Mission Nursing and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Dec 20, 2021

  Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for one of seven residents (Resident#1) reviewed for accidents and supervision; CNA A and NA B removed Resident #1's floor mat that was placed next to the bed as an intervention for falls. CNA A and NA B left Resident #1's room. Resident #1 suffered a fall that resulted in a right nose fracture, C#2 and C#3 fractures, laceration to her forehead and two-day hospitalization . This failure resulted in an identification of an Immediate Jeopardy at 4:44 p.m. on 12/18/21. […]

• Actual harm, isolatedF689Oct 6, 2023

  Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision for one resident (Resident #49) of three residents reviewed for supervision and ensured the environment remained free of accident hazards for 2 of 2 unlocked resident rooms reviewed for supervision in that. 1) The facility failed to ensure Resident #49 received supervision while in the shower. 2 ) The facility failed to ensure the two resident rooms, 323 and 324 were free of cluttered storage of equipment, furniture, boxes, walkers, wheelchairs in a secured manner. These failures could place residents at risk of being in an unsafe environment and at risk for accidents and injury. […]

• No harm, potential for more than minimal, widespreadF880Oct 6, 2023

  Based on interview, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling Legionella through a program that identifies areas in the water system where Legionella can grow and spread for 1 of 1 facility. The facility failed to have a system in place for preventing and controlling Legionella through a program that identifies areas in the water system where Legionella could grow and spread. This deficient practice places the facility residents at risk for airborne infections. The findings included: Interview on 10/05/23 with the Maintenance Director at 10:10 a.m., he stated he did not know what Legionnaire's was. He stated he had been working at the facility for 2 years. […]

• No harm, potential for more than minimal, patternF760Apr 2, 2026

  Based on observation, record review and interview, the facility failed to ensure residents were free of any significant medication errors for 1 of 3 residents (Resident #13) reviewed for pharmacy services. The facility failed to ensure Resident #13 received the correct dose of:Amiodarone HCI oral tablet 200 mg, Apixaban oral tablet 2.5 mg, and Metoprolol Tartrate Oral Tablet 25 mg. This failure could place residents at risk of medical complications and not receiving the therapeutic effects of their medications. […]

• No harm, potential for more than minimal, patternF641Dec 20, 2021

  Based on observation, interview and record review, the facility failed to ensure assessments accurately reflected the status for 1 of 7 residents reviewed for assessments. (Resident #1). LVN E did not perform a fall risk assessment after Resident #1 had a fall on 08/21/21. Resident #1's 10/22/21 fall risk assessment did not reflect a fall that Resident #1 had on 08/21/21. Resident #1's Quarterly MDS completed on 10/29/21 did not reflect a fall that Resident had on 08/21/21 at facility. These failures could place residents at risk of not having individual needs met and a decreased quality of life. The findings were: Record review of Resident #1s Order Summary Record, dated 12/18/21, revealed Resident #1 was a [AGE] year-old female and was admitted to the facility on [DATE]. […]