Mission Nursing Home

Inspectors wroteBased on interviews and document review the facility failed to ensure the State Ombudsman for Long Term Care (LTC) was notified of a transfer to the hospital for 1 of 3 residents (R6) when transferred to the hospital for medical treatment.

Inspectors wroteBased on interview and document review, the facility failed to monitor and implement interventions per physician orders for 1 of 1 resident (R16) reviewed for heart failure.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure appropriate personal protective equipment (PPE) was used for 2 of 2 residents (R11 and R44) who required enhanced barrier precautions (EBP). In addition, the facility failed to ensure nationally accepted standards of practice for bodily fluid removal from catheter drainage bag were followed for 2 of 2 residents (R11 and R44).

Inspectors wroteBased on interview and record review, the facility failed to ensure that each resident receiving hospice services had a comprehensive written plan of care included both the most recent hospice plan of care and a description of the services furnished by the facility to help the resident attain or maintain their highest practicable physical, mental, and psychosocial well being for 1 of 3 residents (R1) reviewed for hospice services.

Inspectors wroteBased on interview and document review the facility failed to protect 1 of 1 resident (R1) from staff to resident abuse when R1 was physically and verbally abused by nursing aid (NA)-A which resulted in psychosocial harm to R1 who was crying and visibly upset during the abuse incident. The facility implemented corrective action, and the deficient practice was corrected on 2/19/26, prior to the survey and was issued at past non-compliance.

Inspectors wroteBased on interview and document review, the facility failed to perform comprehensive skin assessments (at least weekly) as ordered, which included assessment for new wounds and documenting wound measurements and other wound characteristics for 3 of 3 residents (R1, R2, R3) reviewed for pressure injury.

Inspectors wroteBased on document review and interview, the facility failed to ensure a system of registry verification approved by the State before allowing nursing assistant to do nursing or nursing-related services in the facility for 4 of 7 nursing assistants (NA-A, NA-B, NA-C, NA-D) reviewed for the required certificate status.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure call lights were answered in a timely manner for 2 of 3 residents (R3, R4) reviewed for dignity.

Inspectors wroteBased on interview and document review the facility failed to ensure 1 of 3 resident (R2) was free of significant medication errors when physician's orders for Darbepoetin (causes the bone marrow to produce red blood cells and used to treat anemia in people with chronic kidney failure) was not administered as prescribed, resulting in seven missed doses of Darbepoetin.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure appropriate hand hygiene was performed during personal cares for 1 of 1 resident (R4) reviewed for infection prevention and control.

Inspectors wroteBased on interview and document review, the facility failed to ensure pain medications were re-ordered and available for administration per physician orders for 1 of 3 residents (R2), who had chronic pain and utilized pain medication. This resulted in actual harm when R2 was not administered the physicians ordered pain medication before a pre-scheduled surgery prior to leaving the facility for surgery, and arrived at the surgery center tearful and in severe pain. The facility implemented immediate corrective action prior to the survey and was therefore issued at past non-compliance.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure call lights were within reach and accessible for 1 of 3 residents (R2) who was dependent on staff for care.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure adaptive equipment was provided for 1 of 2 residents (R3) reviewed for safety while smoking.

Inspectors wroteBased on interview and record review, the facility failed to develop a plan that defined measurable goals and create a system to collect feedback from resident and resident representatives. This had the potential to affect all 56 residents in the facility. Findings Include: During entrance interview on 3/10/25 at 12:54 p.m., a request for a copy of the Quality Assurance and Performance Improvement (QAPI) plan was made to the director of nursing (DON). On 3/13/25 at 1:37 p.m., another request was made for a copy of the QAPI plan. On 3/13/25 at 2:25 p.m., the facility's QAPI program policy was provided. On 3/12/25 at 2:44 p.m., the director of nursing (DON) provided meeting minutes for the last four quarters, but failed to provide an overall plan. [...]

Inspectors wroteBased on observation, interview and document review the facility failed to ensure a thorough smoking assessment was completed on residents who wished to smoke for 5 of 5 residents (R54, R16, R34, R52 and R19) reviewed for smoking.

