Mission Nursing and Rehabilitation Center

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure residents were free of any significant medication errors for 1 of 3 residents (Resident #13) reviewed for pharmacy services. The facility failed to ensure Resident #13 received the correct dose of:Amiodarone HCI oral tablet 200 mg, Apixaban oral tablet 2.5 mg, and Metoprolol Tartrate Oral Tablet 25 mg. This failure could place residents at risk of medical complications and not receiving the therapeutic effects of their medications.

Inspectors wroteBased on interview and record review, the facility failed to complete the baseline care plan for one (Resident #89) of three residents reviewed for base line care plans. The facility failed to provide Resident #89 a written summary of his baseline care plan completed within 48 hours of admission. This failure placed three newly admitted residents reviewed at risk of not receiving continuity of care and communication among nursing home staff, increase resident safety and safeguard against adverse events that are most likely to occur right after admission.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #38) of 6 residents reviewed for comprehensive care plans. The facility failed to include Resident #38's enhanced barrier precautions in his care plan. This failure could place residents at risk of not receiving the appropriate care, services or treatment needed in a timely manner.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible for 1 of 3 resident (Resident#10) reviewed for indwelling catheters. The facility failed to prevent Resident#10's urinary catheter tubing (bag) from touching the floor. This failure could place residents at risk for cross contamination and urinary tract infections.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 7 residents (Resident #71) reviewed for pharmacy services. The facility failed to compare the instructions written on Resident #71's blister pack with the physician's order for Gabapentin before it was administered on 03/19/2026. This deficient practice could place residents at risk of not receiving the therapeutic effects from their medications as intended by the prescribing physician order. Record review of Resident #71's face sheet, dated 03/19/26, revealed a [AGE] year-old female admitted on [DATE] and readmitted [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were labeled and stored appropriately for 1 of 3 residents (Resident #28) reviewed for labeling and storage. The facility failed to put an open date for Resident #28's Trelegy inhaler. This failure could have placed residents at risk of not receiving the therapeutic effects of the medication.

Inspectors wroteBased observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 (Resident #38) residents reviewed for infection control. The facility failed to ensure Resident #38 had an EBP sign on the door. This failure could place residents at risk for healthcare associated cross-contamination and the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles in 1 of 4 medication carts (700 hall medication cart) reviewed for medication storage. The facility failed to ensure the medication aide medication cart for 700 hall was secured by a lock when it was left unattended by MA A. This failure could place residents at risk of injury if medication left unsecured was consumed.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents have the right to request, refuse, and or discontinue treatment and to formulate an advance directive for 1 (R#22) of 4 residents whose records were reviewed for OOH-DNR Order forms: The facility failed to have the physician sign at the bottom of R#22's Out of Hospital Do Not Resuscitate (OOH-DNR) order, which mad the advance directive invalid. This failure could place residents at risk for not having their end of life wishes honored.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 4 residents (Resident #34) reviewed for respiratory care. The facility failed to ensure Resident #34 received oxygen at the prescribed rate. This failure could place residents at risk for respiratory distress.

Inspectors wroteBased on interviews and record reviews, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable, physical, mental, and psychosocial well-being for 1 (CNA D) of 4 CNAs reviewed for competent nursing care. The facility failed to ensure CNA D communicated R#22's change of condition to the charge nurse on 12/23/2024. This failure could place residents at risk of not having change in conditions assessed immediately resulting in delayed treatment and a decreased in quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services including procedures that ensure accurate administering of all drugs and biologicals to meet the needs for 2 of 10 (Resident #5 and Resident #22) residents reviewed for pharmacy services. 1. The nursing staff did not administer Resident #5's Tramadol as prescribed by her physician. This failure could place resident s with pain at risk of not receiving the intended therapeutic benefit of their medications. 2. MA documented she had administered Resident #22 a frozen nutritional treat on 01/07/2025 when the facility did not have the frozen nutritional treat available on 01/07/2025. This failure could place residents at risks of not receiving the intended therapeutic benefit of their medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for, 1 of 5 residents (Resident #32) observed for infection control issues in that: CNA F and CNA G revealed CNA F used wipes to cleanse the perineal area, folding it, and using the wipes again and CNA G noticed not sanitizing between glove changes. This deficient practice could place residents at-risk for infection due to improper hand sanitizing and incontinent care practices.

