Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 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.
Food handling and storage practices were not followed when a CNA touched a dirty tray and then a clean tray without hand hygiene or changing gloves, and a dietary staff member cleaned soiled kitchen surfaces with a rag and then handled produce without hand hygiene or glove change. Surveyors also found multiple unlabeled or expired food items, including pepperoni, dry cereal, paprika, and sour cream containers, while the ADM and DS confirmed that food removed from original packaging must be labeled and expired items discarded.
Overflowing Trash Bins and Improper Garbage Storage: Three large trash bins were observed overflowing with waste, with paper cups and paper towels on the ground in the trash bin area. The DS stated the bins must be covered and secured at all times, and the DON stated trash left open or on the ground can attract vermin. The facility policy required food waste to be kept in sealed, leak-proof, tightly closed containers and stored in clean, vermin-proof areas.
Infection control failures occurred when two residents’ nasal cannula tubing was left undated despite weekly change orders, an LPN did not perform hand hygiene when entering and exiting a room with EBP for a resident with a wound vac, the EBP sign was not posted outside that resident’s room, and the same LPN failed to perform hand hygiene after giving a rectal suppository before handling an oral med. Facility policy and staff interviews confirmed the required infection control practices.
Incomplete and missing informed consent was identified for a resident receiving multiple psychotropic medications, including an antipsychotic, mood stabilizer, antidepressants, and an anxiolytic. The DON confirmed that consent forms for some medications were signed but not dated, making them incomplete, and there was no documented consent for Divalproex Sodium and Klonopin. The resident, who had moderate cognitive impairment and diagnoses including schizoaffective disorder and bipolar disorder, stated she was told those medications did not need consent.
Failure to Honor Resident Diet Preferences: A cognitively intact resident with CHF, depression, and HTN was placed on a puree/easy-chew diet without clear documentation or resident input, despite stating she did not have chewing or swallowing problems and repeatedly objected to the texture change. The resident reported staff never discussed the change with her, while ST later documented safe tolerance to regular texture and notified the MD that the diet could be upgraded.
A resident with Mandarin as the preferred language and moderately impaired cognitive function had the activity calendar, facility rules, and meal menu posted in English in the room. The resident stated she could not speak or read English and could not understand the posted information. Staff reported using Google Translate at times for communication, while the DON stated interpreter services must be used and Google translation is not to be used per policy.
Failure to notify the physician of a resident's significant change in condition occurred when a resident with CVA, DM, and dysphagia had decreased appetite and poor oral intake, including 0% meal intake and an unopened protein shake. CNA did not tell licensed staff the resident did not want to eat, and the DON confirmed the resident's decreased appetite and that the attending MD should have been informed. The resident also was not assessed for weight loss during the period of poor intake.
Failure to Reposition Resident per Physician Order: A resident with Parkinson's disease and cognitive impairment was identified as being at risk for pressure ulcers and had a physician order to be repositioned every 2 hours while in bed. Records showed the resident was turned only 3 times a day, and observations found the resident lying on his back in bed with the HOB elevated. The resident stated he was always on his back and not assisted to reposition, and the DSD said there were no logs or tracking systems documenting repositioning.
Failure to provide enough food/fluids to maintain health involved a resident with CVA, DM, dysphagia, and cognitive impairment whose weight dropped from 147 lbs. to 127 lbs. over several months. The DON stated the resident had 0% meal intake and that the change in condition should have been reported to the MD, but weekly weights ordered for weight loss were not performed and ordered sugar-free ice cream was not served with lunch. The care plan and IDT documentation reflected ongoing nutritional concerns and a weight goal below the resident’s actual weight.
A resident with sepsis, acute respiratory failure with hypoxia, and ESBL infection was observed with a double-lumen midline catheter that had an expired dressing and no Curos disinfecting cap in place. The DSD confirmed the dressing was past due for its weekly change, and the dressing was dated but had no time documented. Facility policy required IV dressings to be dated and changed as scheduled and required cleansing or protection of the lumen port.
Oxygen therapy was not consistently provided or maintained for two residents. One resident with respiratory failure and asthma was observed with O2 not in place despite an order for continuous O2 via NC, and staff said she frequently removes her cannula and that placement was not consistently verified after reapplication. Another resident had tubing and a face mask on the bed, and the tubing was past the facility's replacement interval and not properly dated. The IP confirmed the tubing was expired, and the facility policy required tubing to be dated and replaced every seven days.
Incorrect Calcium Carbonate Dose Prepared for a Resident: An LVN prepared a resident’s calcium carbonate dose by cutting a 750 mg tablet into quarters and planning to administer three quarters, totaling about 562.5 mg, even though the physician ordered 500 mg twice daily. The LVN acknowledged the dose was higher than ordered and identified it as a medication error. The DON stated medications must be given according to the physician’s order and that the nurse must verify the dose before preparation.
A facility failed to monitor psychotropic medication use for two residents. One resident receiving Abilify for psychosis had no documented monitoring of the specific behavior of hearing voices, and another resident receiving quetiapine for insomnia had no documented monitoring of hours of sleep in the MAR, progress notes, or care records. The DON and an LVN confirmed the missing monitoring, and the facility policy required review of indication, behavior monitoring, side effects, and effectiveness.
Unsecured Medication and Syringe on Medication Cart: An LVN left a medication cart in a hallway with an unlabeled small white pill on top of the cart, and the LVN could not identify the pill. The DON stated medications should be locked and accessible only to authorized staff. The facility also had a used syringe sitting on top of a pharmaceutical waste container on the cart, where it could be removed by hand instead of being secured inside the container. The LVN and DON both stated the syringe should have been placed inside the waste container.
