Inspection Reports for
Mission Care Center
8487 Magnolia Ave, Riverside, CA 92504, United States, CA, 92504
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
83% worse than California average
California average: 4 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 16, 2025
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding resident rights and quality of care at the facility.
Complaint Details
The investigation was triggered by a complaint concerning resident rights and quality of care. The complaint was substantiated by findings that the resident's code status and medical device information were not properly communicated during transfer.
Findings
The facility failed to ensure that the code status and presence of a medical device were accurately communicated to the receiving hospital when Resident A was transferred. The transfer form incorrectly indicated a DNR status and omitted tracheostomy tube details, despite Resident A being a full code at discharge.
Deficiencies (1)
Failure to ensure the code status and presence of medical device were accurately communicated during resident transfer to the hospital.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) | Interviewed regarding transfer form completion and information accuracy. | |
| Director of Nursing (DON) | Interviewed about transfer form details and code status changes. | |
| Respiratory Therapist (RT) | Interviewed about resident's code status and tracheostomy details at discharge. |
Inspection Report
Routine
Deficiencies: 4
Date: Feb 13, 2025
Visit Reason
The inspection was conducted to assess compliance with professional standards related to food safety, garbage disposal, infection control, and resident room size requirements at the facility.
Findings
The facility was found deficient in multiple areas including improper storage and handling of food service items (oven gloves), improper disposal of garbage and refuse outside the facility, inadequate infection control practices related to emergency water storage, and failure to provide required bedroom space in multiple resident rooms. Waivers were requested and recommended for the room size deficiencies.
Deficiencies (4)
Failed to store, prepare, handle, and serve food in accordance with professional standards; observed dirty oven gloves with potential for cross contamination affecting seven residents.
Failed to ensure garbage and refuse were properly disposed off the facility grounds; multiple discarded items stored beside a trailer container potentially attracting pests and rodents.
Failed to ensure appropriate infection control practices; emergency water bottles stored on soiled floor next to chemicals in a cluttered shed with debris and pest access.
Failed to provide required bedroom space of at least 80 square feet per resident in 15 rooms; facility has a waiver for these rooms.
Report Facts
Residents affected: 7
Resident rooms with inadequate space: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding dirty oven gloves and food safety | |
| Registered Dietician | Interviewed regarding food safety and oven gloves | |
| Maintenance Supervisor | Interviewed regarding garbage disposal and emergency water storage | |
| Director of Nursing | Interviewed regarding room size deficiencies and waivers |
Inspection Report
Routine
Deficiencies: 13
Date: Jan 11, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, infection control, dietary services, and safety standards.
Findings
The facility was found deficient in multiple areas including failure to provide written bed hold notice upon hospital transfer, improper enteral feeding handling, inadequate bed rail assessments and documentation, improper medication disposal, dietary service deficiencies including food safety and preparation, infection control lapses including lack of Legionella testing and undated suction equipment, failure to offer pneumonia vaccine per guidelines, and maintenance issues with kitchen equipment and resident rooms not meeting space requirements.
Deficiencies (13)
Failure to provide written notice of bed hold policy to resident or representative upon hospital transfer.
Enteral feeding bag not changed within manufacturer's recommended 48-hour timeframe, risking bacterial growth.
Inadequate risk assessments and documentation for bed rail use for multiple residents, including lack of size/weight relation and alternative use documentation.
IV antibiotic medication not discarded timely after therapy completion, risking medication errors.
Dietary staff unable to accurately verbalize hazardous food cool down temperature; pureed food served with chunks risking choking.
Pureed diet food served with inappropriate texture (chunks present), risking aspiration and choking.
Resident received smaller portion size than physician ordered, risking inadequate nutrition.
Multiple kitchen and food storage areas and equipment were dirty, dusty, or had mold; kitchen floors were damaged and unclean; resident refrigerator contained unlabeled food items.
Facility water system not tested for Legionella for multiple years, risking resident exposure to waterborne pathogens.
Suction tubing and Yankauer tips for residents with tracheostomies were not dated or changed per policy, risking respiratory infections.
