Health inspection·December 29, 2023

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted 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 which the kidneys are damaged and cannot filter blood as well as they should) and Benign Prostatic Hyperplasia (BPH - Non - cancerous enlargement of the prostate gland) with lower urinary tract symptoms. During a review of Resident 1 ' s Order Summary Report (OSR- monthly physician ' s orders reports) dated 11/2/23, the OSR indicated, Foley Catheter (F/C) French (Fr) size 16 change as needed (PRN) when clogged or pulled out. And to monitor and record Intake and Output and output every shift for Foley catheter use for 30 Days. During a concurrent record review and interview with Director of Nursing (DON) on 12/15/23, at 2:30 p.m. indicated, there was no care plan developed and implemented for Resident 1 that included the instructions needed to to monitor and record intake and output as ordered by the physician. During a review of the facility ' s policy and procedure (P&P) titled, Care Planning dated October 2023, the P&P indicated, I. The Facility will develop a person-centered Baseline Care Plan for each resident within 48 hours of admission. The Baseline Care Plan will include at least the following information: A. Initial goals based on admission orders B. Physician Order (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: 055991 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 12/29/2023 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)