Inspection Reports for Mission at Community Living Rehabilitation Center

The facility was found compliant with most regulatory requirements, including policies, procedures, employee training, resident care, medication administration, and emergency preparedness. Some minor noncompliances were noted, particularly in medical records documentation.

The complaint alleged that during a rafting trip on 05/30/2023, a maintenance staff member, an activities staff member, and the Assistant Director of Nursing consumed alcohol while transporting residents. The incident was not reported to the State Survey Agency. The facility did not investigate the allegations thoroughly and failed to report the incident timely.

The facility failed to timely report suspected abuse involving staff alcohol use while transporting residents, did not thoroughly investigate the allegations, lacked complete laboratory and immunization records for some residents, had food safety violations, inadequate infection control practices, and did not provide ongoing staff training on substance abuse and abuse reporting after the incident.

The complaint alleged that during a resident rafting trip, staff members drank alcohol, including a staff member arrested for DUI with alcohol in a facility vehicle. The facility failed to report the incident timely and did not investigate the allegations thoroughly. Resident identifiers involved were 6, 10, and 90.

The facility failed to timely report suspected abuse involving a staff member arrested for DUI with alcohol in a facility vehicle, did not thoroughly investigate allegations, lacked complete laboratory and immunization records, had food safety violations, inadequate infection control practices, and failed to provide ongoing staff training on substance abuse and abuse prevention.

The complaint investigation found that for 5 out of 19 sampled residents, the facility did not report alleged violations of abuse, neglect, exploitation, or mistreatment within 2 hours of the allegation. The facility also failed to submit investigation results to the State Survey Agency within 5 working days. Specific incidents on 6/1/23 and 8/3/23 were not reported timely, and required exhibits were missing or submitted late.

The facility failed to ensure that all alleged violations of abuse, neglect, exploitation, or mistreatment were reported immediately, but no later than 2 hours after the allegation was made. Additionally, the facility did not submit investigation results to the State Survey Agency within 5 working days as required. Multiple incidents involving residents were not reported timely or lacked required documentation.

The complaint investigation found multiple deficiencies including failure to timely report abuse allegations, lack of discharge summaries, inadequate care for urinary tract infections, incomplete physician reviews, lack of pharmacist follow-up on drug regimen irregularities, failure to provide dental care, improper food preparation and storage, and absence of Legionella testing in infection control.

The facility failed to timely report suspected abuse incidents, did not provide discharge summaries, failed to ensure appropriate treatment for urinary tract infections, lacked complete physician reviews during required visits, did not ensure monthly pharmacist drug regimen reviews with physician follow-up, failed to provide routine and emergency dental care, did not provide food prepared to meet individual needs, improperly stored food items, and lacked a system to test for Legionella in the infection prevention program.

The facility failed to develop and implement comprehensive, person-centered care plans for residents, did not provide ordered medications due to staff unawareness of medication delivery device location, did not ensure monthly drug regimen reviews were fully documented by physicians, and had inaccurate medical records regarding medication administration.