Inspectors wroteBased on interview and document review, the facility failed to ensure a level II pre-admission screen and resident review (PASSAR) was completed prior to admission for 1 of 1 residents (R54) reviewed who required a level II PASSAR screening for mental illness.

Inspectors wroteBased on interview and document review the facility failed to ensure the infection control program included symptom tracking and ongoing analysis of trending of resident infections to prevent the spread of infections. This deficient practice had the potential to affect all 58 residents in the facility.

Inspectors wroteBased on interview and document review the facility failed to implement a process for antibiotic stewardship to determine appropriate indications, dosage, duration, symptoms, analysis of trends and efficacy of antibiotic use. This had the potential to affect any of the 58 residents in the facility.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure dignity was maintained for 1 of 1 resident (R19) reviewed for dignity.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident received unopened mail for 1 of 2 residents reviewed for their right to receive communication with privacy.

Inspectors wroteBased on interview and document review, the facility failed to ensure advanced directives were accurately documented in the resident's electronic medical record (EMR) under physician orders for 1 of 1 residents (R109) reviewed for accurate code status.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident rooms were kept clean and in good condition for 1 of 2 residents (R36) reviewed for environment.

Inspectors wroteBased on interview and document review the facility failed to ensure a written notification of transfer was sent to the office of the Ombudsman for long term care for 1 of 2 residents (R44) reviewed for hospitalization.

Inspectors wroteBased on interview and record review the facility failed to accurately implement physician's orders for 1 of 1 resident (R44) reviewed for hospitalizations.

Inspectors wroteBased on observation, interview, and document review, the facility failed to prevent an avoidable pressure injury related to improper placement and use of a mechanical lift sling for 1 of 1 residents (R19) reviewed for pressure injuries. This deficient practice resulted in actual harm for R19 who developed pressure and shearing related injury to his groin, thighs, and buttocks.

Inspectors wroteSurveyor: [NAME], [NAME] M. Based on observation, interview, and document review, the facility failed to perform mechanical lift and lift sling assessments for 1 of 1 residents (R19) to ensure appropriate use and proper size. Further the facility failed to adequately train staff on manufacturers guidelines for use of mechanical lift. This deficient practice had the potential to effect all residents requiring assist with a mechanical lift.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure ongoing monitoring of weight was completed as directed for 1 of 3 residents (R45) reviewed for nutrition.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure post-dialysis assessment and monitoring was completed for 1 of 2 residents (R42) reviewed for dialysis.

Inspectors wroteBased on record review and interview the facility failed to ensure a clinical rationale for the extended use of an as needed (PRN) antianxiety medication (Ativan) beyond 14 days was documented for 1 of 1 resident (R25) reviewed for hospice services.

Inspectors wroteBased on interview and record review the facility failed to ensure 1 of 5 residents (R35) received a pneumococcal vaccine offered by the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure confidentiality of personal records for one of one resident (R1) reviewed. The facility gave R1's medical information to his probation officer and the electric health monitor case manager. Findings Include: R1's Face sheet printed on 4/24/24 indicated R1 was admitted to the facility on [DATE]. Diagnoses included alcoholic gastric without bleeding, alcohol induced acute pancreatitis, and alcohol dependence. R1's progress note dated 2/16/24 indicated R1 was admitted to the facility for alcohol induced gastritis, esophagitis, and metabolic acidosis. R1's brief interview for mental status (BIMS) assessment dated [DATE] indicated R1 had a score of 15 which meant R1 was cognitively intact. R1's progress note dated 3/14/24 indicated facility staff found empty bottles of alcohol in R1's room. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure appropriate personal protective equipment (PPE) for source control was worn by all staff, per the Centers for Disease Control (CDC) grid, directing everyone should mask in communal areas of the facility while in COVID-19 outbreak status. This had the opportunity to affect all residents and visitors.

Inspectors wroteBased on interview and document review, the facility failed to provide a timely influenza immunization as recommended by the Centers for Disease Control (CDC) for 1 of 5 residents (R2) residents reviewed for immunizations.