Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mission Convalescent Home during CMS and state inspections, most recent first.
Surveyors found that food items, including frozen meats and produce, were stored directly on the floor of freezers and refrigerators instead of on shelves, and bins of dry goods were undated and unlabeled. Expired food and items with heavy ice build-up were present, and a pink/brown residue, identified as likely mildew, was observed in the ice machine. Staff interviews confirmed these practices were inconsistent with facility policy and professional standards.
An LPN failed to don PPE while administering medication through a PEG tube and performing wound care for two residents who required enhanced barrier precautions due to a feeding tube and a pressure ulcer. Facility policy required gown and gloves for these high-contact care activities, but observations confirmed the LPN did not follow these protocols. The DON confirmed that PPE should have been used in these situations.
A resident with severe cognitive impairment and high fall risk experienced multiple falls, but the facility did not complete required post-fall assessments, resident evaluations, or obtain staff statements as mandated by policy. Documentation and interviews confirmed that these critical steps were missing after each incident.
A facility failed to accurately document a resident's dialysis status on their annual MDS. Despite the resident having intact cognition and a diagnosis of End Stage Renal Disease, dialysis was not recorded. The MDS Coordinator acknowledged that dialysis should have been included, highlighting a deficiency in the assessment process.
A resident with severe cognitive impairment and bedridden status was found on the floor, wrapped in a blanket, despite being dependent on staff for all care. The facility's policy required updating the care plan after a fall, but this was not done. The DON confirmed the care plan should have been revised to include interventions for the fall.
A facility failed to adhere to a physician's order for a resident's oxygen therapy. The resident, who was cognitively intact and had multiple health conditions, was prescribed oxygen at 2 liters per minute. However, observations showed the resident receiving higher oxygen levels of 3 and 4.5 liters per minute. The DON confirmed the discrepancy, acknowledging the oxygen was set incorrectly.
A resident with End Stage Renal Disease (ESRD) did not have a physician's order for dialysis, as required by the facility's policy. Despite having intact cognition and multiple diagnoses, including ESRD, the resident's medical record lacked documentation for dialysis. The Director of Nursing confirmed the absence of the necessary order.
The facility failed to ensure proper food storage and handling, as evidenced by frozen chicken breasts with ice build-up in a freezer, and unlabeled, undated food in a nourishment refrigerator. The refrigerator's freezer was dirty and lacked a thermometer and temperature log. The Certified Dietary Manager confirmed these deficiencies, indicating non-compliance with facility policies.
The facility failed to document the mandatory annual 12 hours of in-service training for four CNAs, as confirmed by the DON during an interview. The CNAs, hired between 1999 and 2022, lacked documented training hours for the past year.
Improper Food Storage, Labeling, and Ice Machine Sanitation
Penalty
Summary
The facility failed to ensure proper storage, labeling, and handling of food items in accordance with professional standards and its own policies. Surveyors observed multiple instances where frozen foods, including chocolate meringue pies, chicken, ground beef, ribs, and hams, were stored directly on the floor of freezers and refrigerators, rather than on shelves to allow for proper air circulation. Additionally, bins containing corn meal, sugar, and flour were found to be undated and unlabeled. Expired food items, such as hot dogs, Salisbury steaks, and Tater Kegs, were present in the freezers, and several food items exhibited a thick build-up of ice crystals. A bag of lettuce was also found stored on the floor of a refrigerator. These practices were inconsistent with the facility's food storage policy, which requires all products to be dated upon receipt and preparation, and for expired or outdated food to be discarded. Further deficiencies were identified in the maintenance and cleanliness of the ice machine. A pink/brown substance, identified by the Certified Dietary Manager (CDM) as likely mildew, was observed along the inside of the ice machine's plastic dispenser. The CDM confirmed the presence of residue after wiping the area with a paper towel. Interviews with facility staff revealed uncertainty regarding responsibility for cleaning the ice machine, with the Maintenance Supervisor indicating that the task would be assigned to a floor technician. The CDM also acknowledged that food items and storage bins should be labeled and dated, and that food should not be stored on the floor of freezers or refrigerators.
Failure to Use PPE During High-Risk Resident Care Activities
Penalty
Summary
A deficiency occurred when a Licensed Practical Nurse (LPN) failed to follow infection prevention and control practices by not donning Personal Protective Equipment (PPE) while providing care to residents requiring enhanced barrier precautions. Facility policy required the use of gown and gloves during high-contact care activities, such as device care and wound care, for residents with wounds or feeding tubes. Despite these requirements, the LPN accessed a resident's Percutaneous Endoscopic Gastronomy (PEG) tube for medication administration and performed wound care on another resident with a stage 3 pressure ulcer, both without wearing the required PPE in enhanced barrier rooms. Medical record reviews confirmed that both residents had orders or care plans indicating the need for enhanced barrier precautions due to their medical conditions, including a PEG tube and a pressure ulcer. Observations by surveyors documented the LPN's failure to use PPE during these high-risk care activities. The Director of Nursing confirmed in an interview that nurses are expected to don PPE when administering medications through a PEG tube and when performing wound care, as per facility policy.
Failure to Complete Required Post-Fall Assessments and Documentation
Penalty
Summary
The facility failed to ensure that resident assessments and post-fall assessments were completed following falls for one resident with a history of severe cognitive impairment and high fall risk. Despite the facility's policies requiring incident reports, neuro checks, fall investigations, staff statements, and completion of fall assessments in the electronic medical record after each fall, these procedures were not consistently followed. Specifically, for three separate falls, the facility was unable to provide the required resident assessments, post-fall assessments, or staff statements as outlined in their protocols. Medical record reviews showed that the resident experienced multiple falls in the bathroom, with documentation indicating no injuries but repeated high fall risk scores. Progress notes and incident reports described the circumstances of each fall, but the necessary follow-up documentation and assessments were missing. Interviews with the DON confirmed that the required assessments and staff statements were not completed or available for review, despite the facility's policy and the resident's high risk for falls.
