Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mission Care Center during CMS and state inspections, most recent first.
Failure to Provide Written Transfer and Discharge Notice: A resident with severe cognitive impairment, chronic respiratory failure, tracheostomy, and ventilator dependence was transferred to an acute hospital after a change in condition and altered mental status. The SSD stated the Notice of Proposed Transfer/Discharge was mailed to the resident representative by standard mail, but there was no documentation of when it was sent and no confirmation it was received. The DON stated certified mail should be used to ensure receipt, and the facility policy required the notice to include the reason for transfer, appeal rights, and related contact information.
Unsafe handling of a hazardous medication occurred when an LVN crushed letrozole for a resident with breast cancer without gloves during a med pass. The RN, DSD, IP, and DON stated they were unaware letrozole was hazardous and relied on pharmacy notification, while the CP confirmed letrozole is on the NIOSH hazardous drug list and requires PPE. Facility policy and the nursing drug reference identified letrozole as a potential teratogen and called for safe handling procedures.
A resident with neck cancer lesions and a tracheostomy experienced a documented change in condition with increased drainage and odor from neck wounds, leading to recommendations for ER evaluation and new wound care orders. Although nursing notes referenced increased wound care and an ER visit for swelling and drainage, there was no ongoing documentation of wound status for the anterior, medial, or lateral neck lesions after the change in condition, despite reports of 50–100% saturated dressings and persistent odor. Required 72-hour monitoring with shift-by-shift progress notes was not completed, and the care plan was not updated to address the increased drainage, odor, or infection risk, contrary to facility policies on change in condition, wound documentation, skin assessment, and comprehensive care planning.
A resident with a tracheostomy and recent change to full code status was transferred to a hospital with a transfer form that incorrectly listed DNR status and omitted the type and size of the tracheostomy tube. Staff interviews and record review confirmed that the transfer documentation did not accurately reflect the resident's current code status or medical device details, as required by facility policy.
The facility failed to properly dispose of garbage and refuse, as multiple discarded items were found stacked beside a storage trailer. The Maintenance Supervisor confirmed these items should have been disposed of in the garbage bin to prevent pest attraction, in accordance with the facility's policy.
The facility failed to maintain professional food service safety standards by using contaminated oven gloves in the kitchen, posing a risk of cross-contamination and potential food-borne illnesses to residents. The gloves were stained and worn, and both the Dietary Manager and Registered Dietician acknowledged they should have been replaced or laundered.
The facility failed to implement proper infection control practices by storing emergency water bottles in a contaminated storage shed. The bottles were placed on a dusty floor next to chemical containers and covered with loose dirt. The area was cluttered with various items, and the shed had a hole that could allow pest entry. The Maintenance Supervisor confirmed the improper storage and acknowledged the need for a clean environment, as per facility policy.
The facility did not meet the required bedroom space of at least 80 square feet per resident in 15 rooms. The DON confirmed the non-compliance but noted a waiver was in place. Residents and staff reported no issues with room size, and no adverse effects were observed. A continued waiver was requested and recommended for approval.
Failure to Provide Written Transfer and Discharge Notice
Penalty
Summary
The facility failed to ensure that the written notice of proposed transfer and discharge was provided to the resident or the resident representative for one of four residents reviewed, Resident 2. Resident 2 was admitted with diagnoses including chronic respiratory failure with hypoxia, tracheostomy, and dependence on a ventilator. The resident's MDS dated April 21, 2026, showed a BIMS score of 05, indicating severe cognitive impairment and inability to understand and make decisions. On May 1, 2026, staff documented a change in condition when respiratory staff observed that Resident 2 looked different, could not be awakened or stimulated, had normal vital signs, no respiratory distress, and was on a ventilator with altered mental status. The resident was transferred to an acute hospital via 911 after the physician was notified, and the physician ordered transfer to acute hospital for altered level of consciousness with a 7-day bed hold if admitted. During interview, the SSD stated the Notice of Proposed Transfer/Discharge was mailed to the resident representative by standard mail, but there was no record of when it was mailed or emailed, and the SSD did not know whether the representative received it. The SSD also stated the facility should have followed up by phone and email to ensure the notice was received and understood. The DON stated the notice should be sent by certified mail to ensure receipt. The facility policy required the transfer/discharge notice to be provided to the resident and representative and to include the reason for transfer, effective date, location, appeal rights, state appeal contact information, appeal form information, assistance information, and Ombudsman contact information.