Unclean Laundry Eye Wash Station: The facility failed to maintain a clean and sanitary laundry room eye wash station, which was observed with green and black stains on the basin surface. The HS stated a dirty eye wash station could lead to an eye infection in staff, and the DON stated that using an unclean station during an emergency could worsen an eye injury or irritation. The facility policy required routine inspection of eye-wash stations and maintaining a safe, clean, and functional environment.
A CNA and a treatment nurse did not wear required isolation gowns while providing high-contact care, including wound treatment and personal hygiene, to a resident on Enhanced Barrier Precautions due to a suprapubic stoma and pressure injuries. Both staff acknowledged forgetting to follow the facility's infection control policy, and the DON confirmed that gown use was required for such care activities.
A resident with paraplegia and existing pressure injuries was found to have a low air loss (LAL) mattress set for a 300-pound person, despite weighing 197 pounds. The treatment nurse admitted to forgetting to adjust the mattress setting according to the resident's weight, as required by facility policy and manufacturer guidelines. The DON confirmed the error and acknowledged the importance of proper mattress settings for pressure injury management.
The facility failed to properly label and store food items, including bell peppers, carrots, and expired cinnamon roll dough, according to professional standards and its own policy. This oversight could lead to foodborne illnesses among the 54 residents. The Dietary Supervisor acknowledged the lapse in following the policy, which requires a 'use by' date for all stored food items.
The facility did not follow its smoking safety policy by failing to post necessary signage and provide a fireproof blanket in the designated Smoking Patio. An Activities Assistant confirmed the absence of a sign indicating the smoking area and a sign prohibiting oxygen use, as well as the lack of a fireproof blanket, which could pose a risk to residents.
A facility failed to ensure a resident's Advance Directive was obtained and available in their medical records. Despite the resident having moderately impaired cognition and a POLST indicating an Advance Directive, it was not present in the records. The Social Services Director was unable to obtain it from the family, and the Director of Nursing highlighted its importance for honoring the resident's wishes. The facility's policy required the Advance Directive to be in the health record, but this was not done.
A facility failed to conduct a background check for a CNA before employment, contrary to its policy. The CNA began working before the background check was completed due to delays attributed to the COVID-19 pandemic. Facility staff misunderstood the continuation of a temporary policy allowing employment to start before background checks were finalized. This oversight increased the risk of exposing residents to potential abuse.
A resident with severe cognitive impairment and chronic conditions was not receiving continuous oxygen therapy as ordered, with the nasal cannula found hanging from the concentrator. The facility's policy on oxygen use was not followed, as confirmed by an Infection Preventionist Nurse.
A resident with glaucoma was incorrectly administered Timolol Maleate Ophthalmic Solution to both eyes instead of the left eye only, as per the physician's order. The LVN did not read the medication label or order correctly, leading to this error. The DON emphasized the importance of following doctor's orders to ensure resident safety.
The facility failed to properly label and store medications, leading to potential issues with medication effectiveness. In one instance, an opened package of Albuterol for a resident with acute respiratory failure was found without an open date label. In another case, an opened package of Albuterol for a resident with COPD was not discarded despite being past its expiration date. The QAN and DON acknowledged the importance of proper labeling to prevent the use of expired medications.
A resident's discharge documentation was inconsistent, with progress notes and the MDS indicating a transfer to a general acute hospital, while the Physician's Discharge Summary incorrectly stated a discharge home. The MRD, responsible for chart audits, confirmed the discrepancy but was unaware of the importance of matching documentation. The DON highlighted the need for accurate records to ensure all parties are informed of resident updates.
The facility failed to maintain the walk-in freezer according to its policy, as temperatures were not documented twice daily, and the freezer had condensation issues. The Dietary Supervisor confirmed that temperatures were only logged once in the morning, and the Kitchen Manager noted reliance on a single thermometer due to another being broken. The Air Conditioning Technician identified a cracked condensate line, contributing to the freezer's issues.
The facility failed to implement effective COVID-19 infection control measures, including visitor screening, biweekly PCR testing, and proper use of PPE and social distancing in common areas. The lack of procedures and equipment, compounded by the unavailability of the medical director and supply shortages, led to deficiencies in managing the spread of the virus.
A resident with severe mobility impairments and high fall risk did not have a wheelchair sensor pad alarm applied as ordered by the physician and outlined in the care plan. The resident was found on the floor, and interviews revealed the sensor pad was often unplugged or missing. The facility's policy emphasized accident prevention, but the failure to implement the care plan interventions exposed the resident to potential falls.
