Health inspection·February 26, 2026

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide ongoing monitoring and assessment, for one of four residents reviewed (Resident 4), when there was a change of condition of increased drainage from the resident's neck lesions/wounds on January 14, 2026. In addition, there were no care plan developed to address Resident 4 who was at risk for infection due to increased wound drainage and odor. Findings:On February 3, 2026, at 9:53 a.m., an unannounced visit was conducted at the facility to investigate a complaint involving quality of care and treatment.On February 3, 2026, Resident 4's medical record was reviewed. Resident 4 was admitted to the facility on [DATE], with diagnoses which included malignant neoplasm of tongue (a serious oral cancer) and tracheostomy (an opening in the neck leading directly to the windpipe).A review of Resident 4's Minimum Data Set (MDS- an assessment tool), dated December 12, 2025, indicated Resident 4 had a BIMS (Brief Interview of Mental Status-a cognitive assessment tool) score of 15 (cognitively intact).A review of Resident 4's COC (Change of Condition)/INTERACT ASSESSMENT FORM, dated January 14, 2026, at 3:02 p.m., indicated, .while dressing change.neck tumors .increased drainage and odor noted.recommendations: transfer to ER (emergency room).rule out infection.A review of Resident 4's Progress Notes, dated January 14, 2026, at 3:38 p.m., indicated, .called doctor.notified regarding resident refusal to be seen at hospital.continue monitor.increase the frequent of wound treatment.every shift.A review of Resident 4's Progress Notes, dated January 15, 2026 at 9:47 p.m., indicated, .per daughter.brought to ER.for the swelling to his neck and drainage.treatment to neck was administered at the hospital.to neck.lateral (side) areas.not the medial (middle).requests it be treated in the morning by the treatment nurse.A review of Resident 4's physician orders indicated the following:-On December 12, 2025, anterior (front) neck cancer lesion: cleanse with hibiclens (antiseptic and antimicrobial skin cleanser) solution pat dry and apply oil emulsion dressing and cover with ABD pad, every day shift.-On January 14, 2026, Cleanse with hibiclens solution pat dry and apply oil emulsion dressing and cover with ABD pad two times a day for Right lateral (side) posterior (back) neck cancer lesion.-On January 14, 2026, Cleanse with hibiclens solution pat dry and apply oil emulsion dressing and cover with ABD pad, two times a day for Right medial posterior neck cancer lesion.A review of Resident 4's progress note, titled, Skilled Evaluation, dated January 16, at 8:57 a.m., indicated, .skin.skin issue : 003: skin issue has not been evaluated.location: anterior neck.Further review of Resident 4's record indicated there was no documented evidence of the status or condition of the anterior, medial, or lateral neck wounds after there was a change in condition of the neck wounds on January 14, 2026. In addition, there was no updated care plan to address the increased drainage from the neck wounds or risk for infection. after the change of condition on January 14, 2026.On February 3, 2026, at 1:17 p.m., a concurrent interview and record review was conducted with Licensed Vocational Nurse (LVN) 1. LVN 1 stated wound care on Resident 4's neck wounds was performed daily due to increased wound drainage. LVN 1 stated the wound Residents Affected - Few (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 02/26/2026 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)