Mission Care Center

In the surveyor’s words

From the most serious findings on record at Mission Care Center, in the surveyor’s own words.

• Actual harm, isolatedF692Dec 3, 2021

  Based on observation, interview, and record review, the facility failed to ensure nutritional care and services were provided, for one of four residents reviewed for weight loss (Resident 3), when: 1. The nutritional needs of a resident requiring tube feeding (way of delivering nutrition directly to the stomach) were calculated based on the adjusted body weight (ABW - a measure used for calculating a person's nutritional needs for a weight loss program, which was lower than the actual body weight) instead of the actual body weight (higher than ABW); and 2. The continued use of [MEDICATION(S)] (diuretic - medication to treat fluid retention) was not evaluated timely when the [CONDITION(S)] (swelling) on both lower extremities was resolved on October 22, 2021. […]

• No harm, potential for more than minimal, widespreadF814Feb 13, 2025

  Based on observation, interview, and record review, the facility failed to ensure garbage and refuse were properly disposed off the facility grounds when multiple items were observed stored and stacked on top of each outside a trailer container. This failure had the potential to attract and harbor pest and rodents. Findings: On February 12, 2025, at 2:54 p.m., during a tour outside the facility with the Maintenance Supervisor (MS), multiple items of discarded wood, poles, signs, broken fans, metal frames, bath chairs, wooden pallets, bags of cement mix, and hoses stacked on top of each were observed beside the storage trailer. In a concurrent interview, the MS verified those items beside the storage trailer were discarded items. […]

• No harm, potential for more than minimal, widespreadF880Jan 11, 2024

  Based on observations, interview, and record review, the facility failed to ensure appropriate infection control were followed when: 1. The facility's water system was not tested for Legionella (a bacteria whichcould cause a serious type of pneumonia [lung infection]) and other waterborne diseases. This failure had the potential to place residents at risk for health complications related to Legionella; and 2. Three suction tubings (flexible tubes used for the removal of secretions) and one Yankauer (a tool used to suction oral secretions) were not dated, for three of three residents (Residents 2, 17 and 34). […]

• No harm, potential for more than minimal, patternF812Feb 13, 2025

  Based on observation, interview, and record review, the facility failed to store, prepare, handle, and serve food, in accordance with professional standards for food service safety for a highly vulnerable population of seven (7) residents who eat frood from the facility kitchen, when, two (2) oven gloves were observed with dark stains thick brown/black substance on the fingers and multiple patches of white substance. This failure had the potential to result in cross contamination and cause food borne illnesses in a highly vulnerable population of seven (7) residents who eat food from the kitchen. […]

• No harm, potential for more than minimal, patternF700Jan 11, 2024

  Based on observation, interview, and record review, the facility failed to ensure: 1. A risk for entrapment (an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail) assessment and least restrictive alternatives were conducted prior to use of bed rails, for sixteen of sixteen residents reviewed for bed rails (Residents 1, 2, 3, 4, 9, 13, 16, 22, 27, 28, 30, 31, 32, 35, 37, and 40). In addition, the risk for entrapment assessment did not indicate the resident's size and weight in relation to the dimensions of the bed being used for the resident according to the facility's policy and procedure. 2. […]