Health inspection·January 24, 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interview, medical record review, facility document review, and facility P&P review, the facility failed to ensure one of two sampled residents (Resident 1) was promptly assessed and notified to the physician and responsible party after a COC was identified as per the facility's P&P. This failure had the potential for the resident to not receive adequate care and risk for adverse complications. Residents Affected - Few Findings: Review of the facility's P&P titled Change in a Resident's Condition or Status revised on 5/2017 showed the facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. The P&P also showed prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider. The P&P further showed the nurse will notify the resident's Attending Physician or physician on call when there has been a(an): (a) accident or incident involving the resident; (b) discovery of injuries of an unknown source; and/or (d) significant change in the resident's physical/emotional/mental condition. Closed medical record review for Resident 1 was initiated on 1/23/24. Resident 1 was admitted to the facility on [DATE], and transferred to the acute care hospital on 1/13/24. Review of Resident 1's H&P examination dated 1/8/24, showed the resident did not have the capacity to understand and make decisions. Review of Resident 1's Order Summary Report dated 1/13/24, showed a physician's order for Resident 1 to be transferred to the acute care hospital via 911 for the resident's bruising and swelling to the right cheek, receiving the blood thinner medication, and lethargy with low BP. On 1/24/24 at 1057 hours, an interview and concurrent closed medical record review with LVN 1 was conducted. LVN 1 stated CNA 3 notified her of Resident 1's swelling and discoloration to the right cheek on 1/13/24 at approximately 0830 hours. LVN 1 verified she did not assess, check the vital signs, or notify the physician and family member promptly as per the facility's P&P. LVN 1 also stated she did not notify the RN supervisor (RN 2) of Resident 1's COC. LVN 1 stated, He [Resident 1] looked fine to me, so I continued with med pass because he was having breakfast and then he got a shower. LVN 1 further stated she notified RN 2 of Resident 1's COC after Family Member 1 arrived at the facility on 1/13/24 at approximately 1000 hours, and requested information on Resident 1's swelling and discoloration to the right cheek and lethargic appearance. LVN 1 acknowledged she did not follow the facility's COC P&P, but should have to ensure the resident was kept safe and health was managed properly. On 1/24/24 at 1140 hours, an interview was conducted with RN 2. RN 2 stated the facility's COC protocol included assessing the resident and notifying the physician and responsible party. RN 2 stated Resident 1's lethargy, low BP, and discoloration and swelling to the right cheek were considered a COC and the facility was to follow the COC P&P. RN 2 further verified Resident 1's BP was assessed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 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 056271 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/24/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Palms Healthcare Center 240 Hospital Circle Westminster, CA 92683 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 0684 Level of Harm - Minimal harm or potential for actual harm once Family Member 1 arrived at the facility. RN 2 stated Resident 1 was transferred to the acute care hospital via 911 due to lethargy, low BP, and swelling and discoloration to the right cheek. On 1/24/24 at 1335 hours, an interview was conducted with the Administrator and DON. The Administrator and the DON verified the above findings. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056271 If continuation sheet Page 3 of 3