Inspection Report Summary
The most recent inspection on July 3, 2025, identified deficiencies related to delayed call light responses, missed medication doses, and inadequate hand hygiene practices. Earlier inspections showed a pattern of issues involving resident care such as call light accessibility, medication management, infection control, and resident rights, including a substantiated complaint about confidentiality breaches and another about coercive use of vaping privileges. Complaint investigations were substantiated for delayed care responses, medication errors, infection control lapses, confidentiality violations, and improper use of resident privileges. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s inspection history shows ongoing challenges with care processes and infection control, with no clear trend of improvement or worsening over time.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
138% worse than Minnesota average
Minnesota average: 3.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jul 3, 2025
Visit Reason
The inspection was conducted based on complaints regarding long call light response times, medication errors, and infection prevention and control concerns at Mission Nursing Home.
Complaint Details
The complaint investigation was triggered by reports of long call light wait times for residents R3 and R4, a medication error involving missed doses of Darbepoetin for resident R2, and inadequate infection control practices related to hand hygiene for resident R4. The complaint was substantiated with findings of delayed call light responses, missed medication doses, and failure to perform hand hygiene.
Findings
The facility failed to ensure timely response to call lights for residents R3 and R4, resulting in prolonged wait times. There was a significant medication error involving seven missed doses of Darbepoetin for resident R2. Additionally, infection prevention and control practices were deficient, as staff failed to perform appropriate hand hygiene during personal care for resident R4.
Deficiencies (3)
Failed to ensure call lights were answered in a timely manner for 2 of 3 residents (R3, R4) reviewed for dignity.
Failed to ensure 1 of 3 residents (R2) was free from significant medication errors; seven missed doses of Darbepoetin were not administered as prescribed.
Failed to ensure appropriate hand hygiene was performed during personal cares for 1 of 1 resident (R4) reviewed for infection prevention and control.
Report Facts
Missed medication doses: 7
Call light wait times: 40
Call light wait times: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA-A | Nursing Assistant | Named in call light response delay and hand hygiene deficiency findings. |
| NA-B | Nursing Assistant | Named in call light response delay and hand hygiene deficiency findings. |
| John Smith | Director of Nursing | Named in call light response expectations and medication error interviews. |
| LPN-A | Licensed Practical Nurse | Named in medication order verification and medication error findings. |
| HUC | Health Unit Coordinator | Named in medication order entry and medication error findings. |
| ADON | Assistant Director of Nursing | Named in medication error and hand hygiene deficiency interviews. |
| Pharmacist (P) | Pharmacist | Named in medication error findings. |
| PharmD (PD) | Pharmacist | Named in medication error findings. |
Inspection Report
Deficiencies: 3
Date: Apr 10, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and medication management at Mission Nursing Home.
Findings
The facility was found deficient in ensuring call lights were accessible to residents dependent on staff, providing adaptive equipment for smoking safety, and ensuring pain medications were reordered and administered as prescribed, resulting in actual harm to a resident during pre-surgical care.
Deficiencies (3)
Failed to ensure call lights were within reach and accessible for 1 of 3 residents (R2) dependent on staff for care.
Failed to ensure adaptive equipment (smoking apron) was provided for 1 of 2 residents (R3) reviewed for safety while smoking.
Failed to ensure pain medications were reordered and available for administration per physician orders for 1 of 3 residents (R2), resulting in actual harm when pain medication was not administered prior to pre-scheduled surgery.
