Mission Hills Post Acute Care

Inspectors wroteBased on interview and record review, the facility failed to allow one of three sampled residents (Resident 1) to return to the facility following a hospitalization. In addition, the facility failed to offer a bed hold to Resident 1 per facility policy. As a result of this failure, Resident 1 had the potential to not receive continuity of care, prolonged Resident 1's hospital stay unnecessarily, and violated Resident 1's rights to return to the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure sufficient staffing for the facility when: 1. Payroll data report from Centers for Medicare & Medicaid Services (CMS-government agency overseeing nursing health facilities) indicated quarter one 2025 triggered for Excessively Low Weekend Staffing .October 1- December 31. 2. Residents in the confidential resident council meeting verbalized not having enough staff. This failure in excessively low weekend staffing resulted in not meeting staffing requirements by CMS and had the potential for residents to not receive an appropriate quality of care.

Inspectors wrote2. On 6/16/25 at 11 A.M. an observation and interview was conducted with Resident 163. Resident 163 was observed with a PICC line on his right upper arm. On 6/18/25 at 3:20 P.M., an interview and record review was conducted with Licensed Nurse (LN) 5. LN 5 stated the facility received Resident 163 with PICC line from the hospital. LN 5 stated their facility had a batch order for PICC lines including dressing change and flushing. According to Resident 163's record, there was no documented evidence of a physician order related to Resident 163's PICC line length and circumference monitoring and there was no documented evidence of monitoring related to Resident 163's PICC line. A review with LN 5 of the facility's policy entitled Acknowledgements, revised date July 2016, indicated .(5) Length of catheter is specific to resident. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to properly store and label medications when: 1. An inhaler (a portable device for administering a drug which is to be breathed in) was identified at a resident's bedside, with no label indicating name or dose (Resident 113), and 2. inhalers were not labeled with an open date 3. external and internal medications were stored together As a result, the facility could not ensure medications were safely stored to ensure their integrity.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a kitchen freezer was serviced and maintained to prevent the formation of condensation. As a result, frozen vegetables stored within the freezer had condensation accumulated, resulting in freezer burn and the risk of contamination.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure appropriate brief size was provided for one of one resident (164). As a result, Resident 164 felt uncomfortable.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately code the Minimum Data Set (MDS- a nursing assessment tool) for one of seven sampled residents (Resident 31) reviewed for MDS accuracy. This deficient practice resulted in providing inaccurate information to the Federal database (information maintained by the federal government) and had the potential for Resident 31 to not receive appropriate care.

Inspectors wroteBased on observation, interview, and record review, the facility did not develop patient centered care plans for one of six residents reviewed for care plans when: 1. Resident 7's bowel and bladder incontinence was not care planned; 2. Resident 7 did not have a care plan for the use of heparin (blood thinner). Cross reference F690 This failure had the potential for Resident 7 to not receive appropriate care, treatment, and interventions.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an Activities program to meet a resident's preferences for one of one residents reviewed for Activities (Resident 36). This failure had the potential to not support Resident 36's psychosocial well being.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain bowel and bladder status for one of three residents reviewed for bowel and bladder incontinence (involuntary loss of feces and urine) . (Resident 7) This failure had the potential for Resident 7 to develop pressure sores and affect Resident 7's dignity and comfort.

Inspectors wroteBased on interview and record review, the facility failed to evaluate the nutritional status of one of two residents reviewed for nutrition (Resident 19). This failure had the potential to result in weight loss or further compromise their health.

Inspectors wroteBased on observation, interview and record review, the facility failed to attempt and evaluate the use of nonpharmacological interventions (NPIs, healthcare treatments that do not involve medications, such as music or massage) for one of one resident reviewed for behaviors (Resident 16). This failure had the potential to result in overmedication.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the medication error rate was less than five percent when two out of 26 medications were administered incorrectly. The facility's error rate was 7.69%. These failures had the potential to negatively affect the residents' health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate storage of respiratory (related to breathing) equipment for one of one resident reviewed for infection control. (Resident 31) This failure had the potential for cross contamination (spread of germs and bacteria) and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect 1 of 5 residents from physical abuse from another resident of the facility. (Resident 2). This failure resulted in Resident 2 being kicked in the shins. In addition, there was a potential for a repeat physical abuse from the same resident.

