The Village at Mission

In the surveyor’s words

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

• Immediate jeopardy, isolatedF678Jan 27, 2026

  The facility identified a census of 53 residents. The sample included nine residents reviewed for Advanced Directives (a legal document that provides instructions for medical care when a person is unable to communicate their wishes). Based on record review, observation, and interview, the facility failed to provide cardiopulmonary resuscitation (CPR) to Resident (R) 1, who elected a full code status. On [DATE] at 05:10 PM, R1's family member reported to the nurse R1 had died. Licensed Nurse (LN) G did not check R1's code status until prompted by a hospice nurse and LN I, approximately 45 minutes later, and then the LNs started resuscitative measures. […]

• Immediate jeopardy, isolatedF726Apr 4, 2023

  The facility identified a census of 34 residents. The sample included three residents. Based on interviews and record review, the facility failed to ensure licensed nursing staff possessed the skills and knowledge necessary to respond to cardiac arrest. On [DATE] between 11:30 and 11:45 AM, Certified Nurse Aide (CNA) M and CNA O prepared to transfer R1 with a full body lift. At that time, R1's representatives entered the room and identified R1 appeared unresponsive. R1's representatives called for Licensed Nurse (LN) G. LN G, a certified cardiopulmonary resuscitation (CPR) instructor, assessed R1 and determined R1 had no pulse (cardiac arrest) and directed the CNA staff who were present to start CPR. […]

• Immediate jeopardy, isolatedF689Jun 30, 2022

  The facility reported a census of 33 residents. The sample included three residents reviewed for elopement (when a cognitive impaired resident with little of poor safety awareness exits the facility without staff knowledge) and one resident reviewed for falls. Based on observation, record review, and interview, the facility failed to ensure Resident (R)1 received adequate supervision and appropriate interventions to prevent elopement. R1 admitted to the facility on [DATE] and was noted to attempt to exit the facility on 06/05/22 at 09:30 AM, he was taken to his room and staff were to check on him frequently. R1 had a high risk for elopement when staff observed him pushing on the front door with exit seeking and behaviors noted. […]

• Actual harm, isolatedF689Jun 4, 2026

  Based on record review and interview, the facility failed to provide an environment free from accidents when staff failed to use a gait belt during a transfer for Resident (R) 1, which resulted in a fractured right femur (thigh bone). Additionally, the facility failed to place an appropriate wheelchair cushion for R2, and instead used a bed pillow which caused the resident to slide out of her wheelchair during a van transport, resulting in bilateral hematomas to her knees. Findings included:- R1's Electronic Medical Record (EMR) documented diagnoses of malignant (the tendency of a medical condition, especially tumors, to become progressively worse, most familiar as a characteristic of cancer) neoplasm (tumor) of the middle third of the esophagus, hypertension (elevated blood pressure),… […]

• No harm, potential for more than minimal, widespreadF812Oct 25, 2023

  The facility identified a census of 34 residents. Based on observations, record review, and interviews, the facility failed to ensure refrigerated food items were covered, labeled, and dated, and failed to ensure consistent temperature monitoring for walk-in refrigerator and walk-in freezer in the kitchen. This deficient practice had the risk to spread foodborne illness to the residents. Findings included: - On 10/23/23 at 07:19 AM a tour of the kitchen revealed the following: Uncovered fruit cocktail; eight opened, pre-thickened containers of juice which were undated; uncovered cake, and undated and uncovered dipping sauces in the cooler/refrigerator. […]