Mission Care Center

Inspectors wroteBased on interview and record review the facility failed to implement timely and appropriately the facility's policy and procedures for infection control of scabies (a tiny skin bug infestation caused by microscopic mites that burrow under the skin, leading to severe itching and a pimple-like rash) outbreak control measures for three of three sampled residents (Resident 1, Resident 2, & Resident 3). The facility failed to: 1. Identify and maintain an ongoing surveillance (line listing) for all facility staff, specifically including nursing and non nursing personnel, who were in direct contact with Resident 1 (admitted on [DATE] with diagnosis of scabies) and Resident 2 (diagnosed on [DATE] with scabies), as recommended by the Acute Communicable Disease Control (ACDC) Program, Scabies Prevention and Control Guidelines. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure physician and family notification of one of three residents (Resident 2's) change in condition when Resident 2 was monitored for and sustained self-inflicted scratches for six days. This deficient practice had the potential to delay physician evaluation and treatment, resulting in worsening of the resident's condition and failure to implement timely interventions.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive, person-centered care plan to address Resident 2's self-inflicted scratches in accordance with facility's Policy and Procedure (P&P) titled Comprehensive Person-Centered Care Planning This deficient practice had the potential to result in delayed wound healing, increased skin infection risk, and worsened tissue damage.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain complete and accurate clinical records for one of three sample residents (Resident 2). Skin assessment and interventions were documented for Resident 2 on dates when the assigned treatment nurse (TXN 1) reported she was on vacation and did not perform the assessments. This resulted in an inaccurate documentation. This deficient practice resulted in an inaccurate documentation that did not accurately reflect Resident 2's care provided, potentially delaying appropriate interventions.

Inspectors wroteBased on interview and record review, the facility failed to provide requested medical records within 48 hours, as written in their policy titled Protected Health Information, for one of three residents sampled for access to medical records (Resident 1) when Family Member (FM) 1 (Resident 1's responsible party [RP]) submitted a written request for Resident 1's medical records on 6/2/2026 at 8:42 AM and the facility did not provide the records until 6/5/2026 at 11:52 AM (75 hours later). This deficient practice violated Resident 1 and his RP's right to timely access to medical information and had the potential to interfere with the RP's ability to make informed decisions regarding Resident 1's care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper food safety and sanitation practices to prevent foodborne illness (also known as food poisoning caused by consuming contaminated food or water containing bacteria, toxins, viruses leading to symptoms like nausea, vomiting, diarrhea and stomach cramps) to the residents in accordance with the facility's policy and procedure titled Labeling and Dating of Foods. by failing to: 1. Perform hand hygiene after certified nurse assistant (CNA) 1 was observed touching a clean meal tray without washing or sanitizing hands after touching a dirty, soiled meal tray. 2. Perform hand hygiene after [NAME] 1 was observed using a rag to clean the soiled kitchen table surface prior to opening the refrigerator to obtain a bell pepper. 3. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to maintain trash in covered, properly contained, and sanitary receptacles. Three out of 3 large trash bins were observed overflowing with waste on the ground. This failure created the potential for vermin infestation and infection riskFindings: During an observation on 3/16/2026 at 2:21 pm, in the facility's trash bin area, three large trash bins were overflowing with multiple paper cups and paper towels were on the ground next to the trash bins. During an interview on 3/16/2026 at 2:30 pm, with the Dietary Supervisor (DS), the DS stated the trash bins need to be covered and secured at all times. DS stated that overflowing trash bins can develop pests and rodents in the facility. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to implement the facility's policy and procedure for infection control by failing to: 1. Label the nasal cannula tubing (small, flexible plastic tube inserted into the body to deliver oxygen) for two of three sampled residents (Resident 52 and 27). 2. Ensure License Vocational (LVN) 2, performed hand hygiene (the act of cleaning your hands to remove germs, dirt, and viruses) when entering and exiting a room with Enhance Barrier Precautions (EBP- a protocol requiring staff to perform hand hygiene, using gowns and gloves when entering a resident's room who has a wound vac [medical device that uses suction to accelerate healing in skin wounds]). 3. Ensure the Enhance Barrier Precautions sign was posted outside the room for one of three sampled residents (Resident 52). 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure informed consent was obtained prior to the use of psychotropic medications for one of eight residents (Resident 17) in accordance with the facility's policy and procedure titled Chemical Restraints and Psychotropic Medication Management. This deficient practice had the potential to violate resident' rights to be informed prior to administering medications without their knowledge or approval. This also placed the resident to be at risk for unnecessary chemical restraint that limit their ability to participate in care decisions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote one of six sampled residents (Resident 35) the right to choose and participate in decision making regarding diet preferences that was important to the resident. This deficient practice violated the resident's rights of Resident 35 that make choices that could result unplanned weight loss and decline in the quality of life.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that information essential for resident understanding-such as activity calendars, facility rules and regulations, and meal menus-was provided in the resident's preferred language for 1 of 1 sampled resident reviewed for language needs (Resident 18). This failure resulted in Resident 18 being unable to understand posted information about facility activities, meal options, and facility rules, despite having a documented preference for Mandarin and moderately impaired cognitive function.