Inspectors wroteBased on interview and record review, the facility failed to ensure a baseline care plan (the minimum healthcare information necessary to properly care for each resident immediately upon their admission) meeting was conducted within 48 hours for two residents (Resident 2 and 6) reviewed for baseline care planning. This failure had the potential for an incomplete and lack of care interventions for residents in an event of a serious change of condition to potentially occur to residents after admission. In addition, the lack of communication among facility staff and responsible party had the potential to affect the quality of care to the resident.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure three of four residents were provided care in a manner that promoted dignity and respect. (Resident 2, 3 and 4) These failures resulted in not ensuring resident's rights to be treated with respect and dignity with the potential to cause psychosocial harm to the involved residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure sufficient staffing was provided for the residents of the facility when: 1. Resident 2 ' s brief was not changed for over nine hours. 2. Resident 3 held her urine for an hour before staff came to assist. 3. Resident 4 ' s brief was not changed for over four hours. As a result, Residents 2 and 3 sat on a soiled and wet pad, and Resident 4 waited over 4 hours to be changed. Failure to change a soiled, wet pads had the potential for residents to develop a skin breakdown and the potential to affect their emotional and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent an avoidable fall for one resident (Resident 2) who had a previous fall history. This failure caused the resident to sustain a right femoral neck fracture (a type of hip fracture). Review of Resident 2 ' s history and physical dated 10/12/23 indicated Resident 2 was admitted on [DATE] for diagnoses which include Pathological Fractures, Fracture of Odontoid Process (a bone in resident ' s spine), recurrent falls, and orthostatic hypotension(symptomatic low blood pressure when changing position). Per History and Physical, Resident 2 was .transferred from another SNF, where she was admitted after an unwitnessed fall and was unable to get up. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide respiratory care services for three residents (Resident 5, 6 and 7) who used CPAP machines (continuous positive airway pressure-a machine that delivers mild air pressure through the nose to keep breathing airways open while asleep) when: 1. There was no ongoing assessment to evaluate resident's respiratory status and response to the use of the CPAP machine. (Resident 5 and Resident 6) 2. The medication administration record was signed when Resident 5's CPAP was not available. In addition, Resident 5's medical record did not indicate staff follow up of Resident 5's CPAP according to physician's order. 3. Resident 7 used a CPAP machine but did not have a physician's order. These failures had the potential for residents to receive inappropriate care and treatment to address their respiratory problems.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control standards of practice when respiratory equipment were not stored appropriately for two residents (Resident 5 and Resident 6). This failure had the potential for residents to acquire an infection. Resident 5 was admitted to the facility on [DATE] with diagnoses including obstructive sleep apnea (OSA- a problem in which breathing pauses during sleep due to blocked airways) according to the facility's admission Record. During an observation and interview on 4/4/24 at 9:42 A.M., Resident 5 was sitting at the edge of her bed with a CPAP machine on top of the bedside drawer. The CPAP machine was connected to a tubing and mask exposed on top of the machine. Resident 5 further stated nobody from the facility had checked the machine or if she had applied it or not. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to assess a resident ' s ability to self-administer medications for one of one resident reviewed for self-administration of medications. (Resident 2). This failure had the potential to affect Resident 2 ' s health and safety. In addition, this failure resulted in Resident 2 to run out of the medication without staff knowledge.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate assistance to a resident who required total dependence on activities of daily living (ADL). (Resident 4) As a result, Resident 4 fell off the bed.

