Mission Pines Nursing and Rehab Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF644Oct 13, 2023

  Based on observation, interview, record review and document review, the facility failed to ensure there was a process in place to identify and refer residents for pre-admission screening and resident review (PASARR) level two for 15 of 15 sampled residents (Residents 4, 8, 30, 31, 42, 61, 70, 91, 94, 96, 99, 106 112, 150, and 172) with psychiatric diagnoses. The deficient practice had the potential to deprive residents of necessary behavioral health services. Findings include: The Intervention and Monitoring Behavioral Assessment policy revised March 2019, documented all residents would receive a Level one PASARR screening prior to admission. […]

• No harm, potential for more than minimal, widespreadF812Oct 13, 2023

  Based on observation, interview, and document review, the facility failed to ensure 1) kitchen equipment was cleaned, 2) food items were labeled with dates in the dried food storage, 3) expired food was discarded, 4) pans were not stacked wet, and 5) two of two nourishment room's equipment and surfaces were routinely cleaned, was free of personal items, documented freezer temperature logs, and meal products were labeled and dated. The deficient practice had the potential to serve foods to residents at an increased risk of food safety. […]

• No harm, potential for more than minimal, widespreadF802Nov 8, 2022

  Based on observation and interview, the facility failed to provide sufficient dietary personnel to ensure timely meal service and consistent cleaning of the kitchen. Failure to provide sufficient staff had the potential to adversely impact all residents in the facility. Findings include: 1) Timely meal service: On 11/03/22 at 08:05 AM, a meal service tray line was underway with the following staff on hand: One cook, two dietary aides, the Registered Dietitian (RD), and the Staffing Coordinator. Food in the steamtable included scrambled eggs, cinnamon rolls, sausage patties, pureed sausages, cinnamon rolls, and gravy. The staff in the kitchen worked rapidly as if rushed or hurried. The cook was dishing up the plates. […]

• No harm, potential for more than minimal, widespreadF804Nov 8, 2022

  Based on observation, interview, the facility failed to ensure food was palatable and served at an appetizing temperature for three of 35 sampled residents (Resident #35, #91, and #105) and seven unsampled residents. The failure had the potential to affect all residents residing in the facility. Failure to serve palatable food at an appetizing temperature could adversely affect each resident's quality of life and their nutritional status. Findings include: 1) Tough, dry chicken: The 11/01/2022 the menu indicated the lunch entree was encrusted pork loin. On 11/01/2022, at 1:00 PM, there were twenty-five residents seated at tables in the North dining room. About half of the residents in the North dining room were served a chicken fillet entree, and the other half received a pork entree. […]

• No harm, potential for more than minimal, widespreadF812Nov 8, 2022

  Based on observation, interview and document review, the facility failed to store, prepare, and serve food from a sanitary environment. The deficient practice had the potential to affect all residents in the facility. Failure to keep the kitchen clean and sanitary had the potential to spread food-borne disease or attract pests. Findings include: During an inspection on 11/01/22 at 8:30 AM, with the Regional Dietary Director, the kitchen floor was covered with scattered debris and patchy discoloration consistent with a buildup of grime. The floor area under the dish machine had the greatest extent of buildup of debris and grime. The Regional Dietary Director verbalized the floor needed a deep cleaning. […]