Inaccurate Assessment of Dialysis Status
Penalty
Summary
The facility failed to ensure that assessments accurately reflected the status of a resident undergoing dialysis. A review of the medical record showed that a resident, who was admitted with multiple diagnoses including End Stage Renal Disease, did not have dialysis documented on their annual Minimum Data Set (MDS). The resident had a Brief Interview for Mental Status (BIMS) score indicating intact cognition. During an interview, the MDS Coordinator confirmed that dialysis should have been coded on the annual MDS, indicating a lapse in accurately documenting the resident's medical status.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise and update the care plan for a resident who was reviewed for care plans. According to the facility's Fall Prevention Program policy, when a resident experiences a fall, the care plan should be reviewed and updated as necessary. The resident in question was admitted with diagnoses including Alzheimer's, Gastronomy, and Dysphagia, and was noted to have severe cognitive impairment, being dependent on staff for all care, and always incontinent of bowel and bladder. Despite having no falls since admission, the resident was found on the floor next to her bed on 8/1/2024, wrapped in a blanket, with staff unable to determine how she got out of bed as she was bedridden. The care plan was not updated to reflect this fall and the necessary interventions, which was confirmed by the Director of Nursing during an interview.
Failure to Follow Physician's Oxygen Orders
Penalty
Summary
The facility failed to ensure staff followed physician orders for a resident receiving oxygen therapy. The facility's policy on oxygen administration requires that oxygen be administered under a physician's order, except in emergencies. A resident, who was cognitively intact and had diagnoses including sepsis, multiple myeloma, anxiety, congestive heart failure, depression, and chronic respiratory failure, was admitted with a physician's order for oxygen at 2 liters per minute via binasal cannula. However, observations revealed that the resident was receiving oxygen at higher rates of 3 liters and 4.5 liters per minute on different occasions. The Director of Nursing confirmed that the resident's oxygen was set at 4.5 liters per minute, which was not in accordance with the physician's order of 2 liters per minute.
Lack of Physician's Order for Dialysis in Resident with ESRD
Penalty
Summary
The facility failed to have a physician's order for dialysis for a resident with End Stage Renal Disease (ESRD), which is a requirement according to the facility's Dialysis Policy. The policy, dated August 12, 2015, mandates that residents receiving dialysis should have care consistent with professional standards, including having physician's orders. The policy also requires documentation of skin integrity at the access site, the presence of thrill and bruit of the AV graft/fistula, and evidence of infection or other complications every shift. Resident #7, who was admitted with diagnoses including Dysphagia, Diabetes, Congestive Heart Failure, Chronic Obstructive Pulmonary Disease, and ESRD, did not have a documented order for dialysis in their medical record. The annual Minimum Data Set (MDS) assessment indicated intact cognition with a BIMS score of 15, but dialysis was not documented. The Director of Nursing confirmed during an interview that there should have been a physician's order for dialysis, which was not present in the records.
Improper Food Storage and Handling Practices
Penalty
Summary
The facility failed to ensure proper food storage and handling practices, as evidenced by several observations and policy reviews. In one of the reach-in freezers, four bags of frozen chicken breasts were found with a thick white build-up of ice, indicating improper storage conditions. These bags were frozen together at the bottom of the freezer, which suggests that the freezer was not maintaining the appropriate temperature as per the facility's policy that requires frozen meat and poultry to be stored at 0 degrees or less. Additionally, the nourishment refrigerator contained unlabeled and undated food items, including a water bottle, peanut butter crackers, a bottle of lemonade, a banana, and a container of food, which were not in compliance with the facility's policy requiring perishable food to be sealed, dated, and placed in refrigeration. Further observations revealed that the nourishment refrigerator's freezer was dirty, with multiple brown sticky spots and food particles on both the top and bottom areas and on the door shelves. The freezer also lacked a thermometer and a temperature log, which are necessary for monitoring and ensuring the proper storage conditions. During an interview, the Certified Dietary Manager confirmed that the freezer should be clean, all food should be initialed and dated, and a thermometer and temperature log should be present. The manager also acknowledged that the kitchen's freezer should not contain compromised frozen foods, indicating a lapse in adherence to the facility's food storage policies.
Deficiency in CNA In-Service Training Documentation
Penalty
Summary
The facility failed to ensure that four Certified Nursing Assistants (CNAs) completed the mandatory annual 12 hours of in-service training required for their roles. The CNAs in question, identified as CNA A, B, C, and D, were hired on various dates ranging from 1999 to 2022. Upon review of staff in-service records, it was found that the facility could not provide documentation to confirm that these CNAs had completed the necessary training hours over the past 12 months. During an interview, the Director of Nursing (DON) acknowledged the inability to provide the required documentation, confirming the deficiency in maintaining proper training records for the CNAs.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Jackson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Laurelwood Health Care Center | 1.2 mi | ★★★★★ | 5 | 1 |
| Cypress Grove Post Acute | 1.7 mi | ★★★★★ | 0 | 0 |
| West Tennessee Post Acute | 1.7 mi | ★★★★★ | 0 | 0 |
| Maplewood Health Care Center | 4 mi | ★★★★★ | 3 | 0 |
| Northbrooke Post Acute | 4.9 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.