Mission Pines Nursing and Rehab Center

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure a resident was free from abuse for 1 of 7 sampled residents (Resident 1). The deficient practice had the potential to result in physical injury, pain, emotional distress, fear, and psychosocial harm to the resident as a result of resident-to-resident physical aggression.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure a comprehensive care plan was updated to include interventions surrounding supervised visitation by a specific family member with criminal history for 1 of 7 sampled residents (Resident 4). The deficient practice had the potential to compromise the safety of the resident and violate the privacy of other residents in the secured unit.

Inspectors wroteBased on interview, record review and document review, the facility failed to ensure the medical record contained complete information for 1 of 7 sampled residents (Resident 4). The deficient practice had the potential to negatively impact on the resident's quality of care.

Inspectors wroteBased on interview and record review, the facility did not ensure the Water Management Program was complete and included all required elements.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure 1) a medication with instructions to refrigerate was stored in the refrigerator, 2) an opened multi-dose vial (MDV) was labeled with opened date and 3) expired over the counter (OTC) medications were discarded. The deficient practice had the potential to affect the efficacy of medications being provided to residents.

Inspectors wroteBased on interview and document review, the facility failed to ensure the facility assessment tool contained a staffing plan. The deficient practice had the potential to impact the quality of care provided to residents due to staffing levels.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure food was served at a preferable and appetizing temperature for four sampled residents (Residents 12, 54, 72, and 119) and two unsampled residents (Residents 27 and 141). The deficient practice had the potential to negatively affect the amount of nutrients consumed by the residents and therefore affect their nutritional status.

Inspectors wroteBased on interview, record review and document review, the facility failed to ensure the facility followed through on a resident's request regarding personal mail for 1 of 38 sampled residents (Resident 176). The deficient practice had the potential to negatively impact the resident's well-being. Resident 176 (R176) R176 was admitted on [DATE], with diagnoses including idiopathic neuropathy, depression and generalized anxiety disorder. On 11/05/2024 at 11:13 AM, R176 appeared neat, well-groomed with pleasant demeanor while seated inside the resident's room in the semi-secured unit. R176 indicated living in a church-based homeless shelter prior to being admitted to the facility in May 2024. [...]

Inspectors wroteBased on interview, employee file review, and document review, the facility failed to ensure verification of a professional license was conducted in accordance with the abuse prevention policy for 1 of 10 sampled employee files (Employee 9). The failure resulted in Employee 9 (E9) working as a Registered Nurse (RN) in the care of residents for over six months using another person's RN license. An unqualified person practicing as an RN could result in an adverse health outcome to residents.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) level two referral was completed for 3 of 38 sampled residents (Residents #39, 50, & 82). The deficient practice had the potential to deprive the residents of concern and other residents of necessary behavioral health services.

Inspectors wroteBased on interviews, record review, and document review, the facility failed to ensure a care plan was revised after resident-to-resident incidents for 1 of 38 sampled residents (Resident 167). The deficient practice placed the resident at risk for inappropriate care, supervision, and accidents.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure an opened multi-dose vial (MDV) of Tubersol (used for intradermal Tuberculosis (TB) testing) was dated. The deficient practice could potentially result in inaccurate TB readings which could compromise the facility's TB surveillance protocol.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the resident's food preferences were honored for one unsampled resident (Resident 60). The failure could have resulted in the resident having an allergic reaction to the provided food.

Inspectors wroteBased on observation, document review and interview, the facility failed to ensure stored foods were stored in accordance with professional standards for food service safety and hand washing areas were accessible to kitchen staff. This deficient practice posed a potential risk to safety and health standards which could lead to contamination and place residents at risk of foodborne illness.

Inspectors wroteBased on observation, interview, record review and document review, the facility failed to ensure there was a process in place to identify and refer residents for pre-admission screening and resident review (PASARR) level two for 15 of 15 sampled residents (Residents 4, 8, 30, 31, 42, 61, 70, 91, 94, 96, 99, 106 112, 150, and 172) with psychiatric diagnoses. The deficient practice had the potential to deprive residents of necessary behavioral health services.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure 1) kitchen equipment was cleaned, 2) food items were labeled with dates in the dried food storage, 3) expired food was discarded, 4) pans were not stacked wet, and 5) two of two nourishment room's equipment and surfaces were routinely cleaned, was free of personal items, documented freezer temperature logs, and meal products were labeled and dated. The deficient practice had the potential to serve foods to residents at an increased risk of food safety.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure the resident's right of dignity was honored for one unsampled resident (Resident 142). The deficient practice had the potential to have psychosocial impact on residents of the memory care unit. Resident 142 (R142) R142 was admitted on [DATE] with diagnoses including Alzheimer's disease, bipolar disorder, and major depressive disorder. A Brief Interview for Mental Status (BIMS) documented R142 had a score of 99 which indicated the resident was not able to complete the evaluation. On 10/10/23 at 12:41 PM, R142 was in dining room calling out for assistance and a Registered Nurse (RN) was sitting at nursing station approximately 25-30 feet away. The RN yelled to the resident to question what was being requested and when R142 did not respond, the nurse kept on working at station and said nope in quiet tone. [...]

Inspectors wroteBased on interview, record review and document review, the facility failed to provide documented evidence the Minimum Data Set (MDS) assessments were performed in accordance with the Resident Assessment Instrument (RAI) Manual for 1 of 36 sampled residents (Resident 57). The deficient practice had the potential for the facility failing to ensure the assessments accurately reflected the resident's status and failing to identify the correct interventions for the resident.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure the correct strength of a medication was available during the medication pass for 1 of 31 sampled residents (Resident 118). This deficient practice could lead to potential medication errors, and increased the risk of administering an incorrect dosage.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure the physician orders for wound healing and management were followed as ordered for 1 of 31 sampled residents (Resident 57). This deficient practice left the resident's wound soaked in urine, posing a potential risk of irritation and infection.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure physician orders for the utilization, size of an indwelling Foley catheter, and care management were obtained and transcribed for 1 of 31 sampled residents (Resident 58). This deficient practice could potentially increase the risk of catheter-related complications, including urinary tract infections, patient discomfort, trauma, and pain.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure a physician order for the use of Oxygen (O2) was obtained and transcribed for 2 of 31 sampled residents (Residents 4 and 119 ). This deficient practice could have the potential to compromise the resident's health and well-being, inadequate or inappropriate medical interventions and treatments and delayed or suboptimal care.

Inspectors wroteBased on interview, record review, and document review, the facility failed to ensure the medication regimen review (MRR) was completed on at least a monthly basis for 5 of 36 sampled residents (Residents 172, 70, 21, 91, and 61). This deficient practice could have the potential of several risks, including medication errors, adverse drug reactions, ineffective management of medications and compromised quality of care.

Inspectors wroteBased on interview, record review and document review, the facility failed to ensure the physician's order for the use of a psychotropic medication was clarified for 1 of 36 sampled residents (Resident 99). The deficient practice had the potential for the facility to incorrectly identify the indicator for use of a psychotropic medication.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure documentation was accurate in the Medication Administration Record for 1 of 36 sampled residents (Resident 7). The deficient practice had the potential for the facility not maintaining accurate documentation for care and services being provided to residents.