Unsafe Handling of Hazardous Medication
Penalty
Summary
The facility failed to ensure services provided met professional standards of practice for one resident with breast cancer who had a physician’s order for letrozole 2.5 mg via G-tube daily. During a medication pass observation, an LVN was seen preparing and crushing eight medications on top of the medication cart in the hallway in front of the resident’s room without wearing gloves. One of the medications being crushed was letrozole 2.5 mg, and the pharmacy label on the bubble pack included a warning not to use the medication if pregnant, suspect pregnant, or breastfeeding and to consult a doctor or pharmacist. During interviews, the LVN stated she did not wear gloves because she did not know letrozole was considered a hazardous drug and said gloves should have been worn. The RN, DSD, IP, and DON each stated they were unfamiliar with letrozole being a hazardous drug and indicated they expected the pharmacy to notify staff when a medication required special handling. The RN and DON stated nursing staff needed to wear PPE when handling hazardous drugs, and the DON stated staff would have needed gloves, gowns, and a mask when crushing hazardous drugs. The consultant pharmacist stated letrozole was on the NIOSH hazardous drug list and had reproductive risks, and that nursing should have worn PPE such as gloves when handling it. The facility’s Nursing Drug Reference Handbook identified letrozole as a hormonal agent and potential teratogen and directed safe handling procedures. The facility’s policies on hazardous drugs and handling of hazardous drugs stated that safe handling procedures and appropriate PPE were required, and that pharmacy prescription labels would include if a packaged medication was a hazardous drug.
Failure to Monitor and Care Plan for Resident’s Neck Wounds After Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to provide ongoing monitoring, assessment, and care planning after a documented change in condition for a resident with neck cancer lesions. The resident, cognitively intact and diagnosed with malignant neoplasm of the tongue and a tracheostomy, experienced increased drainage and odor from neck tumors on a specified date, as documented on a Change of Condition/INTERACT Assessment Form. The form recommended transfer to the ER to rule out infection. A progress note recorded that the physician was notified, the resident refused hospital evaluation, and staff were to continue monitoring and increase the frequency of wound treatment every shift. Subsequent documentation showed that the resident’s daughter later brought the resident to the ER for neck swelling and drainage, and that wound treatment was administered at the hospital to the lateral neck areas, with a request that the treatment nurse address the wounds in the morning. Physician orders included specific wound care regimens for the anterior neck cancer lesion and, later, for right lateral posterior and right medial posterior neck cancer lesions, with cleansing using hibiclens and application of oil emulsion dressings and ABD pads at prescribed frequencies. A skilled evaluation note indicated that a skin issue on the anterior neck had not been evaluated. Despite these orders and the identified change in condition, there was no documented evidence of the status or condition of the anterior, medial, or lateral neck wounds after the change in condition on the specified date. Interviews and record reviews further confirmed the lack of required monitoring and care planning. A LVN reported that wound care to the neck was performed daily due to increased drainage, with dressings 50–100% saturated, but this level of drainage and related assessments were not documented as required. An RN stated that the anterior, medial, and lateral neck wounds were odorous before the resident left for an oncology appointment and remained odorous upon return from the ER, and that the ER nurse had advised monitoring and treatment as needed. Both RNs and the DON stated that after a change of condition, staff should document progress notes every shift for 72 hours and update care plans, but the 72-hour monitoring process was not followed, and there was no updated care plan addressing the increased drainage, odor, or risk for infection, contrary to facility policies on change in condition, wound documentation, provision of quality care, and skin assessment.