Inspectors wroteBased on observation, interview, and record review the facility failed to safely store a medication for one of one resident reviewed for drug storage. (Resident 2) This failure had the potential for unauthorized people or residents to have access to the medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain accurate and complete medical records when: 1. A treatment administration record for a resident (Resident 2) was inaccurately signed by a licensed nurse and 2. A resident ' s (Resident 9) inventory of personal belongings was not completed upon resident ' s discharge. As a result, Resident 2 ' s clinical record contained an inaccurate documentation and Resident 2 did not receive the care and skin treatment as ordered by the physician. In addition, Resident 9 ' s personal belongings went missing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nutrition interventions were consistently implemented and re-evaluated for effectiveness to prevent an unplanned severe insidious weight loss of 31.9 pounds (22.7%) in six months, for one of seventeen sampled residents (Resident 29). The resident's nutrition status interventions were not re-assessed for effectiveness, and the care plan goals were not updated to reflect the resident's desired weight goal, according to facility policy and standards of practice. This deficient practice led to continued weight loss and the facility's inability to meet the resident's desirable body weight range, which further impaired nutrition and health status.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure overall systematic operations of the food and nutrition services with the necessary oversight to ensure the daily nutritional needs of the residents were met. This deficient practice led to a resident (Resident 29), to experience severe avoidable weight loss in six months, the potential for other facility residents to experience weight loss, malnutrition, and widespread food borne illness, which can affect all residents in the facility. The facility census was 66. Cross reference F692, F802, F803, F806, F809 and F812

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure snacks were consistently offered to residents three times a day, particularly an evening snack as per facility policy. This failure had the potential to negatively alter nutrition status and not meet the nutritional needs of residents in need of an evening snack.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe and sanitary measures were met in the kitchen during dietary operations according to standards of practice when: 1. A Diet Aide (DA 1) found 12 oatmeal/soup bowls stored as clean with crusted brown oats, dirt and food debris; 2. Food items were not properly labeled and dated, including thawed ReadyCare (protein shakes), an opened clear bin of dried black eyed peas, and a bag of cilantro leaves; 3. The following items were stored inappropriately in a food preparation area: a gallon of liquid bleach, a staff personal belonging, and a radio; and 4. Six scoopers and one spatula were stored wet in a drawer. These findings had the potential to expose the facility's residents to unsafe and unsanitary food practices that could lead to widespread foodborne illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide RNA (Restorative Nursing Assistant) range of motion (ROM) exercises per physician's order for Residents 31, 38, and 43. This had the potential to promote the development of contractures (condition of shortening and hardening of muscles, tendons, or other tissue leading to deformity and rigidity of joints).

Inspectors wroteBased on observation, interview and facility document review, the facility failed to ensure the Food and Nutrition Services staff maintained current competency in dietetic task operations to safely carry out the kitchen functions in a sanitary manner according to the facility's policies and standards of practice when: 1. The A.M. and P.M. cooks did not take food temperatures of the lunch meal served on 1/24/22, including the chicken breast, green beans, pureed rice and pureed black beans; 2. CK1 and the DSS were unable to verbalize the proper final cooking temperature of chicken; 3. CK1 poured sanitizer solution from a red bucket in the food preparation (prep) sink that splashed on three trays of uncovered sliced chicken breast; and 4. CK 2 improperly calibrated a food thermometer. [...]

Inspectors wroteBased on observations, interviews, and document reviews, the facility failed to ensure the recipes for the beef enchilada, chicken jambalaya, and alternate menu's chef's salad and turkey sandwich, were followed as printed and per menu guidance. These failures led to residents not receiving food on the menu or a substitution, as planned, which had the potential to reduce food intake and impact nutritional status.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Physicians Orders for Life Sustaining Treatment (POLST) forms were accurate and matched the facility's code status (the level of medical interventions a person wishes to have if their heart or breathing stops) for one of nine residents (Resident 4) reviewed for advanced directives. This failure had the potential for Resident 4 to receive the incorrect care in the event of an emergency.