Inspectors wroteBased on observation, interview and record review, the facility failed to notify the physician for the significant change of condition when one out of six sample residents (Resident 4) who had a decrease in appetite and was not assessed for weight loss from 2/27/2026 to 3/18/2026 in accordance with the policy and procedures titled Change In Condition. This deficient practice had delayed in the doctor being notified and Resident 4 not being reassessed for weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent development of pressure ulcer (an area of damaged skin and tissue caused by prolonged unrelieved pressure) by ensuring one of three sampled residents (Resident 43), was repositioned every two hours per the physician's order. This failure had the potential to increase the risk in the resident developing a pressure ulcer.

Inspectors wroteBased on observation, interview, and record review, the facility failed to do ongoing assessment, perform weekly weights and provide revised interventions for one of six sampled residents (Resident 4) who has had weight loss. This deficient practice placed the resident at risk for altered nutritional status and further weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper maintenance of an intravenous (IV) site for 1 of 8 sampled residents (Resident 25). Resident 25 was observed with a double lumen midline catheter with an expired dressing and no Curos disinfecting cap in place. This deficient practice was inconsistent with the facility's Infection Control Policy - Intravenous Therapy, dated 12/2025, which required IV dressings to be dated and changed as scheduled and required cleansing or protection of the lumen port to prevent contamination. This failure had the potential to expose the IV site and lumen to contamination, increasing the risk for infection, including bloodstream infection and sepsis.

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to ensure oxygen therapy was provided in accordance with physician orders and infection control practices for 2 out of 8 sampled residents (Resident 40 and 62) when: The oxygen tubing for Residents 40 and 62 was not dated or was past the facility's required replacement interval. The oxygen therapy for Resident 40 was observed not in place as ordered by the physician. The facility staff failed to consistently monitor and verify oxygen placement for a resident known to remove the nasal cannula. These deficient practices had the potential to result in residents not receiving prescribed oxygen therapy and exposure to infection risk from outdated or improperly maintained oxygen equipment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one out of two sampled residents (Resident 10) received correct dose of calcium carbonate (a dietary supplement that body needs to function and to treat indigestion or heart burn) as prescribed by the physician and in accordance with the facility's policy and procedure titled Medication Administration. This deficient practice placed Resident 10 at risk of ingesting more than the prescribed medication dosage or overdose which included symptoms such as constipation, nausea, vomiting, confusion and irregular heartbeat.