Food Handling, Hand Hygiene, and Labeling Deficiencies
Penalty
Summary
The facility failed to follow its food handling and labeling procedures during kitchen and dining room observations. On 3/16/2026, CNA 1 was observed placing a dirty tray on the tray cart and then immediately touching a clean tray without performing hand hygiene or changing gloves. In a separate kitchen observation on 3/17/2026, [NAME] 1 was observed using a wet rag from a bucket filled with chemical sanitizer to clean dirty kitchen surfaces and then opening the refrigerator to remove bell peppers and place them on the kitchen table without performing hand hygiene or changing gloves. During the kitchen observations, multiple food storage issues were also identified. Pepperoni removed from its original package did not have an open or use-by date, dry cereal stored in individual bowls did not have an open or use-by date, and Hungarian-style paprika had a use-by date of 2/1/2026. Two sour cream containers were observed with an open date of 2/25/2026 and a use-by date of 3/15/2026, and Refrigerator 3 contained two expired sour cream containers with expiration dates of 2/8/2026 and 3/15/2026. Dietary Supervisor 1 confirmed expired food items should be discarded and stated all food items should be labeled with an open date and follow storage guidelines. The Administrator stated that food items removed from their original packaging should be labeled with an open date and a use-by date, and that proper labeling was necessary to ensure food was not spoiled and remained safe for consumption. The facility's policies reviewed by surveyors stated that food must be prepared and served in a safe and sanitary manner, hands must be washed prior to handling food, hands must be washed after handling soiled dishes and utensils, and all food items in storerooms, refrigerators, and freezers must be labeled and dated. The refrigerated storage guidelines also stated that sour cream and similar cultured dairy products should be discarded seven days after opening or by the expiration date, whichever came first.
Overflowing Trash Bins and Improper Garbage Storage
Penalty
Summary
The facility failed to maintain trash in covered, properly contained, and sanitary receptacles. During an observation on 3/16/2026 at 2:21 pm in the trash bin area, three large trash bins were seen overflowing, with multiple paper cups and paper towels on the ground next to the bins. During an interview on 3/16/2026 at 2:30 pm, the Dietary Supervisor stated the trash bins need to be covered and secured at all times and that overflowing trash bins can develop pests and rodents in the facility. During an interview on 03/19/2026 at 9:39 am, the DON stated that if trash bins are not closed adequately and there is trash on the ground, it can attract vermin in the facility which can spread infection. Review of the facility policy titled, Garbage and Trash, dated 2023, indicated all food waste must be placed in sealed leak-proof, non-absorbent, tightly closed containers and that adequate, clean, vermin-proof areas must be provided for storage of garbage and rubbish.
Infection Control Failures With Oxygen Tubing, EBP, and Hand Hygiene
Penalty
Summary
The facility failed to implement its infection control policy and procedure when two residents with orders for weekly oxygen tubing changes had nasal cannula tubing that was not dated. Resident 52 was admitted with acute respiratory failure with hypoxia and pleural effusion, and Resident 27 was admitted with chronic obstructive pulmonary disease, immunodeficiency, and obstructive sleep apnea. During observations, both residents’ nasal cannula tubing was found not dated. Staff interviews confirmed that the tubing is to be changed and labeled weekly, and the Infection Preventionist reviewed the facility policy stating that oxygen tubing is to be replaced every 7 days or as needed and dated when changed. The facility also failed to follow Enhance Barrier Precautions for Resident 52, who had wound vac therapy ordered. During observation outside the resident’s room, LVN 2 did not perform hand hygiene when entering or exiting the room, and the EBP sign was not posted outside the room. LVN 2 stated he did not perform patient care and therefore did not need to perform hand hygiene when entering and exiting the room. The Infection Preventionist reviewed the EBP sign and stated that everyone must clean their hands on room entry and when exiting a room with EBP in place. The facility further failed to ensure hand hygiene was performed after rectal medication administration and before oral medication administration for Resident 10. Resident 10 had diagnoses including left arm fracture, falls, and cellulitis of the left arm, and had orders for bisacodyl suppository and calcium carbonate tablets. During medication administration observation, LVN 2 inserted the bisacodyl suppository while wearing gloves, then removed the gloves but did not perform hand hygiene before handling the oral medication. LVN 2 acknowledged forgetting to perform hand hygiene after the suppository. The Infection Preventionist, DON, and facility policies all stated that hand hygiene is required after rectal medication administration and before other medication administration.
Incomplete and Missing Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure informed consent was obtained before administering psychotropic medications to Resident 17. Resident 17 was admitted with diagnoses including schizoaffective disorder, bipolar disorder, and insomnia, and the MDS dated 1/22/2026 indicated moderate cognitive impairment, meaning the resident had some problems with memory and thinking but was still able to participate in care decisions to a degree. Physician orders dated 1/20/2026 included Abilify, Divalproex Sodium, Duloxetine, Klonopin, and Trazodone for psychosis, mood stabilization, depression, anxiety, and depression. A review of the informed consent form dated 1/20/2026 showed consent was obtained for Duloxetine, Trazodone, and Abilify, but the resident’s signature was not dated, leaving the forms incomplete. During interview and record review, the DON stated the forms needed to be signed and dated to be complete and valid. The DON also stated there was no documented evidence that informed consent was obtained for Divalproex Sodium and Klonopin from Resident 17 or the responsible party, if any. Resident 17 stated she was missing consent for Klonopin and Depakote and said she had been told they were not antipsychotic medications and did not need consent. The DSD stated she was unable to produce the missing consent forms and that both medications required informed consent.
Failure to Honor Resident Diet Preferences
Penalty
Summary
The facility failed to promote Resident 35’s right to choose and participate in decisions about diet preferences. Resident 35 was admitted and later re-admitted with diagnoses including CHF, major depression, and HTN. The resident’s MDS dated 1/19/2026 indicated cognitive intactness and need for assistance with several activities of daily living. The physician order summary dated 8/28/2025 listed a no added salt, easy to chew level 7 texture diet with thin liquids, and the care plan directed the facility to serve the resident no added salt, regular texture, thin liquids consistency. During observation and interview on 3/16/2026, Resident 35 had snacks at bedside and stated peanuts and pretzels were favorite snacks. The resident stated the food had been changed to baby puree food, that she did not have chewing or swallowing problems, that staff did not talk to her about the texture change, and that the change had started a few months earlier. She also stated she had repeatedly told staff she did not like the puree texture and had taken pictures showing the food she was receiving. Speech therapy notes dated 3/17/2026 documented a swallowing evaluation showing safe tolerance to regular texture and that the MD was made aware of the recommendation to upgrade the diet to regular texture. On 3/18/2026, the DON stated the facility could not find the reason Resident 35 was placed on an easy chew level 7 texture diet and could not find documentation from the physician, speech therapy, or staff explaining the change from regular diet to easy-chew texture food.
