Mission Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure the written notice of proposed transfer and discharge was provided to the resident or resident representative (RR), for one of four residents reviewed (Resident 2). This failure had the potential for the resident or resident representative not to be aware of the transfer/discharge rights and process to appeal the transfer/discharge.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided met professional standards of practice, for one of nine residents (Resident 2), when nursing staff did not use appropriate safe handling precautions for a hazardous drug (medication that can cause birth defects and requires special handling for safety), letrozole (used to treat breast cancer), in accordance with professional standards and the facility's policy and procedure. This failure had the potential to expose residents and staff to serious reproductive risks such as infertility, miscarriage, or other pregnancy related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide ongoing monitoring and assessment, for one of four residents reviewed (Resident 4), when there was a change of condition of increased drainage from the resident's neck lesions/wounds on January 14, 2026. In addition, there were no care plan developed to address Resident 4 who was at risk for infection due to increased wound drainage and odor.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the code status (a legal document or instruction that outlines a patient's wishes regarding medical care, particularly if they experience a cardiac or respiratory arrest) and presence of medical device was communicated accurately to the receiving facility when the resident was transferred to the acute hospital, for one of three residents sampled (Resident A). This failure had the potential to result in Resident A not to receive the correct code status during the resident's hospital stay, and could have a delay in care and treatment when the presence of medical device was not initially communicated to the receiving facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure garbage and refuse were properly disposed off the facility grounds when multiple items were observed stored and stacked on top of each outside a trailer container. This failure had the potential to attract and harbor pest and rodents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, handle, and serve food, in accordance with professional standards for food service safety for a highly vulnerable population of seven (7) residents who eat frood from the facility kitchen, when, two (2) oven gloves were observed with dark stains thick brown/black substance on the fingers and multiple patches of white substance. This failure had the potential to result in cross contamination and cause food borne illnesses in a highly vulnerable population of seven (7) residents who eat food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate infection control practices were implemented when emergency water was stored in a clean environment. This failure had the potential for the spread of contaminates and/or infections to residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the required bedroom space measuring at least 80 square feet per resident, in 15 resident rooms (Rooms: 1, 2, 3, 4, 5, 6, 7, 8 , 11, 12, 14, 15, 16, 17, and 18). On February 10, 2025, at 10 :00 a.m., an interview was conducted with the Director of Nursing (DON) regarding the room sizes for resident rooms 1, 2, 3, 4, 5, 6, 7, 8, 11, 12, 14, 15, 16, 17, and 18. The DON stated the rooms did not meet the space requirement of at least 80 square feet per resident in the above mentioned resident rooms. The DON stated the facility has a waiver for the rooms. During the survey dates February 10,11, 12 and 13, 2025, the above listed rooms were observed at different times of the day. [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure appropriate infection control were followed when: 1. The facility's water system was not tested for Legionella (a bacteria whichcould cause a serious type of pneumonia [lung infection]) and other waterborne diseases. This failure had the potential to place residents at risk for health complications related to Legionella; and 2. Three suction tubings (flexible tubes used for the removal of secretions) and one Yankauer (a tool used to suction oral secretions) were not dated, for three of three residents (Residents 2, 17 and 34). In addition, two Yankauers were not changed according to the facility's policy and procedure, for two of three residents (Residents 1 and 17.) This failure had the potential to cause an increased risk for respiratory infection for Residents 2, 17 and 34.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. A risk for entrapment (an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail) assessment and least restrictive alternatives were conducted prior to use of bed rails, for sixteen of sixteen residents reviewed for bed rails (Residents 1, 2, 3, 4, 9, 13, 16, 22, 27, 28, 30, 31, 32, 35, 37, and 40). In addition, the risk for entrapment assessment did not indicate the resident's size and weight in relation to the dimensions of the bed being used for the resident according to the facility's policy and procedure. 2. The risk for entrapment assessments conducted were not specific to the bed rails being used by the residents, for six of sixteen residents reviewed for bed rails (Residents 2, 3, 16, 28, 37, and 40); and 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was served and prepared in a sanitary condition and in accordance with professional standards for food service safety practice when: 1. There were multiple areas in the kitchen, kitchen equipment, and food storage areas that were not clean; 2. The kitchen floor was not clean and had pores, indentation, cracked, and missing flooring tiles; and 3. The resident refrigerator had multiple unlabeled food items. These failures had the potential to place residents at risk for foodborne diseases (illness that result from ingestion of contaminated food) that can cause sickness and or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, two (2) microwave ovens, six (6) refrigerator shelves, six (6) dry storage room shelves, one (1) refrigerator gasket, and one (1) freezer gasket were maintained in a safe operating condition. These failures had the potential to place residents at risk for foodborne diseases (illness that result from ingestion of contaminated food) that can cause sickness and or death.

Inspectors wroteBased on interview and record review, the facility failed to ensure a written notice of bed-hold policy (reserving a resident's bed while resident is out of the facility for therapeutic leave or hospitalization) was provided to the resident/and or resident representative, for one of one resident reviewed (Resident 25) when Resident 25 was transferred to the acute hospital. This failure had the potential for the resident or resident representative not to be informed of their right to hold the bed while out of the facility and the right to be readmitted back to the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an enteral feeding (a tube is inserted through the abdominal wall, through which liquid nutrition is administered) was provided within the safe timeframe to prevent bacterial growth in accordance with the enteral feeding manufacturer's recommendations, for one of 34 residents (Resident 30). This failure had the potential to result in food borne illness for Resident 30.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were disposed timely according to the facility's policy and procedure, for one of one resident (Resident 40), when one intravenous (IV) antibiotic medication was observed hanging on the IV pole, readily available for use after IV therapy was completed. This failure had the potential for Resident 40 to receive discontinued medication and/or could result in medication administration error.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dietary staff were able to carry out the functions of food and nutrition services safely and effectively when: 1. [NAME] 2 was unable to accurately verbalized the starting temperature of cool down process for hazardous foods. This failure had the potential to cause foodborne illness, for five (5) out of five (5) residents who received food from the kitchen; and 2. [NAME] 1 served chunks of pureed spinach casserole (pureed foods should be smooth for residents who have difficulty chewing and/or swallowing) during the noon meal on January 10, 2024. This failure had the potential risk of choking, for one out of one resident (Resident 30) who received pureed food from the kitchen. (Cross referred with F805)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a puree diet (a diet with food texture of smooth pudding-like or smooth mashed potato-like consistency) was prepared and provided, for one of one resident (Resident 30) when the resident received chunks of spinach casserole for lunch on January 10, 2024. This failure placed Resident 30 at risk for aspiration (accidentally inhaling food or liquid into the lungs) and choking.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the physician's prescribed diet order, for one of five resident (Resident 36) observed during lunch on January 9, 2024, when Resident 36 did not receive the prescribed portion size during lunch meal. This failure resulted in Resident 36 to receive less calories from small portion, and could potentially result in unplanned weight loss, further compromising the nutritional and medical status of Resident 36.

Inspectors wroteBased on interview and record review, the facility failed to ensure the pneumonia (lung infection) vaccine was offered, for one of five residents reviewed for immunization (Resident 35). This failure had the potential for an increased risk for Resident 35 to acquire pneumonia.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the required bedroom space measuring at least 80 square feet per resident, in 15 resident rooms (Rooms: 1, 2, 3, 4, 5, 6, 7, 8 , 11, 12, 14, 15, 16, 17, and 18).