Inspectors wroteBased on interview and record review the facility failed to prevent unnecessary use of psychotropic medications (medications that affects mood and behavior) in accordance with the physician's order, and the facility's policy and procedure titled Chemical Restraints and Psychotropic Medication Management for two of the three sampled residents (Resident 6 and 61) by failing to ensure: 1. Resident 6 was monitored for the behavior indicated for the use of Abilify (antipsychotic medication given for psychosis [a severe mental condition in which thought, and emotions are so affected that contact is lost with reality] and other behavioral mental health conditions) for one of six sampled residents. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policies and procedures (P&P) for the proper storage and disposal of medications for two of three Medication Carts (MC 1) by failing to ensure: 1. A used syringe (a medical instrument consisting of a small, hollow tube, a plunger, and usually a needle, designed to inject fluids into or withdraw fluids from the body) was not left on top of MC 1's waste container. 2. An unlabeled small white pill was not left on top of the medication cart This failure had the potential for the residents to take and ingest the medication and the potential to expose residents, visitors, and staff to the unsecured items in the MC.

Inspectors wroteBased on observation, interview and record review, 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. This failure had potential to compromise staff safety during emergency use of the eyewash station (an emergency area used to flush the eyes readily available with clean and appropriate temperate water in case of facility staff getting exposure to hazardous chemicals or irritants).

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the facility's infection control protocols by ensuring Certified Nursing Assistant (CNA) 1 and Treatment Nurse (TN ) 1 wore an isolation gown when providing direct contact care for one of one sampled residents (Resident 1) who was placed on Enhanced Barrier Precautions (EBP-an infection prevention and control intervention to reduce the spread multidrug resistant organisms [MDRO- disease causing organism resistant to medication used to treat infection]) due to the resident having a supra pubic stoma for intermittent catheterization (a small tube placed directly into the bladder through a tiny opening above the pubic bone, to drain urine) and a right heel and left ischium (back part of the hip bone) pressure injury (localized skin and tissue damage from constant pressure). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) who has pressure injuries (damaged skin and tissue from too much pressure) on the left ischium (bottom-rear section of pelvic bone) and right heel had a low air loss mattress ( LAL - designed to prevent and treat pressure injury) set at the setting according to residents weight as indicated in the manufacturer's guidelines to prevent and/or minimize skin pressure on the bony prominences of the body. This deficient practice had the potential to result in delay healing of Resident 1's pressure injuries and may result in new pressure injuries that may negatively affect Resident 1's quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety and facility ' s policy and procedure (P&P) by having an expired Traditional Cinnamon Roll Dough (expired 12/25/2024, 51 days after expiration date) in refrigerator number one and by not labeling: Two (2) bags of bell peppers with a use by date. Three (3) bags of carrots with a use by date. One (1) bag of tomatoes with a use by date. Five (5) lettuce heads with a use by date. Six (6) celery stalk with a use by date. Two bags of cucumbers with a use by date. One box of onions with a use by date. One box of oranges with a use by date. Four (4) cantaloupes with a use by date. Five pineapples with a use by date. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to post a designated No Smoking sign in the patio used by the residents to smoke and have a fireproof blanket available for use in care of fire per the facility ' s policy and procedure (P&P). These deficient practices had the potential to place the residents at risk for burns and the facility at risk for fire hazards.

Inspectors wroteBased on interview and record review the facility failed to ensure one of one sampled resident ' s (Resident 37) Advance Directive (living will, legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves because of illness or incapacity) was obtained and readily available in the resident ' s records (medical chart). This deficient practice had the potential to result in misinformation of medical care and treatment and not honoring resident ' s wishes in cases where the resident and/or responsible party was unable to participate in making healthcare decisions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three Certified Nurse Assistants (CNA 1) was checked for background screening and criminal history prior to employment at the facility in accordance with the facility ' s policy and procedure (P&P) titled, Pre employment Investigation. This failure increased the risk of applicants and employees with possible criminal convictions to have direct access to all patients in the facility and the potential not to be protected from abuse and place the residents at risk of abuse and feelings of intimidation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 3 sampled residents (Resident 150) received oxygen therapy (treatment that provides supplemental, or extra, oxygen) as ordered by the attending physician. This deficient practice has the potential for Resident 150 not to receive enough oxygen to meet the body ' s demand and place the resident at risk for shortness of breath and/or hypoxia (low levels of oxygen in the body tissues) which can lead into serious injury or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent unnecessary medication by ensuring one (1) of three (3) residents (Resident 42) was administered Timolol Maleate Ophthalmic Solution (a medication used to treat high pressure in the eyes) to the left eye only as ordered by the physician reviewed for pharmacy services. This deficient practice had the potential for Resident 42 to have high pressure in the eyes that could lead to blindness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that two (2) medications were in accordance with prescription label in two out of three Medication Carts at the facility. 1. In Medication Cart #1, no open date label found for an opened package of Albuterol (medication used to prevent and treat wheezing, difficulty breathing, chest tightness, and coughing caused by lung diseases) for Resident 203. 2. In Medication Cart #2, an open package of Albuterol with open date of 2/4/2025, was not discarded. This deficient practice had the potential for residents not to receive full strength of the medications and receive ineffective medication dosages.