Inspectors wroteBased on interview and record review, the facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property, for 1 of 4 residents (Resident#2) reviewed for abuse and neglect, in that: Facility staff member, CNA A did not implement their abuse policy related to reporting suspected abuse when Resident #2 was observed to be crying while Resident #2's family member was rubbing her forehead. This failure could place residents at risk of abuse and neglect.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable State laws for 1 of 30 staff (LVN A) reviewed for staff qualifications. The facility failed to ensure LVN A renewed her nursing license before the expiration date in order to practice nursing in the State of Texas. This failure could place residents at risk of not receiving care and services from staff who were properly licensed.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment, were reported immediately to the State Survey Agency, within two hours if the events that cause the allegation that involved abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, for 1 (R #1) of 5 residents reviewed for abuse/neglect. The facility failed to report allegations of resident abuse for R #1 for an incident on 04/24/24 to the State Survey Agency within the allotted time frame of 2 hours. This failure could place all residents at increased risk for potential abuse due to unreported allegations of abuse and neglect.

Inspectors wroteBased on record review and interview 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 (Resident #1) reviewed for quality of care, in that: The facility failed to ensure Resident #1 medication Ipratropium-Albuterol Solution via nebulizer mask was monitored by staff based on their nursing protocols. This failure could place residents at-risk of not receiving adequate respiratory care.

Inspectors wroteBased on interview, and record review, the facility failed to maintain clinical records on each resident that were complete and accurate, for one Resident (R#1), of five residents reviewed for clinical records, in that. The facility failed to ensure LVN E documented the results of vital sign assessments accurately in Resident #1's clinical records. This failure could place residents at risk for not receiving proper care and treatments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision for one resident (Resident #49) of three residents reviewed for supervision and ensured the environment remained free of accident hazards for 2 of 2 unlocked resident rooms reviewed for supervision in that. 1) The facility failed to ensure Resident #49 received supervision while in the shower. 2 ) The facility failed to ensure the two resident rooms, 323 and 324 were free of cluttered storage of equipment, furniture, boxes, walkers, wheelchairs in a secured manner. These failures could place residents at risk of being in an unsafe environment and at risk for accidents and injury.

Inspectors wroteBased on interview, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling Legionella through a program that identifies areas in the water system where Legionella can grow and spread for 1 of 1 facility. The facility failed to have a system in place for preventing and controlling Legionella through a program that identifies areas in the water system where Legionella could grow and spread. This deficient practice places the facility residents at risk for airborne infections.

Inspectors wroteBased on interview and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical mental or psychological status for 1 of 5 residents (Resident #30) reviewed for notification of change of condition. The facility failed to notify the resident's physician when Resident #30's appointment with the orthopedic surgeon was scheduled on 12/27/22, after an acute left femoral neck fracture was identified on x-ray dated 12/18/22. This failure could affect residents with injuries by placing them at risk of delay medical treatment, hospitalization, and decline in condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop the resident's comprehensive care plan for one (Resident #60) of 18 residents reviewed for care plans that describe the services to be provided to attain the resident's highest practicable physical, mental, and psychological well-being in that: The facility failed to develop a care plan to address Resident #60's feeling anxious when door was closed during incontinent care. Resident #60 would refuse to have the door closed while staff provided care. This failure could affect the residents with behavioral healthcare needs at risk for their psychosocial needs not being met.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure and provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 4 ( Resident #291 and Residents #23) residents reviewed for pharmaceutical services, in that: 1. MA J did not check open date on 2 multi dose medication bottles and was going to administer them to Resident #291. 2. Resident #23's medication (zinc oxide 20%) was found on the bedside dresser drawer. These deficient practices could place residents at risk of not receiving the intended therapeutic effect of the medications resulting in exacerbation of the resident's condition and disease process.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain clinical records on each resident that were complete and accurate, for one Resident (R# 81), of eight residents reviewed for clinical records, in that. LVN did not document the results of two skin assessments for pressure ulcers in the sacrum and in left heel in Resident #81's clinical records. This failure could place residents at risk for not receiving proper care and treatments.