Mission Hills Post Acute Care

In the surveyor’s words

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

• Actual harm, isolatedF692Jan 27, 2022

  Based on observation, interview, and record review, the facility failed to ensure nutrition interventions were consistently implemented and re-evaluated for effectiveness to prevent an unplanned severe insidious weight loss of 31.9 pounds (22.7%) in six months, for one of seventeen sampled residents (Resident 29). The resident's nutrition status interventions were not re-assessed for effectiveness, and the care plan goals were not updated to reflect the resident's desired weight goal, according to facility policy and standards of practice. This deficient practice led to continued weight loss and the facility's inability to meet the resident's desirable body weight range, which further impaired nutrition and health status. […]

• No harm, potential for more than minimal, widespreadF800Jan 27, 2022

  Based on observation, interview, and record review the facility failed to ensure overall systematic operations of the food and nutrition services with the necessary oversight to ensure the daily nutritional needs of the residents were met. This deficient practice led to a resident (Resident 29), to experience severe avoidable weight loss in six months, the potential for other facility residents to experience weight loss, malnutrition, and widespread food borne illness, which can affect all residents in the facility. […]

• No harm, potential for more than minimal, widespreadF809Jan 27, 2022

  Based on observations, interviews, and record reviews, the facility failed to ensure snacks were consistently offered to residents three times a day, particularly an evening snack as per facility policy. This failure had the potential to negatively alter nutrition status and not meet the nutritional needs of residents in need of an evening snack. Cross reference F800, F806 Findings: 1. Resident 54 was readmitted to the facility on [DATE], due to diabetes (high blood sugar), per the facility's Admission Record. On 1/25/22 at 4:19 P.M., a review of Resident 54's electronic record was conducted. Resident 54's record indicated a weight loss of 15.7 pounds (lbs) from September 2021 (137.8 lbs on 9/14/21) to January 2022 (122.1 lbs on 1/14/22). […]

• No harm, potential for more than minimal, widespreadF812Jan 27, 2022

  Based on observation, interview and record review, the facility failed to ensure safe and sanitary measures were met in the kitchen during dietary operations according to standards of practice when: 1. A Diet Aide (DA 1) found 12 oatmeal/soup bowls stored as clean with crusted brown oats, dirt and food debris; 2. Food items were not properly labeled and dated, including thawed ReadyCare (protein shakes), an opened clear bin of dried black eyed peas, and a bag of cilantro leaves; 3. The following items were stored inappropriately in a food preparation area: a gallon of liquid bleach, a staff personal belonging, and a radio; and 4. […]

• No harm, potential for more than minimal, patternF578Aug 13, 2026

  Based on interview and record review, the facility failed to ensure eight out of twenty sampled residents' (Residents 85, 30, 4, 9, 91, 59, 12, and 77) advance directives (AD) were obtained and documented in the medical record in accordance with the facility's policy.This failure had the potential to result in the facility providing care or treatment that was inconsistent with the residents' documented advance directive treatment plans.FINDINGS:A review of Resident 85's Face Sheet indicated Resident 85 was admitted to the facility on [DATE].A review of Resident 30's Face Sheet indicated Resident 30 was admitted to the facility on [DATE].A review of Resident 4's Face Sheet indicated Resident 4 was admitted to the facility on [DATE].A review of Resident 9's Face Sheet indicated Resident 9… […]