Inspectors wroteBased on interview and record review, the facility failed to accurately document a resident ' s discharge disposition on the resident ' s discharge summary for one of one sampled resident (Resident 47). This deficient practice resulted in inaccurate documentation of Resident 47 ' s discharge disposition/location for accurate and appropriate tracking purposes of all residents discharged or transferred out of the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the walk-in freezer in good operating condition as indicated in the facility's policy and procedures by failing to: Document temperature readings of the freezers both in the morning and evening as indicated on the facility ' s P&P Procedure for Freezer Storage indicating freezer temperatures should have been recorded twice daily. The walk-in freezer ' s plastic curtain had water dripping down the curtain and had condensation (the process where water vapor becomes liquid) with visible water droplets on the ceiling. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its policy and procedure, and the local public health department's recommendation on infection prevention and control by failing to: 1. Screen visitors for symptoms of Covid19 (a highly contagious respiratory disease caused by the SARS-CoV-2 virus with symptoms of cough, fever, headache, chill, diarrhea etc.) before entering the facility. 2. Conduct biweekly (twice a week) mass PCR testing (a polymerase chain reaction (PCR) laboratory test used to detect if a person is infected with Covid-19) for all residents and staff. 3. Allow only 1-2 residents with face mask and distanced residents in the rehabilitation room (a room used by the staffs when providing exercises to the residents). 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that a wheelchair sensor pad alarm (a weight-sensitive sensor pad that is connected to a monitor unit and activates an alarm if a patient leaves the chair or the bed) was placed on the wheelchair (a mobility device that helps a person with mobility impairment to move around) of one of three sampled residents (Resident 1). This deficient practice had the potential to result in multiple falls with injuries for Resident 1 who was assessed as high riskfor falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote and treat residents with respect, privacy and dignity for three of three sampled residents (Resident 40, 26 and 83) by failing: 1. To ensure Resident 40 ' s lower part of body was not and visible from outside of room. 2. To provide privacy to Resident 26 by leaving the resident ' s post-operative surgical suction drain uncovered. 3. To provide dignity to residents during dining. Licensed Vocational Nurse 1 (LVN 1) was observed drinking coffee during the resident's mealtime. These deficient practices had the potential to cause a psychosocial (mental and emotional well-being) decline, resident ' s individuality, self-esteem, and self-worth.