Report Facts
Medication doses: 6
Medication supply remaining: 10
Medication delivery frequency: 4
Medication reorder lead time: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN-A | Registered Nurse | Discussed call light placement and care for resident R2 |
| RN-B | Registered Nurse | Provided information on resident R2 and R3 care, including call light and smoking apron requirements, and pain medication administration |
| RN-C | Registered Nurse | Nurse during overnight shift for resident R2 on surgery day; involved in medication administration and pharmacy communication |
| DON | Director of Nursing | Provided facility policy information and details on medication refill procedures and incident awareness |
| ADON | Assistant Director of Nursing | Described smoking assessment process and medication reorder procedures |
| DM-A | Door Monitor | Responsible for unlocking smoking room and assisting with adaptive equipment for resident R3 |
Inspection Report
Routine
Deficiencies: 3
Date: Mar 12, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to PASARR screening for mental disorders, smoking assessments for residents who smoke, and the facility's Quality Assurance and Performance Improvement (QAPI) program.
Findings
The facility failed to complete a required Level II PASARR screening for one resident, did not complete thorough smoking assessments for five residents who smoked, and lacked a defined QAPI plan with measurable goals and a system to collect resident feedback.
Deficiencies (3)
Failed to ensure a Level II pre-admission PASARR screening was completed prior to admission for one resident requiring it.
Failed to ensure thorough smoking assessments were completed for 5 residents who wished to smoke, with assessments incomplete, delayed, or missing.
Failed to develop a QAPI plan that defined measurable goals and a system to collect feedback from residents and representatives.
Report Facts
Residents affected: 1
Residents affected: 5
Residents affected: 56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Designee (SS)-A | Confirmed lack of Level II PASARR screening documentation and smoking assessment responsibilities | |
| Director of Nursing (DON) | Provided information on smoking assessment requirements and QAPI plan deficiencies |
Inspection Report
Routine
Deficiencies: 13
Date: May 31, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, care, environment, transfers, nutrition, dialysis, infection control, antibiotic stewardship, and vaccination policies.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, privacy in communication, accurate documentation of advanced directives, cleanliness of resident rooms, notification of transfers to the Ombudsman, implementation of physician orders, pressure ulcer prevention related to mechanical lift use, safe use and training on mechanical lifts, ongoing weight monitoring, post-dialysis assessments, infection control program implementation, antibiotic stewardship, and pneumococcal vaccination administration.
Deficiencies (13)
Failed to ensure dignity was maintained for 1 of 1 resident (R19) reviewed for dignity.
Failed to ensure the resident received unopened mail for 1 of 2 residents reviewed for communication privacy.
Failed to ensure advanced directives were accurately documented in the resident's EMR for 1 of 1 resident (R109).
Failed to ensure resident rooms were kept clean and in good condition for 1 of 2 residents (R36) reviewed for environment.
Failed to ensure a written notification of transfer was sent to the Ombudsman for 1 of 2 residents (R44) reviewed for hospitalization.
Failed to accurately implement physician's orders for 1 of 1 resident (R44) reviewed for hospitalizations.
Failed to prevent an avoidable pressure injury related to improper placement and use of a mechanical lift sling for 1 of 1 resident (R19).
Failed to perform mechanical lift and lift sling assessments and adequately train staff on manufacturer guidelines for 1 of 1 resident (R19).
Failed to ensure ongoing monitoring of weight was completed as directed for 1 of 3 residents (R45) reviewed for nutrition.
Failed to ensure post-dialysis assessment and monitoring was completed for 1 of 2 residents (R42) reviewed for dialysis.
Failed to ensure infection control program included symptom tracking and ongoing analysis of trending of resident infections to prevent spread.
Failed to implement a process for antibiotic stewardship to determine appropriate indications, dosage, duration, symptoms, analysis of trends and efficacy.
Failed to ensure 1 of 5 residents (R35) received a pneumococcal vaccine offered by the facility.