Resident Information Not Provided in Preferred Language
Penalty
Summary
The facility failed to ensure that information essential for resident understanding, including the activity calendar, facility rules and regulations, and meal menus, was provided in the resident's preferred language for Resident 18. The resident was admitted on 12/10/2025 with diagnoses including a tibia fracture and fall, and the MDS dated 12/25/2025 identified Mandarin as the resident's preferred language and noted moderately impaired cognitive/brain function. During an observation on 03/16/2026 at 9:38 AM, the March 2026 activity calendar, facility information, rules and regulations, and weekly meal menu posted in Resident 18's room were in English. During an interview with the resident using a phone interpreter, Resident 18 stated she is not able to speak or read English and could not read the posted facility rules, activity calendar, or weekly meal menu. Staff interviews showed the Activity Director and LVN 4 stated the facility had used Google Translate when communicating with non-English speaking residents, while the DON stated staff must use interpreter services and that Google translation is not to be used per facility policy. The facility policy reviewed indicated the interdisciplinary team will develop and implement a person-centered, culturally competent, and trauma-informed care plan and provide interpreter services for non-English speaking residents if needed or appropriate.
Failure to Notify Physician of Decreased Appetite and Poor Intake
Penalty
Summary
The facility failed to notify the physician when Resident 4 had a significant change in condition related to decreased appetite and poor oral intake, and the resident was not assessed for weight loss from 2/27/2026 to 3/18/2026 in accordance with the facility's Change In Condition policy. Resident 4 was admitted with diagnoses including CVA, DM, and dysphagia, had a BIMS score of 8 indicating moderate cognition, and required setup or clean-up assistance with eating. The resident also had physician orders for a regular diet with thin liquids, large meat/protein portions, fortified foods, diabetic health shakes with meals for malnutrition risk and poor intake, and monitoring of poor oral intake every shift. Resident 4's care plan identified a potential nutritional problem and directed staff to monitor and report signs and symptoms of decreased appetite and unexpected weight loss to the physician as needed. On 3/17/2026 and 3/18/2026, the MAR showed intake of less than 50%. During lunch observation on 3/18/2026, the resident's tray was picked up with 0% meal intake and an unopened protein health shake. CNA 2 stated she did not set up the protein shake because the resident did not like it and said she had not told licensed staff that the resident did not want to eat. The DON observed the tray, agreed the meal intake was 0% and the shake was unopened, and stated the CNA did not notify licensed staff that the resident did not like the shake. The DON verified the resident had a decreased appetite, that not eating the meal was a concern, and that the attending physician should have been made aware.
Failure to Reposition Resident per Physician Order
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met when the facility failed to ensure Resident 43 was repositioned every two hours while in bed, as ordered by the physician. Resident 43 was admitted with Parkinson's disease and, on the MDS dated 10/1/2026, was identified as having moderate cognitive impairment, being at risk for developing a pressure ulcer, and needing substantial/maximal assistance for repositioning. The physician's order dated 2/20/2026 directed that Resident 43 be repositioned every two hours while in bed. However, the Point of Care Response History from 2/16/2026 to 3/17/2026 showed the resident was turned and repositioned three times a day. During multiple observations on 3/16/2026, Resident 43 was found lying in bed on his back with the head of the bed elevated at a 45-degree angle. In an interview on 3/17/2026, Resident 43 stated he was always lying on his back and not assisted to reposition in bed. The DSD stated on 3/18/2026 that there were no logs or tracking systems documenting when residents were repositioned and that CNAs were required to reposition residents according to physician's orders. The facility policy titled Skin and Wound Monitoring and Management stated nursing staff shall implement resident care plans according to physician's orders.
Failure to Monitor Weight Loss and Follow Nutritional Orders
Penalty
Summary
Provide enough food and fluids to maintain a resident’s health was not met for Resident 4, who was admitted with CVA, DM, and dysphagia and was moderately cognitively impaired with setup or clean-up assistance needed for eating. The resident’s weight declined from 147 lbs. on 9/24/2025 to 127 lbs. on 3/2/2026, reflecting a 14.7% loss over five months. The record also showed an order on 11/21/2025 to monitor episodes of depression as evidenced by poor oral intake every shift. The resident’s orders and care plan reflected ongoing nutritional concerns, including an order on 2/27/2026 for weekly weights for 4 weeks, an order on 3/12/2026 for 4 ounces of sugar-free ice cream twice daily with lunch and dinner, and an IDT note on 3/12/2026 stating the resident’s weight was below the goal of 144-154 lbs. During interview, the DON stated the resident did not eat his food and had 0% meal intake, and that this change of condition should have been reported to the attending physician. During a concurrent observation, ice cream was not served with lunch even though it had been ordered. The DON also stated the resident should have been on weekly weights as of 2/27/2026 for weight monitoring due to weight loss, but the weights were not performed. The care plan noted the resident ate less than 50% and included meal replacement, monitoring, and reporting decreased appetite, and the facility policy stated resident response to interventions should be monitored and evaluated, with weekly weights entered into the electronic health record.