Pneumonia vaccine (PCV20) not offered to resident who previously received PCV13, contrary to current CDC recommendations.
Microwave ovens, refrigerator shelves, dry storage shelves, and refrigerator/freezer gaskets were rusted, damaged, or torn, risking food contamination and improper food storage.
Resident rooms did not meet minimum space requirements of 80 square feet per resident; facility had waiver for these rooms.
Report Facts
Residents affected by bed rail deficiencies: 16
Residents affected by suction tubing/Yankauer deficiencies: 3
Residents affected by pneumonia vaccine deficiency: 1
Resident rooms below minimum space requirement: 15
Food items unlabeled in resident refrigerator: 17
Cracked or missing kitchen floor tiles: 16
Microwave oven paint bubbles: 5
Microwave oven rust spots: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 3 | Registered Nurse | Interviewed regarding bed hold notice for Resident 25 |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including bed hold notice, enteral feeding, bed rails, medication disposal, infection control, and room size waiver |
| LVN 1 | Licensed Vocational Nurse | Interviewed regarding enteral feeding bag usage for Resident 30 |
| RT 1 | Respiratory Therapist | Interviewed regarding suction tubing and Yankauer use for Residents 2 and 34 |
| RT 2 | Respiratory Therapist | Interviewed regarding suction tubing and Yankauer use for Resident 17 |
| DSS | Dietary Supervisor | Interviewed regarding dietary service deficiencies and kitchen sanitation |
| CK 1 | Cook | Interviewed regarding pureed food preparation and portion sizes |
| CK 2 | Cook | Interviewed regarding hazardous food cool down temperature |
| RD | Registered Dietitian | Interviewed regarding dietary service deficiencies and food safety |
| CNA 1 | Certified Nursing Assistant | Interviewed regarding resident refrigerator food labeling and microwave oven condition |
| MTD | Maintenance Director | Interviewed regarding water testing and kitchen equipment maintenance |
| IP | Infection Preventionist Nurse | Interviewed regarding water testing and infection control practices |
Inspection Report
Routine
Census: 38
Deficiencies: 4
Date: Dec 3, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to respiratory care, medication administration, food safety, and resident room accommodations at Mission Care Center.
Findings
The facility failed to provide proper respiratory care for a resident with a tracheostomy, ensure accurate medication labeling, maintain safe and sanitary food preparation and storage practices, and meet the required minimum room size per resident in multiple rooms. These deficiencies had the potential for minimal harm or potential for actual harm to residents.
Deficiencies (4)
Failed to implement proper respiratory care for a resident with a tracheostomy, including lack of trach dressing and inadequate monitoring/documentation.
Failed to ensure drugs and biologicals were labeled in accordance with physician's order and facility policy, leading to potential medication error.
Failed to ensure safe and sanitary food preparation and storage practices, including food debris on floor, dirty ice machine bin, unrepaired kitchen ceiling, and lack of air gap on food preparation sink.
Failed to provide rooms that meet the required minimum of 80 square feet per resident in multiple rooms.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 3
Facility census: 38
Rooms not meeting space requirement: 15
Square feet per resident: 77
Square feet per resident: 70.56
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RT1 | Respiratory Therapist | Interviewed regarding trach dressing care and resident behavior |
| RT2 | Respiratory Therapist | Interviewed regarding resident behavior pulling trach dressing and care procedures |
| RT Supervisor | Respiratory Therapy Supervisor | Interviewed about trach care procedures and documentation |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding trach dressing care and medication labeling |
| LVN1 | Licensed Vocational Nurse | Observed and interviewed during medication administration |
| Dietary Services Supervisor | Dietary Services Supervisor (DSS) | Interviewed regarding kitchen sanitation and maintenance |
| Dietary | Dietary Staff (DC) | Interviewed regarding kitchen cleanliness and food debris |
| Maintenance Supervisor | Maintenance Supervisor (MS) | Interviewed regarding ice machine cleaning schedule |
| Administrator | Administrator (ADM) | Interviewed regarding room sizes and waiver request |
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