Health inspection·April 18, 2024

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 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). Residents Affected - Few 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, 12/30/23, 1/1/24, and 1/2/24. The LN 2 and the DON confirmed Resident 1 received the medication on those dates, and acknowledged the facility could not provide documentation indicating Resident 1 ' s systolic blood pressure or heart rate had been assessed prior to the administration of the Metoprolol Tartrate, as per the medication order. During a review of the facility ' s policy and procedure titled Medication - Administration, dated 10/1/23, indicated in part When administration of the drug is dependent upon vital signs or testing, the vital signs/testing will be completed prior to administration of the medication and recorded in the medical record (i.e., BP (blood pressure), pulse (heart rate), finger stick blood glucose monitoring etc.). During a concurrent record review, and interview, on 4/9/24, starting at 2:52 p.m., with LN 2, Resident 2 ' s MAR dated 1/24, was reviewed. Resident 2 ' s MAR indicated Resident 2 refused the ordered medication of Senokot (a medication used to treat constipation) from 1/2/24 through 1/14/24. The LN 2 verbalized no documentation could be found indicating a reason Resident 2 refused the medication during those dates. The LN 2 could not provide documentation indicating Resident 1 ' s physician was notified of the repeat refusals of the Senokot. During a concurrent record review, and interview, on 4/9/24, at 4:25 p.m., with LN 2, and DON, Resident 1 ' s MAR was reviewed. Resident 1 ' s MAR indicated Resident 1 refused the ordered medication of Senokot on 12/22/23, 12/23/23, 12/24/23, 12/26/23, 12/27/23, 12/28/23, 12/29/23, 12/30/23, and 1/1/24. The LN 2 and the DON 1 confirmed the facility did not document a reason why Resident 1 refused (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 04/18/2024 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)