Expired Midline Dressing and Missing Disinfecting Cap
Penalty
Summary
Provide for the safe, appropriate administration of IV fluids when needed was not met for Resident 25. The resident was admitted with diagnoses including sepsis, acute respiratory failure with hypoxia, and ESBL infection. The Minimum Data Set dated [DATE] indicated the resident had moderate cognitive impairment and was independent with bathing, dressing, toileting, and eating. During an observation on [DATE] at 12:06 p.m., Resident 25 was seen with a double-lumen midline catheter. The dressing at the insertion site was expired and past the due date for change, and no Curos disinfecting cap was present on the lumen. During a concurrent observation and interview with the DSD at 12:15 p.m., the midline dressing was observed with a date but no time documented, and the DSD stated the dressing was to be changed weekly on Sundays and confirmed it was past due. The facility policy required IV dressings to be dated and changed as scheduled and required cleansing or protection of the lumen port to prevent contamination.
Oxygen Therapy Not Consistently Provided or Maintained
Penalty
Summary
The facility failed to provide oxygen therapy in accordance with physician orders and infection control practices for two residents. One resident was admitted with acute respiratory failure with hypoxia, asthma, and atrial fibrillation, had severe cognitive impairment, and was totally dependent for activities of daily living. Her care plan included oxygen therapy as ordered and noted episodes of removing the nasal cannula. Her order required continuous oxygen at 2 liters per minute via nasal cannula with oxygen saturation maintained above 90 percent every shift. During observation, she was lying flat in bed with oxygen not in place and was holding the tubing on her chest. Staff confirmed the tubing was not dated, and a nurse stated the resident frequently removes her nasal cannula. The second resident was admitted with atelectasis and sepsis and had moderate cognitive impairment. Her order summary included ipratropium-albuterol solution by nebulizer as needed for shortness of breath and wheezing. During observation, she was lying in bed with treatment tubing and a face mask on the bed, and the tubing was labeled with a date showing it was past the facility's replacement interval. The Infection Preventionist stated oxygen tubing is to be changed weekly on Sundays and confirmed the observed tubing was expired and could allow bacterial buildup and infection. The facility policy required oxygen tubing to be replaced every seven days or as needed when dirty or soiled and to be dated when changed.
Incorrect Calcium Carbonate Dose Prepared for a Resident
Penalty
Summary
Pharmaceutical services failed to ensure that one sampled resident received the correct dose of calcium carbonate as ordered by the physician and in accordance with the facility’s medication administration policy. The resident was admitted and readmitted with diagnoses including a left arm fracture, falls, and cellulitis of the left arm. The resident’s H&P did not indicate decision-making capacity, while the MDS indicated intact cognition. The physician ordered calcium carbonate chewable 500 mg, one tablet by mouth twice a day for indigestion. During medication administration observation, an LVN prepared a bottle of calcium carbonate 750 mg tablets and stated he would cut one tablet into four quarters and give three quarters, totaling approximately 562.5 mg. The LVN then cut the tablet and placed three quarters in a medication cup. When the order was reviewed, the LVN acknowledged the ordered dose was 500 mg. The LVN later stated the medication cup contained 562.5 mg rather than the prescribed 500 mg and identified it as a medication error. The DON stated medications must be administered according to the physician’s order and that the nurse must first clarify whether the dose is correct before preparing and administering medications. The facility’s Medication Administration policy stated that medications are administered in accordance with written physician orders and that partial tablets are clearly identified or highlighted on the MAR.
Psychotropic Medications Not Monitored for Behavior and Sleep Effectiveness
Penalty
Summary
The facility failed to ensure psychotropic medications were monitored in accordance with physician orders and its Chemical Restraints and Psychotropic Medication Management policy for two residents. One resident with diagnoses including diabetes mellitus, Alzheimer’s disease, major depression, and psychosis was receiving Abilify 15 mg daily for psychosis and hearing voices that were not there. Although the care plan and psychiatry evaluation indicated continued medication management and behavior monitoring, the psychiatry evaluation did not identify the specific behavior to monitor, and the record contained no documented evidence that the resident’s psychotic symptoms were monitored. A second resident with diagnoses including falls, Alzheimer’s disease, and a left leg fracture was ordered quetiapine fumarate 25 mg at bedtime for insomnia. The resident’s H&P stated the resident lacked capacity to understand and make decisions. The MAR, progress notes, and other reviewed records did not contain documented evidence that the resident’s hours of sleep were monitored after the medication was started. The care plan included interventions to administer medications as ordered and monitor side effects and effectiveness, and the consent form stated the medication was intended to increase hours of sleep and continue only as long as necessary. During interviews, the DON confirmed that the first resident’s behavior of hearing voices should have been monitored and documented, and that such monitoring helps determine whether the medication can be reduced or discontinued. LVN 3 and the DON also stated that the second resident’s hours of sleep should have been monitored to determine whether quetiapine was effective and whether it was causing excessive drowsiness. The facility policy stated that licensed nurses would review the indication, behavior monitoring, and related adverse side effects, and that the interdisciplinary team would ensure monitoring for adverse consequences and effectiveness of medications.
