Inspection Reports for Mission Convalescent Home
118 Glass Street, Jackson, TN, 38301
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
6.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
52% worse than Tennessee average
Tennessee average: 4.4 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jul 2, 2025
Visit Reason
The inspection was conducted based on complaints regarding failure to complete resident fall assessments, improper food storage practices, and failure to implement infection prevention protocols.
Complaint Details
The complaint investigation focused on failure to complete fall assessments for Resident #29, improper food storage practices, and failure to follow infection control protocols related to PPE use by staff.
Findings
The facility failed to ensure resident assessments were completed after falls for one resident, failed to store food properly including expired and improperly stored frozen food, and failed to ensure staff donned Personal Protective Equipment (PPE) during medication administration and wound care for residents with enhanced barrier precautions.
Deficiencies (3)
Failure to ensure resident assessments were completed at the time of a fall and post-fall assessments for Resident #29.
Failure to ensure food was stored properly including undated and unlabeled bins, expired food, frozen food not stored on shelves to allow circulation, and contamination in ice machines.
Failure to ensure staff donned PPE while administering medications and performing wound care on residents requiring enhanced barrier precautions.
Report Facts
Resident fall risk score: 12
Resident fall risk score: 14
Resident fall risk score: 11
Expired food use-by date: Jun 27, 2025
Expired food use-by date: Jun 19, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Failed to don PPE while administering medications and performing wound care |
| Director of Nursing | Director of Nursing | Interviewed regarding fall assessments and PPE use; confirmed deficiencies |
| Certified Dietary Manager | Certified Dietary Manager | Interviewed regarding food storage practices and ice machine contamination |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding responsibility for cleaning ice machine |
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Sep 18, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including accurate resident assessments, care plan updates, respiratory and dialysis care, food storage, and staff training.
Findings
The facility was found deficient in multiple areas including failure to accurately document dialysis status for a resident, failure to update care plans after a fall, failure to follow physician orders for oxygen administration, lack of physician orders for dialysis, improper food storage and sanitation, and failure to provide mandatory annual CNA in-service training hours.
Deficiencies (6)
Failed to ensure assessments were completed to accurately reflect the resident's status for dialysis for 1 of 1 sampled residents.
Failed to revise and update a care plan for 1 of 2 residents reviewed after a fall.
Failed to ensure staff followed physician orders for oxygen administration for 1 of 1 residents reviewed.
Failed to have a physician's order to provide dialysis for 1 of 1 residents reviewed.
Failed to ensure food was stored properly; found frozen chicken breasts with ice buildup, unlabeled and undated foods, dirty freezer without thermometer or temperature logs.
Failed to ensure mandatory annual 12 hours of CNA in-service training hours were completed for 4 of 19 sampled CNAs.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Bags of frozen chicken breasts: 4
CNA staff without required in-service hours: 4
Required CNA in-service hours: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Confirmed dialysis should be coded on MDS, confirmed oxygen order and settings, confirmed care plan update needed, and confirmed lack of CNA in-service documentation. |
| Certified Dietary Manager | Certified Dietary Manager | Confirmed food storage deficiencies including lack of thermometer, dirty freezer, and unlabeled/undated foods. |
| MDS Coordinator | MDS Coordinator | Confirmed dialysis should be coded on the annual MDS. |
Inspection Report
Routine
Deficiencies: 11
Date: Nov 9, 2023
Visit Reason
The inspection was a routine survey to assess compliance with federal regulations regarding resident rights, care, safety, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity and respect, delayed conveyance of resident funds after death, failure to provide required notices for Medicare coverage, incomplete resident assessments signed by a registered nurse, failure to honor resident preferences for showers, inadequate fall risk assessments and supervision, improper medication storage and administration practices, failure to maintain infection control practices, and unsafe, unsanitary resident room conditions.
Deficiencies (11)
Failure to maintain or enhance residents' dignity and respect during observations when staff failed to use courtesy titles, knock or announce themselves, and stood while assisting with dining.
Failure to convey funds to the estate of a deceased resident within the 30 days requirement.
Failure to provide Advanced Beneficiary Notice (ABN) to residents when therapy services were discontinued.
Failure to ensure Minimum Data Set (MDS) resident assessments were signed by a Registered Nurse as required.
Failure to ensure resident choice for receiving showers was honored and documented.
Failure to ensure residents were free from accident hazards including incomplete fall risk assessments, unsecured chemicals in storage, and unsecured sharps on medication carts.
Failure to ensure feeding tubes were used according to physician orders and appropriate care was provided.
Failure to have registered nurse coverage for 8 consecutive hours on weekend days for multiple months.
Failure to ensure medications were properly stored and secured and nurses failed to remain at bedside during medication administration.
Failure to provide and implement an effective infection prevention and control program including failure to perform proper hand hygiene, clean reusable equipment, and monitor for Legionella.
Failure to maintain a safe, sanitary, and comfortable environment in resident rooms including presence of stains, dust, and unclean equipment.
Report Facts
Days past refund deadline: 54
Facility census: 44
RN coverage missing days: 26
Medication administration observations: 6
Resident rooms observed unclean: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding staff expectations, RN coverage, and infection control practices. |
| Business Office Manager | Business Office Manager (BOM) | Interviewed regarding refund policies and storage room security. |
| Minimum Data Set Coordinator | MDS Coordinator | Interviewed regarding MDS assessment signatures and ABN letters. |
| Housekeeping Staff | Housekeeping Staff | Interviewed regarding storage room security and cleaning responsibilities. |
| Administrator | Facility Administrator | Interviewed regarding facility policies, environmental cleanliness, and Legionella prevention. |
| LPN #2 | Licensed Practical Nurse | Observed and interviewed regarding medication administration, PEG site care, and hand hygiene. |
| LPN #3 | Licensed Practical Nurse | Observed during medication administration and infection control practices. |
| LPN #1 | Licensed Practical Nurse | Observed during medication administration and infection control practices. |
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