Inspectors wroteBased on interview and record review the facility failed to develop and implement individualized person-centered plans of care with measurable objectives, timeframes, and interventions to meet the residents ' needs for six (6) of 6 sampled residents (Residents 1, 16, 27, 26, 31, and 30). 1. For Resident 26, the facility failed to develop a care plan to indicate interventions to manage Resident 26 ' s peripheral intravenous catheter (IV, a thin plastic tube inserted into a vein using a needle allowing for the administration of medications, fluids and/or blood products). 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three sampled residents (Resident 16 and 26) follow the facility ' s policy and procedure on Intravenous Therapy by failing to: 1. Label and date intravenous catheter (IV, a thin plastic tube inserted into a vein using a needle allowing for the administration of medications, fluids and/or blood products) for Resident 26. 2. Obtain a physician order for IV catheter insertion for Resident 16. These deficient practices had the potential to put the residents at risk for intravenous complications without appropriate intervention or preventive measures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote resident safety in administering oxygen for four (4) of 4 sampled residents (Residents 40, 154, 205, and 30) who were receiving oxygen therapy, in accordance with the facility ' s policy and procedure: 1. For Resident 40, that facility failed to ensure the resident ' s nasal cannula tubing (flexible plastic tubing used to deliver oxygen through nostrils and the tubing is fitted over the patient's ears) was not touching the floor when in use. 2. For Resident 154, the facility failed to ensure the Yankaeur suction tip (an oral suctioning tool) was not on the floor and post Oxygen/no smoking signage for Resident 154. 3. For Resident 30, the facility failed to have the resident ' s room post a signage indicating Oxygen in use and No Smoking Sign, as per facility policy. 4. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow proper sanitation and safe food handling based on the facilities policy and procedure by failing to ensure: 1. Kitchen staff wear hair covering while in the kitchen to prevent hair from falling on food surface areas that can lead to contamination 2. Label used or opened food items with an open or use by date in the kitchen refrigerator, kitchen freezer, food preparation area and dry goods storage area to indicate when foods are no longer safe to eat. These deficient practices had the potential to put residents at risk for foodborne illnesses (illness caused by food contaminated with bacteria, viruses, parasites, or toxins).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, sanitary environment to help prevent the spread of transmission of infections to residents, staff members, visitors in accordance with the facility ' s policy and procedure on infection control by failing to: Ensure an open plastic container of sliced fruits for staff was not at the nursing station. Ensure Community Liaison (CL) wore personal protective equipment (PPE) that included an isolation gown (gown used to protect clothing from contaminants or contacting disease causing organism) and gloves while in the room of Resident 18, who was under contact isolation (containing one in an area prevent transmission of infectious agents which are spread by direct or indirect contact with the resident or resident ' s environment) precautions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of need for one of one sampled resident (Resident 157) who was at risk for fall, by failing to ensure the resident's call light was within reach as indicated in the facility's policy and procedure and resident's care plan. This deficient practice had the potential for Resident 157 not to receive or received delayed care to meet necessary care and services that could result in fall and accident.

Inspectors wroteBased on interview and record review, the facility failed to follow the facility's policy on Notice Requirements Before Transfer or Discharge for one (1) of three (3) sampled residents (Resident 53), by failing to: 1. Ensure the Notice of Proposed Transfer and Discharge was provided to the resident's responsible party. 2. Provide documentation to show that the State Long Term Care Ombudsman (public advocate) was notified of Resident 53 ' s transfer to the General Acute Hospital (GACH) on 11/26/2024. This deficient practice had the potential for Resident 53's rights to ensure for an appropriate discharge/transfer from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish a system of surveillance designed to prevent the spread of communicable diseases that included Coronavirus -19 (COVID 19 - a highly contagious disease caused by a virus) for one of 24 sampled residents (Resident 1), who had a positive test result and symptomatic for the COVID 19 virus. In addition, the facility failed to report the COVID 19 positive resident as a potential disease outbreak, to the local health officer and the California Department of Public Health (CDPH). This deficient practice had the potential for the virus to spread among residents, staff, and visitors which can negatively affect the resident ' s health and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy on HIPAA Privacy and Security Operational Policy and Procedure to protect the residents private and confidential information when two of two sampled residents' (Residents 1 and 2) discharge records were sent out to different residents on 8/28/2023. LVN 1 gave Resident 1's medical records to Resident 2's family member (Family 1) during Resident 2's discharge to home on 8/28/2023. LVN 2 gave Resident 2's medical records to the 911 emergency services during transfer of Resident 1 to the acute hospital on 8/28/2023. A written notification from the facility was provided to the resident's families on 9/14/2023. The California Department of Public Health (CDPH) was notified by the facility in writing via certified mail on 10/13/23 (29 days). [...]