Unsecured Medication and Syringe on Medication Cart
Penalty
Summary
The facility failed to follow its policies and procedures for the proper storage and disposal of medications for Medication Cart 1. During an observation in the hallway, an LVN left the medication cart to enter a resident’s room, and an unlabeled small white pill was observed on top of the cart. When interviewed at that time, the LVN stated she could not identify the pill and said that if someone ingested it, it could cause harm to that individual. The DON later stated that all medications should be locked with only authorized staff having access, and that an unauthorized person using the unlabeled pill could have been harmed. The facility policy titled, Storage of Medications, stated the medication supply was to be accessible only to licensed nursing personnel, pharmacy personnel, or staff lawfully authorized to administer medications. The facility also failed to properly dispose of a used syringe on Medication Cart 1. During inspection of the cart, a pharmaceutical waste container on the right side of the cart had a syringe visible on top of the lid, and the syringe could be taken out by hand rather than being secured inside the waste bin. The LVN stated the syringe had been administered by her and should not have been there because it was easily accessible to residents and visitors, and that it must be inside the waste container. The DON stated nurses must throw used syringes inside waste containers and that used syringes could contain infectious material that could spread infections to residents. The facility policy titled, Disposal of Medications, Syringes, and Needles, stated used syringes and needles are to be disposed of safely and immediately placed into puncture-resistant, one-way containers designed for that purpose.
Unclean Laundry Eye Wash Station
Penalty
Summary
The facility failed to maintain a clean and sanitary physical environment in one of one staff-use emergency safety areas observed, the laundry room eye wash station. During an observation in the laundry area, the eye wash station was seen with green and black stains on the basin surface. In an interview, the Housekeeping/Laundry Supervisor stated that using a dirty eye wash station could lead to an eye infection in staff. In a later interview, the DON stated that if staff use an unclean eye wash station during an emergency, it could worsen an eye injury or irritation. A review of the facility's Maintenance Policy dated 12/2025 stated that the facility was required to maintain a safe, clean, and functional environment and conduct routine inspection of eye-wash stations, electrical and fire safety systems.
Failure to Follow Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
Certified Nursing Assistant (CNA) 1 and Treatment Nurse (TN) 1 failed to follow the facility's infection control protocols by not wearing an isolation gown while providing direct contact care to a resident who was on Enhanced Barrier Precautions (EBP). The resident had a suprapubic stoma for intermittent catheterization and pressure injuries on the left ischium and right heel, conditions that placed them at higher risk for multidrug resistant organisms (MDROs). During wound care, bed bathing, and brief changing, both CNA 1 and TN 1 provided high-contact care without donning the required isolation gown, despite signage at the resident's doorway and facility policy indicating the necessity of gown and glove use for such activities. Interviews with CNA 1 and TN 1 revealed that both staff members acknowledged forgetting to wear the gown during the high-contact care activities, and recognized that this was contrary to facility policy and infection control standards. The Director of Nurses (DON) confirmed that the resident was on EBP due to their medical conditions and that staff were required to wear gowns during high-contact care, such as bathing, changing briefs, and wound care. Review of the facility's infection prevention and control policy further supported that gown and glove use was mandatory for residents on EBP during these types of care activities.
Incorrect LAL Mattress Setting for Resident with Pressure Injuries
Penalty
Summary
A resident with a history of paraplegia, recent genitourinary surgery, urinary retention, and existing pressure injuries on the left ischium and right heel was admitted to the facility and assessed as being at moderate risk for pressure injuries. The resident required a low air loss (LAL) mattress as part of their care plan to manage and prevent further skin breakdown. According to the resident's current weight of 197 pounds, the LAL mattress was supposed to be set according to the manufacturer's guidelines, which specify adjusting the mattress pressure based on the patient's weight. During observation and interview, it was found that the LAL mattress was incorrectly set for a 300-pound person, rather than the resident's actual weight. The treatment nurse acknowledged responsibility for ensuring the correct mattress setting and admitted to forgetting to adjust it that morning. The DON confirmed that the mattress should have been set according to the resident's weight and that the incorrect setting could delay healing of existing pressure injuries and potentially result in new ones. Facility policy and manufacturer guidelines both require the LAL mattress to be set according to the resident's weight.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards for food service safety and its own policy and procedure regarding the storage and labeling of food. During an observation, it was found that several food items, including bell peppers, carrots, tomatoes, lettuce, celery, cucumbers, onions, oranges, cantaloupes, and pineapples, were not labeled with a 'use by' date. This lack of labeling could lead to the food going bad, potentially causing foodborne illnesses among the 54 residents in the facility. The Dietary Supervisor acknowledged that all food items in the refrigerator should have a 'use by' date to prevent spoilage and ensure resident safety. Additionally, an expired box of Traditional Cinnamon Roll Dough was found in the refrigerator, 51 days past its expiration date. The Dietary Supervisor confirmed that the expired dough should not have been stored in the refrigerator, as it could mistakenly be used by staff, posing a risk of foodborne illness to residents. The facility's policy, as reviewed, mandates that commercially processed, ready-to-eat foods intended for storage longer than 24 hours must be marked with a 'use by' date. The Dietary Supervisor admitted that the facility was not following this policy, which could affect all residents by increasing the risk of consuming expired or spoiled food.
