Mission Convalescent Home

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure food was stored properly when frozen food was not stored on a shelf to allow circulation, the corn meal, sugar, and flour bins were undated and unlabeled, expired food and frozen food was observed with thick build-up of ice crystals in 2 of 2 reach-in freezers and 1 of 1 reach-in refrigerators, and a pink/brown substance found in 1 of 1 ice machines.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 1 of 2 (Licensed Practical Nurse (LPN A) failed to don Personal Protective Equipment (PPE) while administering medications and performing wound care to 2 of 3 (Resident #22 and #33) residents reviewed for Percutaneous Endoscopic Gastronomy (PEG) (a tube in the stomach that provides nutrition) tube and pressure ulcers.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure resident assessments were completed at the time of a fall and that a post fall assessment was completed after falls for 1 of 12 (Resident #29) residents reviewed for falls.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure assessments were completed to accurately reflect the resident's status for dialysis for 1 of 1 (Resident #7) sampled residents reviewed for dialysis.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to revise and update a care plan for 1 of 2 (Resident #11) residents reviewed for care plans.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure staff followed physician orders for 1 of 1 (Resident #88) sampled residents reviewed receiving oxygen.

Inspectors wroteBased on policy review, medical record review and interview, the facility failed to have a physician's order to provide dialysis for 1 of 1 (Resident #7) sampled residents reviewed for dialysis.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure food was stored properly when 4 bags of frozen chicken breasts and a thick build up of ice crystals were found in 1 of 2 reach-in freezers, and 1 of 1 nourishment refrigerator had unlabeled, undated foods, and a dirty freezer that did not have a thermometer or temperature logs.

Inspectors wroteBased on review of staff in-services, and interview the facility failed to ensure the mandatory annual 12 hours of Certified Nursing Assistant (CNA) in-service training hours were completed for 4 of 19 sampled CNA's (CNA A, B, C and D) reviewed for inservices.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to maintain or enhance residents' dignity and respect during random observations when 1 of 1 (Licensed Practical Nurse (LPN) #2) failed to use courtesy titles when addressing residents, and during dining when 8 of 10 staff members (Certified Nursing Assistant (CNA) #1), CNA #2, CNA #3, CNA #4, CNA #5, CNA #6, CNA #7, and LPN #2, and LPN #3, failed to knock and/or announce themselves, stood to assist with dining, failed to use courtesy titles when addressing residents, and when 1 of 1 (LPN #2) failed to knock or announce self before entering a resident's room during medication administration.

Inspectors wroteBased on review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument (RAI) Manual, medical record review, and interview, the facility failed to ensure the facility assessments were signed by a Registered Nurse (RN) as required by Federal Regulations for 12 of 12 (Resident #1, #9, #10, #20, #25, #31, #33, #39, #41, #43, #44, and #146) sampled residents reviewed.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure residents were free of accident hazards when the facility failed to ensure fall risk assessments were complete for 1 of 1 (Resident #10) reviewed for falls, chemicals were observed 1 of 1 unsecured and unattended storage room, and when sharps were left unsecured on top of 1 of 4 (South Medication cart) medication carts.

Inspectors wroteBased on the facility Monthly Schedules, Report of Nursing Staff Direct Responsible Resident Care Report, Registered Nurse (RN) Time Punches, and Daily Work Up Sheets, the facility failed to ensure there was RN coverage for 8 consecutive hours a day on Saturday and Sunday weekend days from April 1, 2023, to June 24, 2023 and October 14, 2023 to October 22, 2023. The facility census was 44.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure proper infection control practices were followed when 3 of 3 (Licensed Practical Nurse (LPN #1, #2, and #3) nurses failed to perform proper hand hygiene during medication administration, when 1 of 1 (LPN #3) failed to clean reusable equipment, and when 1 of 1 (LPN #2) failed to clean medical supplies after dropping it on the floor during Percutaneous Endoscopic Gastrostomy (PEG) site care, and when the facility failed to maintain and monitor for an effective infection prevention and control program for 3 of 3 (Resident #15, #24, and #30) sample residents reviewed for Legionella Disease.

Inspectors wroteBased on policy review, medical record review, and interview, the facility failed to convey the funds to the estate of a deceased resident within the 30 days requirement for 1 of 1 (Resident #97) resident reviewed for personal fund account.

Inspectors wroteBased on the [Named facility] HEALTH & REHABILITATION CENTER FINANCIAL RESPONSIBILITY AGREEMENT), medical record review, and interview, the facility failed to provide 3 of 4 sampled residents (Resident #23, #32, and #40) with the Advanced Beneficiary Notice (ABN), Center for Medicare and Medicaid Services (CMS)-10055 when therapy services were discontinued and the resident remained in the facility for long-term care services or was discharged from the facility. This failure left residents without information related to the cost of therapy services if they desired to continue the services in the facility and did not allow for them to have an informed choice.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure choices to receive showers was provided for 1 of 1 (Resident #41) sampled residents reviewed for ADL care.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure staff was following physician orders for automatic [auto] flush for a Percutaneous Gastrostomy (PEG) tube feeding for 1 of 1 (Resident #25) sampled residents reviewed for enteral feedings.

Inspectors wroteBased on policy review, medical record review, observation, and interview, the facility failed to ensure medications were properly stored and secured when during random observations 1 of 3 (Licensed Practical Nurse (LPN) #2) nurses failed to remain at the bedside when administering Resident #33 and #41's medications and when 1 of 1 (LPN #2) failed to ensure medications were properly secured during PEG (percutaneous endoscopic gastrostomy) site care for Resident #25.

Inspectors wroteBased on policy review, observation, and interview, the facility failed to ensure a safe, sanitary, and comfortable environment for 7 of 43 (Resident #1, #4, #13. #15, #24, #25 and #40) resident rooms.