Failure to Accurately Communicate Code Status and Medical Device During Resident Transfer
Penalty
Summary
The facility failed to accurately communicate a resident's code status and the presence of a medical device during a transfer to an acute hospital. Specifically, the transfer form for a resident with respiratory failure, a tracheostomy, and aphasia indicated a DNR (Do Not Resuscitate) status, while the most current POLST signed by the family member that morning indicated full code status. Additionally, the transfer documentation did not include the type and size of the resident's tracheostomy tube, which was required information for ongoing care. Interviews with facility staff, including the RN, DON, and RT, confirmed that the transfer form should have reflected the resident's current code status and included details about the tracheostomy tube. The facility's own policy required that advanced directive information, resident status, and all special instructions or devices be communicated during transfers. The failure to provide accurate and complete information was identified during a complaint investigation and was supported by a review of the resident's medical record and staff interviews.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse outside the facility grounds. During an observation on February 12, 2025, multiple discarded items such as wood, poles, signs, broken fans, metal frames, bath chairs, wooden pallets, bags of cement mix, and hoses were found stacked beside a storage trailer. The Maintenance Supervisor confirmed that these were discarded items and acknowledged that they should not be stored beside the trailer but disposed of properly in the garbage bin to prevent attracting pests and rodents. The facility's policy on the disposal of garbage and refuse, dated December 19, 2022, requires that surrounding areas be kept clean to minimize debris accumulation and insect/rodent attractions, and that storage areas and receptacles for refuse be maintained in good repair and cleaned frequently to prevent buildup and attraction of pests.
Improper Food Handling Practices with Contaminated Oven Gloves
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. Two oven gloves used in the kitchen were found to be in poor condition, with dark stains, a thick brown/black substance on the fingertips, and multiple patches of white substance. One of the gloves also had worn areas with loose threads and discoloration. These gloves were hanging on a hook in the kitchen and were intended for use by the cook, posing a risk of cross-contamination and potential food-borne illnesses to the residents who consume food prepared in the facility's kitchen. Interviews with the Dietary Manager and a Registered Dietician confirmed that the gloves should not have been used in their current state. The Dietary Manager acknowledged that the gloves should have been replaced to prevent cross-contamination. The Registered Dietician also stated that the gloves should have been laundered or replaced, as their condition could lead to cross-contamination and possible food-borne illness among the vulnerable residents. The facility's policy on food safety and storage, dated November 2024, mandates that all equipment used in food handling must be clean, sanitized, and handled to prevent contamination, which was not adhered to in this instance.
Inadequate Storage of Emergency Water
Penalty
Summary
The facility failed to ensure appropriate infection control practices were implemented in the storage of emergency water. During an observation, several gallons of emergency water bottles were found stored in a storage shed outside the facility. These bottles were placed directly on a soiled and dusty floor next to chemical containers with warning labels. The tops of the water bottles were covered with loose dirt, and the area was cluttered with various items, including tools, soap dispensers, a broken fan, a broom, and mop sticks. The ceiling of the shed had loose particles and debris that had accumulated and fallen onto the water bottles. Additionally, there was a buildup of debris by a hole in the shed, which could allow pests to enter. The Maintenance Supervisor acknowledged that the water had been stored in this manner for many years and confirmed that the emergency water bottles should be stored in a clean environment. A review of the facility's policy indicated that emergency water should be stored in medication rooms or other clean utility rooms.
Facility Room Size Deficiency
Penalty
Summary
The facility failed to provide the required bedroom space of at least 80 square feet per resident in 15 resident rooms. During a survey conducted over several days, it was observed that rooms 1, 2, 3, 4, 5, 6, 7, 8, 11, 12, 14, 15, 16, 17, and 18 did not meet this requirement. The Director of Nursing (DON) confirmed that these rooms did not comply with the space requirement but stated that the facility had a waiver for them. Interviews with residents and nursing staff revealed no issues with room size or crowding, and no adverse effects on residents' quality of life were observed. The facility requested a continued waiver for these rooms, and approval of the waiver was recommended as it would not adversely affect residents' health and safety.
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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 Riverside
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Alta Vista Healthcare & Wellness Centre | 0.6 mi | ★★★★★ | 1 | 0 |
| Extended Care Hospital Of Riverside | 0.6 mi | ★★★★★ | 15 | 0 |
| Woodcrest Post Acute & Rehabilitation | 0.6 mi | ★★★★★ | 14 | 0 |
| Villa Health Care Center | 0.7 mi | ★★★★★ | 2 | 0 |
| Citrus Grove Post Acute | 1.2 mi | ★★★★★ | 21 | 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 August 2026) and official state health department websites.