Failure to Implement Smoking Safety Measures
Penalty
Summary
The facility failed to adhere to its policy and procedure regarding smoking safety measures in the designated Smoking Patio. During an observation, it was noted that the Smoking Patio lacked a sign indicating it was a designated smoking area and a sign prohibiting the use of oxygen in the area. Additionally, the patio did not have a fireproof blanket available, which was required by the facility's policy. These omissions were confirmed during an interview with the Activities Assistant, who acknowledged the absence of the necessary signage and fireproof blanket. The Activities Assistant expressed concerns that without proper signage, residents might not be aware of the designated smoking area, and those on oxygen might inadvertently enter the area, posing a risk of burns. The absence of a fireproof blanket was also highlighted as a safety concern, as it would serve as a backup in case the fire extinguisher was not functional. The facility's policy, reviewed during the interview, clearly stated the requirement for both a fire extinguisher and a fireproof blanket in the smoking area, indicating non-compliance with established safety protocols.
Failure to Obtain and Document Resident's Advance Directive
Penalty
Summary
The facility failed to ensure that a resident's Advance Directive was obtained and readily available in the resident's medical records. The resident, who was admitted with diagnoses including a urinary tract infection, difficulty walking, and hypertension, had moderately impaired cognition as indicated by the Minimum Data Set. Despite having decision-making capacities noted in the History and Physical, the resident's Physician Orders for Life Sustaining Treatment indicated the presence of an Advance Directive. However, during a review of the resident's medical chart and electronic records, the Quality Assurance Nurse confirmed that the Advance Directive was not present. Interviews with facility staff revealed that the Social Services Director had been unable to obtain the Advance Directive from the resident's family member, despite repeated requests. The Director of Nursing emphasized the importance of having the Advance Directive to honor the resident's and family's wishes, especially if the resident becomes unable to make decisions. The facility's policy required obtaining and placing a copy of the Advance Directive in the resident's health record, but this was not done, leading to the potential for misinformation and not honoring the resident's wishes in healthcare decisions.
Failure to Complete Background Check Before Employment
Penalty
Summary
The facility failed to ensure that a Certified Nurse Assistant (CNA 1) underwent a background screening and criminal history check prior to employment, as required by the facility's policy and procedure titled 'Pre-employment Investigation.' CNA 1 was offered employment on a contingent basis pending the results of reference checks, a criminal background check, and a drug screening. However, CNA 1 began working at the facility on November 7, 2024, before the background check was completed on November 20, 2024. This oversight was attributed to delays in obtaining background check results due to the national public health emergency declared during the COVID-19 pandemic. Interviews with facility staff revealed a misunderstanding regarding the continuation of a temporary policy that allowed staff to begin employment before completing their background checks during the pandemic. The Director of Staff Development (DSD) and Human Resources (HR) staff indicated that they believed CNA 1 was cleared to work based on outdated guidance. The Director of Nursing (DON) confirmed that the facility's policy requires background checks to be completed before starting the orientation process. The facility's failure to adhere to its policy increased the risk of applicants and employees with potential criminal convictions having direct access to residents, thereby placing them at risk of abuse and feelings of intimidation.
Failure to Administer Ordered Oxygen Therapy
Penalty
Summary
The facility failed to ensure that Resident 150 received oxygen therapy as ordered by the attending physician. Resident 150 was admitted with diagnoses including hemiplegia, hemiparesis, and chronic kidney disease. The Minimum Data Sets (MDS) indicated that the resident's cognition was severely impaired and that they were receiving continuous oxygen therapy. A physician's order dated 2/11/2025 specified that the resident should receive continuous oxygen at 2 liters via nasal cannula to maintain oxygen saturation above 90% for shortness of breath. During an observation on 2/14/2025, Resident 150 was seen sitting in bed without the nasal cannula in use, as it was hanging from the oxygen concentrator. The Infection Preventionist Nurse confirmed that the nasal cannula should not have been hanging and that the resident should have been receiving continuous oxygen therapy. The facility's policy on the use of oxygen, revised in May 2007, emphasizes promoting resident safety in administering oxygen, which was not adhered to in this instance.
Failure to Follow Medication Administration Orders
Penalty
Summary
The facility failed to prevent unnecessary medication administration for one resident by not adhering to the physician's order for Timolol Maleate Ophthalmic Solution. The order specified that the medication should be administered to the resident's left eye only, once a day, to treat glaucoma. However, during a medication pass observation, a Licensed Vocational Nurse (LVN) was seen administering the medication to both the left and right eyes of the resident. The resident involved had been admitted with diagnoses including metabolic encephalopathy and primary open-angle glaucoma. The LVN admitted to not reading the medication bottle label or the specific part of the order that indicated the medication was to be administered to the left eye only. The Director of Nursing confirmed that all nurses are expected to check and follow doctor's orders to ensure the correct medication is given, highlighting a lapse in following the facility's medication administration policy.
Medication Labeling and Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were labeled and stored according to prescription labels, leading to potential issues with medication effectiveness. In Medication Cart #1, an opened package of Albuterol Inhalation Solution for a resident with acute respiratory failure and other conditions was found without an open date label. This package contained four out of five plastic vials, and the Quality Assurance Nurse (QAN) acknowledged that the prescription label indicated an expiration date of seven days after opening. The absence of an open date label could result in the administration of expired medication. In Medication Cart #2, another opened package of Albuterol Inhalation Solution for a resident with COPD and other diagnoses was observed with an open date of 2/4/2025, but it was not discarded despite the expiration date being seven days after opening. The QAN confirmed that the package contained only one plastic vial left and stated that it would be discarded to prevent its use. The Director of Nursing (DON) emphasized the importance of labeling medications with open dates to avoid administering expired medications, as they would not be as effective.
