Other·September 14, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during the investigation of two complaints. Complaint Numbers: CA00587731 CA00588158 Representing the Department of Public Health: Surveyor ID #: 28114 RN, Sr. HFEN Severyor ID#: 37662 RN, HFEN The inspection was limited to the specific complaints investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for complaint number CA00587731 and CA00588158.

F660 SS=D Discharge Planning Process CFR(s): 483.21(c)(1)(i)-(ix)

F660 08/24/2018 §483.21(c)(1) Discharge Planning Process The facility must develop and implement an effective discharge planning process that focuses on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to postdischarge care, and the reduction of factors leading to preventable readmissions. The facility's discharge planning process must be consistent with the discharge rights set forth at LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ERLH11 Facility ID: CA950000050 If continuation sheet 1 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555796 (X3) DATE SURVEY COMPLETED 08/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MISSION CARE CENTER 4800 Delta Ave Rosemead, CA 91770 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 483.15(b) as applicable and(i) Ensure that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident. (ii) Include regular re-evaluation of residents to identify changes that require modification of the discharge plan. The discharge plan must be updated, as needed, to reflect these changes. (iii) Involve the interdisciplinary team, as defined by §483.21(b)(2)(ii), in the ongoing process of developing the discharge plan. (iv) Consider caregiver/support person availability and the resident's or caregiver's/support person(s) capacity and capability to perform required care, as part of the identification of discharge needs. (v) Involve the resident and resident representative in the development of the discharge plan and inform the resident and resident representative of the final plan. (vi) Address the resident's goals of care and treatment preferences. (vii) Document that a resident has been asked about their interest in receiving information regarding returning to the community. (A) If the resident indicates an interest in returning to the community, the facility must document any referrals to local contact agencies or other appropriate entities made for this purpose. (B) Facilities must update a resident's comprehensive care plan and discharge plan, as appropriate, in response to information received from referrals to local contact agencies or other appropriate entities. (C) If discharge to the community is determined to not be feasible, the facility must document who made the determination and why. (viii) For residents who are transferred to another SNF or who are discharged to a HHA, IRF, or LTCH, assist residents and their resident representatives in selecting a postFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ERLH11 Facility ID: CA950000050 If continuation sheet 2 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555796 (X3) DATE SURVEY COMPLETED 08/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MISSION CARE CENTER 4800 Delta Ave Rosemead, CA 91770 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE acute care provider by using data that includes, but is not limited to SNF, HHA, IRF, or LTCH standardized patient assessment data, data on quality measures, and data on resource use to the extent the data is available. The facility must ensure that the post-acute care standardized patient assessment data, data on quality measures, and data on resource use is relevant and applicable to the resident's goals of care and treatment preferences. (ix) Document, complete on a timely basis based on the resident's needs, and include in the clinical record, the evaluation of the resident's discharge needs and discharge plan. The results of the evaluation must be discussed with the resident or resident's representative. All relevant resident information must be incorporated into the discharge plan to facilitate its implementation and to avoid unnecessary delays in the resident's discharge or transfer. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to plan for a safe discharge that met the health and safety needs for one of 3 sampled residents (Resident 1), including, 1. Failure to ensure Resident 1's family member (FM 1) was trained to take care of the resident. 2. Failure to ensure FM 1 has the capacity and capability to perform required care for Resident 1. These deficient practices resulted in Resident 1 was transferred to the hospital via 911 (emergency call) on the same day after being discharged from the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ERLH11 Facility ID: CA950000050 If continuation sheet 3 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555796 (X3) DATE SURVEY COMPLETED 08/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MISSION CARE CENTER 4800 Delta Ave Rosemead, CA 91770 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Findings: A review of Resident 1's Admission Record indicated resident was admitted to the facility, on 3/8/18, with diagnoses that included history of falling, difficulty in walking, muscle weakness, and displaced intertrochanteric (upper part for the thigh bone) fracture of left femur (thigh bone). A review of the Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 5/19/18, indicated Resident 1's cognition (ability to think and process information) was moderately impaired. Resident 1 required extensive assistance (resident involved in activity, staff provide weight bearing support) with activity of daily livings (ADLs) such as bed mobility, transfer, walking in room and in corridor, locomotion on and off unit, dressing, eating, toilet use and personal hygiene. A review of Resident 1's Physician Orders, dated 5/18/19, indicated to discharge the resident home, on 5/19/18, with remaining medication, and home health Physical Therapy (PT) and nursing for medication management. On 8/3/18 at 4 p.m., during an interview, the Certified Nursing Assistant 1 (CNA 1) stated Resident 1 needed extensive assistant from staff during transfer and ADL. The CNA 1 stated Resident 1 had hip surgery and she was in pain. On 8/16/18 at 11 a.m., during an interview, the Director of Rehabilitation (DOR) stated ADLs was where Resident 1 was having the problem. Resident 1 was inconsistent with gait level due to the resident cognition. The DOR stated PT was discontinued due the Resident 1 was not able to perform what PT staff was trying to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ERLH11 Facility ID: CA950000050 If continuation sheet 4 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555796 (X3) DATE SURVEY COMPLETED 08/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MISSION CARE CENTER 4800 Delta Ave Rosemead, CA 91770 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE teach the resident. On 8/16/18 at 11:21 a.m., during a telephone interview, the Assistant Director of Nursing (ADON) stated Resident 1 occasionally asked for pain medication. The ADON stated care giver training was scheduled for FM 1, but FM 1 did not receive any training due to he did not show up on the scheduled time. On 8/16/18 at 13:56 p.m., during a telephone interview, the DSD stated Resident 1 was discharged to a hotel with FM 1 without medical equipment due to FM 1 refused the medial equipment. The DSD stated she did not ensure that the hotel was a safe environment for Resident 1 to be discharged, and FM 1 did not received care giver training. A review of the Nursing Progress Notes, dated 5/18/18, indicated Resident 1 will be discharge to a hotel with son. Resident 1 ambulate with Front Wheel Walker (FWW) and Single Point Cane (SPC). The notes indicated Resident 1's barriers to safe and effective discharge included left hip pain and fall risk. Resident 1 required maximum assistance with lower body dressing, toileting, bathing; moderate assistance with toilet transfer, bed mobility, functional transfers, and minimum assistance for upper body dressing. A review of the Discharge Summary and Post Discharge Plan of Care, dated 5/19/18, indicated Resident 1 did not has the capacity to make her needs know, the resident had anxiety with excessive irritability. Resident 1 used wheelchair as assistance device and the resident needed extensive assistance with ADLs. A review of the facility's policy and procedure titled "Transfer and Discharge Right," revised FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ERLH11 Facility ID: CA950000050 If continuation sheet 5 of 6 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555796 (X3) DATE SURVEY COMPLETED 08/17/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MISSION CARE CENTER 4800 Delta Ave Rosemead, CA 91770 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 11/2016, indicated the facility's discharge planning process shall consider caregiver/support person availability and the resident's or caregiver's/support person(S) capacity and capability to perform required care, as part of the identification of discharge needs. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ERLH11 Facility ID: CA950000050 If continuation sheet 6 of 6