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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIERICLIA (XZ) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
MISSION HOSPITAL REGIONAL MEDICAL CENTER 27700 Medical Center Rd, Mis~'lff~i~ 92~1-s~JYbr&.NG'E-'doUNTY
Any den Ieney slatement ending with an asterisk (•) denotes a deficiency which the Institution may be ex · sed from correcllng providing It is delennlned
that other safeguards provide sufficient protection to the patients. Except for nursing homes, the findings above are dlsclosable 90 days following Ihe date
of survey whether or not a plan of correction Is provided. For nursing homes, the above findings and plans of correction are dlscfosable 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.
1 of6
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STATEMENT Of DEfiCIENCIES (X1) PROVIDERISUPPLIERICLIA {X2) MULTIPlE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
050567 B. WING 06/28/2011
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, Cl'tv. STATE, ZIP CODE p {1'\ . 2 5B
MISSION HOSPITAL REGIONAL MEDICAL CENTER 27700 Medical Cente~~~~~ Vie~, cA d2S91-6426 ORANGE COUNTY
A ' dericlency statement ending with an asterisk (•) denoles a deficiency which the institution may e excusedlrrom correcting providing It Is detennlned
that other safeguards provide sufficient protection to the patients. Except for nursing homes, lhe findings above are dlsclosable 90 days following the dale
of survey whether or not a plan of correction Is provided. For nursing homes, the above findings and plans of correction are dlsclosable 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
parUclpatlan.
State-2567 2of6
i'
i
6/13/2012
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Event ID:NDLF11 3:48:02PM
TITLE {X6)DATE
ency statement ending with an asterisk (' ) denotes a deficiency which lhe institution may be ex used fro correcting providing ills determined
that other safeguards provide sufficient prolecUon to the patients. Except for nursing homes, lhe findings above are dlsclosable 90 days following the date
of survey whether or not a plan of correction Is provided. For nursing homes, lhe above findings and plans of correction are dis closable 14 days following
lhe dale these documents are made available to the facility. If deficiencies are cited, an approved plan of correction Is requisite to continLJed program
participation.
State-2567 3 are
CAUFORNIA HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF PUBLIC HEALTH
STATEMENT OF DEFICIENCIES {X1) PROVIDERJSUPPLIERICLIA {X2) MULTIPLE CONSTRUCTION {X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
050567 06/28/2011
B. WING
.......
NAME OF PROVIDER OR SUPPLIER sTREETADDREss . cJTY.STAnE.ZIP cooE ZOlZ JUL ~ n· c. ~o
MISSION HOSPITAL REGIONAL MEDICAL CENTER 27700 Medical Center Rd, Mission Viejo, CA 92691-6426 ORANGE COUNTY
'ZevkJ n U:J- . .
ficiency statement ending with an asterisk (•) denotes a deficiency which the institution IT@Y-6'e exc~ d from correcting providing ills determined
that other safeguards provide sufficient protection to the patients. Except for nursing homes, the findings 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 or 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.
State-2567 4 ora
CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF PUBLIC HEALTH
STATEMENT OF DEFICIENCIES (X1 ) PROVIDER/SUPPLIERICLIA (X2) MULTIPLE CONSTIRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
Any deli m;y statement ending vlith an asterisk (' ) denotes a deficiency which the Institution may excus from correctlng providing it Is determined
that other safeguards provide sufficient protection to the patients. Except for nursing homes, the findings above are disclosable 90 days following the date
or survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correcllon are dis closable 14 days following
the date these doc~ments are made available to the facility. If deficiencies are cited, an approved plan of correcllon is requisite to continued program
partlclpatlon.
State-2567 sora
CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY
DEPARTMENT OF PUBLIC HEALTH
STATEMENT OF DEFICIENCIES (X1) PROVIDERISUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING
050567 B. WING 06/28/2011
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ?01? II II c:: p fll ? ~Q
MISSION HOSPITAL REGIONAL MEDICAL CENTER 27700 Medical Center Rd, Mission Vle/0, ~ 925'91 -642'6' ORANGE t:outft+
~ '/..&~<.) ){ J I ~,~6/d-----
Any deflclen y statement eding with an asterisk (") denotes a deficiency which the Institution may be excused from correctrng providing it is detennlned
that other safeguards provide sufficient protecUon to the patients. Except for nursing homes, the findings above are disclosable 90 days following the date
or survey whether or not a plan of correction Is provided. For nursing homes, the above findings and plans of correclion are dlsclosable 14 days following
the date these documents are made available to the facility. If delic:lencles are cited, an approved plan of correction Is requisite to continued program
participation.
State-2567 6 ofS