Inaccurate Discharge Documentation for a Resident
Penalty
Summary
The facility failed to accurately document a resident's discharge disposition on the discharge summary, resulting in inconsistent records for Resident 47. The resident was admitted with conditions including a nasal bone fracture, gait abnormalities, and type 2 diabetes mellitus. The resident had decision-making capacities and was scheduled for a left knee skin graft surgery. However, discrepancies were found in the documentation regarding the resident's discharge location. The nursing progress notes and the Minimum Data Set (MDS) indicated that the resident was discharged to a general acute hospital center (GACH), while the Physician's Discharge Summary incorrectly stated that the resident was discharged home. Interviews with the MDS Nurse and Medical Records Director (MRD) revealed that the MRD was responsible for auditing resident charts and ensuring accurate documentation. The MRD confirmed the inconsistency in the discharge location between the Physician's Discharge Summary and the MDS but admitted to not understanding the importance of matching documentation. The Director of Nursing emphasized the importance of accurate documentation for keeping all parties informed of resident updates and dispositions. The facility's policies on admission, transfer, discharge, and documentation stress the need for accurate and consistent record-keeping.
Failure to Maintain Walk-In Freezer in Good Operating Condition
Penalty
Summary
The facility failed to maintain the walk-in freezer in good operating condition as per its policy and procedures. The deficiency was identified through observation, interview, and record review, revealing that the facility did not document temperature readings of the freezers both in the morning and evening as required. The facility's policy indicated that freezer temperatures should be recorded twice daily, but the Dietary Supervisor (DS) confirmed that temperatures were only logged once in the morning. Additionally, the temperature logs did not specify which thermometer was used, and only one thermometer reading was recorded for freezer number three, which was the walk-in freezer. During an inspection, the walk-in freezer was found to have a plastic curtain with water dripping down and condensation with visible water droplets on the ceiling. The temperature readings from different thermometers in the freezer varied significantly, with the outside thermometer reading 19 degrees Fahrenheit, the inside thermometer near the door reading 20 degrees Fahrenheit, and the thermometer at the back reading negative two degrees Fahrenheit. The Air Conditioning Technician (AC Tech) noted that the thermometer by the door would not provide an accurate reading due to heaters along the door, and the freezer had a cracked condensate line that needed repair. The facility's policy also required that each freezer have two visible thermometers and maintain a temperature of zero degrees Fahrenheit or lower. However, the Kitchen Manager (KM) stated that the facility only checked the temperature readings once a day and relied on the thermometer in the back of the walk-in freezer, as the other thermometer was broken. The DS and Administrator (ADM) acknowledged that the facility was not following its policy and procedures, which could potentially put residents at risk for foodborne illness or contamination due to improper freezer maintenance.
Inadequate COVID-19 Infection Control Measures
Penalty
Summary
The facility failed to implement its infection prevention and control policy and the local public health department's recommendations, leading to deficiencies in managing COVID-19. During an unannounced visit, it was observed that the facility did not have a procedure to screen visitors for COVID-19 symptoms before entering. The Administrator and a Licensed Vocational Nurse confirmed that visitors were only required to log in and wear a facemask, without any symptom screening or antigen testing. The facility also failed to conduct biweekly PCR testing for all residents and staff as instructed by a public health nurse and a county physician. The Administrator stated that the testing could not be initiated because the medical director, whose signature was required, was on vacation and unreachable. Additionally, the facility's breakrooms were not equipped with necessary infection control supplies such as hand sanitizers, facemasks, and wipes, and did not adhere to occupancy limits or ventilation recommendations. Furthermore, the rehabilitation room was observed to be overcrowded, with more people than allowed and without proper mask usage or social distancing. The Infection Preventionist admitted to not ensuring compliance with the recommendations, including signage for mask changes and the availability of masks in breakrooms. The facility also faced challenges in acquiring air purifiers due to supply shortages, contributing to the inadequate infection control measures.
Failure to Implement Wheelchair Sensor Pad Alarm for High-Risk Resident
Penalty
Summary
The facility failed to ensure that a wheelchair sensor pad alarm was placed on the wheelchair of a resident who was assessed as high risk for falls. The resident, who had difficulty walking, hemiplegia, and hemiparesis, was admitted and readmitted to the facility with a physician's order to use a sensor pad in bed and in a wheelchair to prevent unassisted movement. The resident's care plan also included the use of a sensor pad as a safety precaution. However, the resident was found lying on the floor in the dining room, indicating that the sensor pad was not in use. Interviews and record reviews revealed that the resident's wheelchair sensor pad was often unplugged or missing, as noted by a family member on multiple occasions. The Director of Staff Development confirmed that the sensor alarm was not applied to the resident's wheelchair during a visit. The Director of Nursing acknowledged that the facility's failure to implement the care plan interventions could expose residents to accidents, such as falls, which could lead to serious injuries. The facility's policy on fall management emphasized the importance of providing an environment free of accident hazards and adequate supervision to prevent accidents.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 6,679 citations issued within 25 miles in the last 12 months — including the 39 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Rosemead
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Broadway Healthcare Center | 0.8 mi | ★★★★★ | 18 | 0 |
| Pine Grove Healthcare & Wellness Centre, Lp | 0.9 mi | ★★★★★ | 18 | 0 |
| Royal Vista Care Center | 1.2 mi | ★★★★★ | 30 | 0 |
| Live Oak Rehab Center | 1.3 mi | ★★★★★ | 36 | 1 |
| Ivy Creek Healthcare & Wellness Centre | 1.4 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 June 2026) and official state health department websites.