The Rio at Mission Trails

In the surveyor’s words

From the most serious findings on record at The Rio at Mission Trails, in the surveyor’s own words.

• Immediate jeopardy, patternF684Jan 24, 2023

  Based on observation, interview, and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 8 residents (Resident #1) reviewed for treatment and services. The facility failed to ensure Resident #1 received skin care, showers/baths, ostomy care and wound care including weekly skin assessments, weekly wound measurements to the following wounds: -pressure ulcer to sacrum -pressure ulcer to left heel -pressure ulcer to right buttocks -pressure ulcer to right ankle -shear injury to right posterior thigh -shear injury to left posterior thigh -shear injury to right posterior flank -shear injury to right lower back Resident #1 suffered symptoms of anxiety… […]

• Immediate jeopardy, patternF835Jan 24, 2023

  Based on interview and record review, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 8 Residents (Resident #1) reviewed for quality of care, in that; The facility failed to ensure Resident #1 was appropriately placed in the nursing facility when he had a history of personal care and wound care refusals and uncontrolled pain and failed to promptly discharge Resident #1 when his continued refusals of personal hygiene, assessments and wound care prevented appropriate treatment of his medical conditions and resulted in sepsis, infestation of insects including maggots, gnats and flies and death. […]

• Immediate jeopardy, isolatedF600Feb 24, 2025

  Based on observation, interview, and record review, the facility failed to ensure each resident was free from neglect for 1 of 5 Residents (Residents #1) reviewed for neglect. During a capping trial on [DATE], Resident #1 was not monitored, and no staff were physically present in her room. Resident #1 became unresponsive and had to be transported to the ER for treatment. The facility did not have a policy/procedure in place for capping trials at the time of the incident. Resident #1 died at the hospital on [DATE]. This failure resulted in an IJ on [DATE] at 5:00 PM. […]

• Immediate jeopardy, isolatedF695Feb 24, 2025

  Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 5 Residents (Residents #1) reviewed for respiratory care. During a capping trial on [DATE], Resident #1 was not monitored, and no staff were physically present in her room. Resident #1 became unresponsive and had to be transported to the ER for treatment. The facility did not have a policy/procedure in place for capping trials at the time of the incident. Resident #1 died at the hospital on [DATE]. This failure resulted in an IJ on [DATE] at 5:00 PM. […]

• Immediate jeopardy, isolatedF925Jun 20, 2024

  Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free from pests for 3 of 7 residents (Resident #1, Resident #2 and Resident #5) reviewed for pest control, in that: The facility failed to ensure an effective pest control program was in place to keep flies out of resident rooms resulting in an infestation of maggots in Resident #1's left heel wound. On 05/30/2024 at 5:16 p.m., an Immediate Jeopardy (IJ) was identified. […]