Mission Convalescent Home

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF880Dec 16, 2021

  Based on the Centers for Disease Control and Prevention (CDC) guidelines, policy review, Employee Time Cards, Employee Screening Logs, and interview, the facility failed to properly prevent and/or contain COVID-19 when 21 of 49 staff members (Registered Nurse (RN) #1, Licensed Practical Nurse (LPN) #1, #2, #3, #4 and #5, Certified Nursing Assistant (CNA) #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10, Environmental Staff #1, #2, and #3, Maintenance Staff #1, and Laundry staff #1) failed to complete screenings for COVID-19 prior to working for 14 of 14 days (11/27/2021-12/10/2021) reviewed. […]

• No harm, potential for more than minimal, patternF812Jul 2, 2025

  Based on policy review, observation, and interview, the facility failed to ensure food was stored properly when frozen food was not stored on a shelf to allow circulation, the corn meal, sugar, and flour bins were undated and unlabeled, expired food and frozen food was observed with thick build-up of ice crystals in 2 of 2 reach-in freezers and 1 of 1 reach-in refrigerators, and a pink/brown substance found in 1 of 1 ice machines. The findings include: 1. Review of the facility's policy titled, Food Storage, with a revised date of 11/1/2014, revealed .Any expired or outdated food products should be discarded.All products should be dated upon receipt and when they are prepared. Use use-by-dates on all food stored in refrigerators. […]

• No harm, potential for more than minimal, patternF880Jul 2, 2025

  Based on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 1 of 2 (Licensed Practical Nurse (LPN A) failed to don Personal Protective Equipment (PPE) while administering medications and performing wound care to 2 of 3 (Resident #22 and #33) residents reviewed for Percutaneous Endoscopic Gastronomy (PEG) (a tube in the stomach that provides nutrition) tube and pressure ulcers. The findings include: 1. […]

• No harm, potential for more than minimal, patternF550Nov 9, 2023

  Based on policy review, observation, and interview, the facility failed to maintain or enhance residents' dignity and respect during random observations when 1 of 1 (Licensed Practical Nurse (LPN) #2) failed to use courtesy titles when addressing residents, and during dining when 8 of 10 staff members (Certified Nursing Assistant (CNA) #1), CNA #2, CNA #3, CNA #4, CNA #5, CNA #6, CNA #7, and LPN #2, and LPN #3, failed to knock and/or announce themselves, stood to assist with dining, failed to use courtesy titles when addressing residents, and when 1 of 1 (LPN #2) failed to knock or announce self before entering a resident's room during medication administration. The findings include: 1. […]

• No harm, potential for more than minimal, patternF642Nov 9, 2023

  Based on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to ensure the facility assessments were signed by a Registered Nurse (RN) as required by Federal Regulations for 12 of 12 (Resident #1, #9, #10, #20, #25, #31, #33, #39, #41, #43, #44, and #146) sampled residents reviewed. The findings include: 1. Review of the Centers for Medicare Services (CMS) RAI Manual Version 3.0 Manual dated October 2023 pages Z6- Z7 revealed, .the person signing the attestation must review the information to assure accuracy and sign for those portions on the date the review was conducted .Federal regulation requires the RN assessment coordinator to sign and thereby certify that the assessment is complete .use the… […]