Report Facts
Resident weight: 268.2
Resident weight: 265.6
Resident weight: 263.1
Resident weight: 245.7
Resident weight: 244.7
Resident weight: 248.8
Resident weight: 237.1
Fluid restriction: 2000
Fluid restriction: 1500
Resident weight gain: 19.9
Resident weight gain: 28.5
Resident weight gain percentage: 8
Resident weight gain percentage: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN-A | Registered Nurse | Interviewed regarding code status and transfer orders for resident R109 and fluid restriction for resident R44 |
| DON | Director of Nursing | Interviewed regarding expectations for resident dignity, clothing, advanced directives, room cleanliness, transfer notifications, weight monitoring, dialysis care, infection control, antibiotic stewardship, and vaccination administration |
| CNA-B | Certified Nursing Assistant | Interviewed regarding resident clothing and mechanical lift use |
| CNA-C | Certified Nursing Assistant | Interviewed regarding resident clothing and mechanical lift use |
| CNA-D | Certified Nursing Assistant | Observed assisting with mechanical lift and resident clothing adjustment |
| CNA-E | Certified Nursing Assistant | Observed assisting with mechanical lift |
| CNA-F | Certified Nursing Assistant | Observed assisting with mechanical lift |
| CNA-G | Certified Nursing Assistant | Observed assisting with mechanical lift |
| CNA-H | Certified Nursing Assistant | Observed assisting with mechanical lift |
| RN-D | Registered Nurse | Observed assisting with mechanical lift |
| RN-B | Registered Nurse | Interviewed regarding code status for resident R109 |
| RN-E | Registered Nurse | Observed assisting with mechanical lift |
| LPN-A | Licensed Practical Nurse | Infection preventionist interviewed regarding infection control and antibiotic stewardship |
| ADON | Assistant Director of Nursing | Interviewed regarding mechanical lift use and training |
| RD-H | Registered Dietitian | Interviewed regarding resident weight monitoring and nutrition |
| O-C | Pharmacist | Interviewed regarding PRN psychotropic medication use |
| RN-D | Registered Nurse | Observed assisting with mechanical lift |
| RN-A | Registered Nurse | Interviewed regarding code status and mechanical lift use |
| LPN-SDC | Licensed Practical Nurse and Staff Development Coordinator | Interviewed regarding staff training on mechanical lifts |
| COTA | Certified Occupational Therapy Assistant | Interviewed regarding therapy evaluations and recommendations for mechanical lifts |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 24, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure confidentiality of personal and medical records for one resident (R1).
Complaint Details
This was a complaint investigation related to confidentiality breaches. The facility was found to have shared resident R1's medical information without authorization. The report notes that R1 did not give permission for the facility to speak with his probation officer or electronic health monitor. The complaint was substantiated by interviews and record review.
Findings
The facility disclosed R1's medical information to his probation officer and electronic health monitor case manager without documented authorization. Interviews and record reviews confirmed concerns about R1's alcohol use and non-compliance with monitoring, with facility staff contacting R1's probation officer without a release of information on file.
Deficiencies (1)
Failed to keep residents' personal and medical records private and confidential by sharing R1's medical information with his probation officer and electronic health monitor case manager without authorization.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Interim Director of Nursing | Interim Director of Nursing | Signed progress notes regarding R1's condition and involvement with probation officer. |
| Admission Director | Admission Director | Communicated with R1's probation officer and electronic health monitor case manager regarding R1's status and facility concerns. |
| Registered Nurse A | Registered Nurse | Interviewed regarding contact with R1's probation officer about compliance. |
Inspection Report
Routine
Deficiencies: 2
Date: Dec 12, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with infection prevention and control protocols during a COVID-19 outbreak and to assess the facility's policies and procedures for influenza and pneumonia vaccinations.
Findings
The facility failed to ensure all staff wore appropriate personal protective equipment (PPE) for source control during a COVID-19 outbreak, with multiple staff observed not wearing masks in communal areas despite active cases. Additionally, the facility failed to provide timely influenza immunization for one resident as recommended by CDC guidelines.
Deficiencies (2)
Failed to ensure appropriate personal protective equipment (PPE) for source control was worn by all staff during a COVID-19 outbreak.
Failed to provide a timely influenza immunization for 1 of 5 residents reviewed for immunizations.
