
On [DATE], at 1 p.m., an interview was conducted with the Registered Nurse (RN). The RN stated when a
resident was sent out, transferred to the hospital, the facility would fill in a transfer form, which would
include most of the information about the resident. The RN stated the type of trach and size of the trach
should be noted on the transfer form, and the current code status should also be indicated in the transfer
form.
On [DATE], at 2:30 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated
Resident A's transfer form indicated DNR, and the tracheostomy size and type should have been indicated
on the transfer form, the [family member] changed the POLST to full code the morning of Resident A ' s
transfer.
On [DATE], at 1:20 p.m., an interview was conducted with the Respiratory Therapist (RT). The RT stated at
the time of Resident A's discharge from the facility, on [DATE], Resident A was a full code, not a DNR.
A review of the facility's policy titled Transfer and Discharge, dated [DATE], indicated, .For transfer to
another provider .Advanced directive information .resident status .all special instructions and/or precautions
for ongoing care .treatments and devices .all other information necessary to meet the resident's needs
.Anticipated transfers or discharges-resident-initiated discharges .obtain physicians' orders .the
interdisciplinary team completes relevant sections of the discharge summary. The nurse caring for the
resident at time of discharge is responsible for ensuring the discharge summary is complete and includes
.resident's status .the comprehensive, person-centered care plan shall contain the resident's goals for
admission and desired outcomes .supporting documentation shall include evidence of the resident's or
resident representative's verbal or written notice of intent to leave the facility .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
055542
If continuation sheet
Page 2 of 2
