Health inspection·August 11, 2023

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. 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 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). Residents Affected - Few 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 client's physical condition and behavior. · reaction to treatment through communication with . the health team members. RN is continually making collaborative and independent judgments related to the appropriateness/effectiveness of the plan of care and makes modifications based on changes in patient condition . RN plays the predominate role in the timely communication of the patient's response or lack of response to treatment to others, i.e., informing the physician. During a review of the facility's policy and procedure (P&P) titled, Change of Condition, dated 8/17, the P&P indicated It is the facility's policy that it should promptly notify . attending physician . of changes in that resident's medical/mental condition and/or status. In the PROCEDURE part indicated, Acute medical changes or any sudden change in condition manifested by a marked change in .mental .status: a. License nurse will notify the physician. During a review of Resident 1's medical record, the resident information document (face sheet) indicated, resident was a [AGE] year-old female, admission date 7/10/23, diagnosis included depression, and mood disorder due to known physiological condition with major depressive like episode. The Minimum Data Set (MDS-assessment tool), dated 7/16/2, indicated, Brief Interview for Mental Status (BIMS- a test used to get a quick snapshot of functioning cognitively), resident's score was 13. A score of 13 to 15 suggests the patient is cognitively intact, 8 to 12 suggests moderately impaired and 0 to 7 suggests severe impairment. Resident 1 required extensive assistance with one-person physical assist for bed mobility, dressing, toilet use, personal hygiene and did not walk in room or corridor. Medications included Buspirone (treat generalized anxiety disorder) 15 milligrams (mg) by mouth 3 times a day. Venlafaxine (treat depression) ER 112.5 mg by mouth daily. During a review of Resident 1's nurses note, dated 7/11/23 at 10:48 p.m., created by LN 2, the note indicated, Resident on bed, alert and oriented times 3. Suicidal ideation noted. Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055991 If continuation sheet Page 2 of 3 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 055991 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/11/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Park Healthcare Center 623 West Junipero Street Santa Barbara, CA 93105 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 0658 Level of Harm - Minimal harm or potential for actual harm verbalizes that her family hates her and that she is depressed, noted resident crying. Verbalizes that she wants to take her own life and needs help to complete that . Resident was crying. The nurses note, dated 7/12/23, at 1:30 p.m., indicated,, Times two episodes of verbalizing sadness . hopelessness. Residents Affected - Few The nurses note, dated 7/12/23, at 9:10 p.m., indicated, Constant verbalization of sadness reported throughout shift. During a concurrent observation and interview, on 7/19/23 at 2:30 p.m., with Resident 1, in resident's room, resident was observed in bed. Less than three minutes into the conversation, the resident started crying without reason. Resident stated, I am sad. My family left me here . Resident kept on crying unconsolably and non-stop. Then resident requested to be left alone. During an interview with Licensed Nurse (LN 1) caring for resident on 7/19/23 at 2:40 p.m., LN 1 was asked if resident had cried before. LN 1 stated, Yes, lately she has been crying all the time. During an interview on 7/19/23, at 1:27 p.m., with Occupational Therapist (O.T.), the O.T. stated, Resident is in bed most of the time, has not gotten up or out of bed since she arrived. She refuses to participate with P.T. and O.T. She seems depressed and sad most of the time. During a concurrent record review and interview, on 7/19/23, at 4:35 p.m., with Director of Nursing (DON), Resident 1's medical record was reviewed. DON was asked what the expectation of the nursing staff was if a resident expressed suicidal ideations. The DON reported, the expectation is that if a resident expressed suicidal ideations the nursing staff would notify the physician; this will be considered a Change of Condition (COC). The DON was asked to show surveyor the COC documentation and the notification to the physician when resident expressed suicidal ideations on 7/11/2,3 at 10:48 p.m. The DON navigated the record for a while and was not able to locate a COC documentation for the incident. The DON acknowledged and confirmed, there was no COC or any documentation in the record indicating the nursing staff notified the physician regarding resident expressing suicidal ideations on 7/11/23. Furthermore, confirmed psychiatry service had not been consulted or called for this resident. During a concurrent record review and interview, on 8/3/23, at 11:31 a.m., with LN 2, LN 2 confirmed authoring the nurses note dated, 7/11/23, at 10:48 p.m., not completing a COC documentation in the resident's record, and not notifying the physician that resident had expressed suicidal ideations on 7/11/23. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055991 If continuation sheet Page 3 of 3