Report Facts
COVID-19 cases: 3
Residents reviewed for immunizations: 5
Residents affected by PPE deficiency: Many residents affected as stated
Residents affected by immunization deficiency: Few residents affected as stated
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Receptionist (R)-A | Observed not wearing a mask in communal area | |
| Social Services (SS)-A | Observed not wearing a mask in communal area | |
| Facility Administrator | Observed not wearing a mask in communal areas | |
| Physical Therapist (PT)-A | Observed pushing resident in wheelchair without mask | |
| Nursing Assistant (NA)-A | Observed not wearing mask in communal area | |
| Licensed Practical Nurse (LPN)-A | Observed not wearing mask in communal area | |
| Trained Medication Aide (TMA)-A | Observed not wearing mask in communal area | |
| Director of Nursing (DON) | Stated staff should wear masks and discussed immunization tracking | |
| Assistant Director of Nursing (ADON) | Stated COVID outbreak start date | |
| Medical Director (MD)-A | Stated staff should wear masks in affected areas | |
| Licensed Practical Nurse (LPN)-B | Shared responsibility for immunization tracking and unaware of resident's vaccine request |
Inspection Report
Routine
Deficiencies: 2
Date: Dec 12, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control protocols during a COVID-19 outbreak and to evaluate the facility's policies and procedures for influenza and pneumonia vaccinations.
Findings
The facility failed to ensure all staff wore appropriate personal protective equipment (PPE) for source control during a COVID-19 outbreak, with multiple staff observed not wearing masks in communal areas despite active COVID cases. Additionally, the facility failed to provide timely influenza immunization for one resident as recommended by CDC guidelines.
Deficiencies (2)
Failed to ensure appropriate personal protective equipment (PPE) for source control was worn by all staff during a COVID-19 outbreak.
Failed to provide a timely influenza immunization for 1 of 5 residents reviewed for immunizations.
Report Facts
COVID cases in building: 3
Residents reviewed for immunizations: 5
Resident not immunized: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse B | Licensed Practical Nurse | Shared responsibility of tracking and administration of immunizations; unaware resident wanted influenza immunization |
| Director of Nursing | Director of Nursing | Stated staff should wear masks in communal areas; stated resident was not given influenza vaccine; shared responsibility for immunization tracking |
| Assistant Director of Nursing | Assistant Director of Nursing | Stated current COVID outbreak started on 12/9/23 |
| Medical Director A | Medical Director | Stated staff should wear masks in halls and resident areas where COVID is present |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 12, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to honor a resident's right to refuse care, specifically concerning the use of vaping privileges as a form of coercion or punishment.
Complaint Details
The complaint investigation found that the facility used vaping privileges as a coercive tool to enforce compliance with care activities, which violated the resident's right to refuse care. The facility lacked a formal process for removing smoking/vaping privileges and policies did not support such punitive measures. The resident reported distress and anxiety related to the threat of losing vaping privileges.
Findings
The facility failed to honor the rights of one resident (R10) by using vaping privileges as an incentive and threatening to take them away if the resident refused care. Interviews with the resident, nursing staff, director of nursing, administrator, and social services revealed a lack of formal policy and inconsistent practices regarding smoking/vaping privileges and resident rights to refuse care.
Deficiencies (1)
Failed to honor resident's right to refuse care by threatening to take away vaping privileges as punishment.
Report Facts
Residents Affected: 1
Date of survey completed: Jul 12, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN-A | Registered Nurse | Stated use of vaping privileges as incentive and described resident noncompliance |
| Director of Nursing | Director of Nursing | Described assessment and policy regarding smoking/vaping privileges and acknowledged lack of formal process |
| Administrator | Administrator | Acknowledged smoking/vaping as a privilege and its removal for noncompliance |
| NA-A | Nursing Assistant | Expressed personal views on smoking/vaping privilege removal and lack of training |
| SS-A | Social Services | Described lack of formal process and typical practice of warnings instead of privilege removal |
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