Mission Nursing Home

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600May 27, 2021

  Based on observation, interview and document review, the facility failed to assess and implement interventions for 1 of 1 residents (R1) with escalating behaviors, including a newly recorded incident of physical assault. These findings resulted in an immediate jeopardy (IJ) situation for R2 and potentially other residents who R1 may become verbally or physically aggressive with. The IJ began on 5/12/2021, at 4:26 p.m. when R1, who had a documented history of verbal aggression and threatening behavior, hit R2 on the right side of the face. R1 was subsequently removed from the facility by law enforcement for a felony arrest warrant and was returned to the facility on [DATE] at 6:15 p.m. […]

• Actual harm, isolatedF600Feb 25, 2026

  Based on interview and document review the facility failed to protect 1 of 1 resident (R1) from staff to resident abuse when R1 was physically and verbally abused by nursing aid (NA)-A which resulted in psychosocial harm to R1 who was crying and visibly upset during the abuse incident. The facility implemented corrective action, and the deficient practice was corrected on 2/19/26, prior to the survey and was issued at past non-compliance. Findings include: R1's admission Minimum Data Set (MDS) dated [DATE], indicated R1 had diagnoses of stroke and cancer with prognosis less than six months to live. […]

• Actual harm, isolatedF697Apr 10, 2025

  Based on interview and document review, the facility failed to ensure pain medications were re-ordered and available for administration per physician orders for 1 of 3 residents (R2), who had chronic pain and utilized pain medication. This resulted in actual harm when R2 was not administered the physicians ordered pain medication before a pre-scheduled surgery prior to leaving the facility for surgery, and arrived at the surgery center tearful and in severe pain. The facility implemented immediate corrective action prior to the survey and was therefore issued at past non-compliance. […]

• No harm, potential for more than minimal, widespreadF867Mar 12, 2025

  Based on interview and record review, the facility failed to develop a plan that defined measurable goals and create a system to collect feedback from resident and resident representatives. This had the potential to affect all 56 residents in the facility. Findings Include: During entrance interview on 3/10/25 at 12:54 p.m., a request for a copy of the Quality Assurance and Performance Improvement (QAPI) plan was made to the director of nursing (DON). On 3/13/25 at 1:37 p.m., another request was made for a copy of the QAPI plan. On 3/13/25 at 2:25 p.m., the facility's QAPI program policy was provided. On 3/12/25 at 2:44 p.m., the director of nursing (DON) provided meeting minutes for the last four quarters, but failed to provide an overall plan. […]

• No harm, potential for more than minimal, widespreadF851May 31, 2024

  Based on document review and interview, the facility failed to submit complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data, during 1 of 1 quarter reviewed (quarter one), to the Centers for Medicare and Medicaid Services (CMS) according to specifications established by CMS. Findings include: Review of the facility Payroll Based Journal Report (PBJ) [NAME] Report 1705 D for quarter one (10/1/23 to 12/31/23) identified a 1-star staffing rating and failure to submit PBJ data. […]