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe and comfortable homelike environment was provided to its residents when: 1. Three of four residents reviewed for personal belongings reported items missing and not replaced (35, 43, 50), and, 2. A medication was found in a public hallway. These failures had the potential to negatively impact the residents' health and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to assess multiple red and black discolorations observed on both arms and both legs for one of two residents reviewed for skin conditions (Resident 52). This failure had the potential to result in delayed provision of care and treatment for the resident's skin condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure LN 2 followed the facility's policy and procedure prior to administering medications through a tube feeding for one of one residents observed for tube feeding (Resident 31). This failure had the potential for Resident 31 to further develop medical complications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the medication error rate was less than five percent. The facility's medication error rate was 7.14%. Two medication errors were observed, a total of 28 opportunities, during the medication administration process for two of six randomly observed residents (Residents 2, 5, 15, 31, 47, and 256). As a result, the facility could not ensure medications were correctly administered to all residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that substitutes and meal alternatives were offered and made available to accommodate a resident's allergies and food preferences for one of three residents reviewed for food preferences (Resident 21). This failure led to Resident 21 to receive foods listed as dislikes or allergies on his meal card, and had the potential to impair food intake and nutrition status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food and kitchen equipment were maintained in accordance with professional standards of food service safety when: 1. Frozen dough was not sealed properly inside one of one freezers; 2. An ice machine was not cleaned thoroughly for one of one ice machines; and 3. Raisins stored in the dry storage area were not stored properly. These failures had the potential for cross contamination and to placed residents at risk for food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to maintain acceptable noise levels at night for two of 18 sampled residents (34, 213), and for three of five CRs (CR 2, CR 3, CR 4). This failure resulted in residents being unable to sleep at night.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a baseline care plan for PTSD (Post traumatic stress disorder-an anxiety disorder that develops following distressing life events. Symptoms include flashbacks, nightmares of the incident, avoiding people or memories of the trauma, anger, and difficulty sleeping) for one of twenty-one sampled residents (162) reviewed for care plans. This deficient practice created the potential for Resident 162 to not receive services related to the PTSD.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two residents reviewed for psychosocial well-being, received a psychosocial assessment (162). This deficient practice created the potential for Resident 162 to not have received needed mental health treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two residents (162) reviewed for mental conditions, received treatment. This deficient practice resulted in Resident 162 to have experienced emotional distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure: 1. A medication card was labeled accurately for Resident 215 during medication administration observation. 2. An expired IV (intravenous) solution bag was removed from one of one IV carts inspected. These failures had the potential for adverse reactions.

Inspectors wroteBased on dietary staff observations, interviews, and document reviews, the facility failed to ensure safe and effective Dietetic Service oversight between the facility and the Registered Dietician. Failure to ensure effective oversight of the day to day dietary operations had the potential to place 74 residents at nutritional risk, and in turn, further compromising the residents medical status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to employ dietary staff with the competencies and skills to carry out the daily functions of food and nutrition services, when: 1. DA 1 did not know the correct concentration of the sanitizing solution used to sanitize kitchen surfaces; and, 2. CK 2 performed and documented food temperature checks 45 minutes before lunch was served. Theses failures had the potential for kitchen surfaces not being sanitized correctly and food temperature to be incorrect at the time of plating, which could have placed residents at risk of gastrointestinal illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure personal food brought in for residents by family and friends was stored in a safe manner for one of one designated refrigerators when: 1. Refrigerator temperatures were not being monitored daily to ensure correct temperatures were maintained; and, 2. Resident food was not labeled and dated properly when placed in the residents refrigerator. This failure had the potential for residents to be exposed to foodborne illnesses (food poisoning) if consumed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately and consistently document urine outputs (a method used to measure fluid balance within the body), according to professional standards for one of three residents (59) reviewed for catheter care. This failure had the potential for Resident 59's fluid imbalances not to being identified by staff in a timely manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control practices when: 1. A blood pressure cuff was not sanitized (to clean and make free of disease causing elements) between resident use. (34, 216); and, 2. A urinary catheter collection bag was not positioned below Resident 59's bladder and was allowed to touch the floor. These failures had the potential to spread infection and cause illnesses.