Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors observed a medication cart on the 700 hall left unlocked and unattended while a medication aide was inside a resident room. When the aide returned, she found the cart unsecured and then locked it. In an interview, the aide admitted responsibility for the cart, acknowledged she was expected to lock it whenever she walked away, and stated she had forgotten to do so. The DON reported that she, the ADON, and other staff were responsible for ensuring carts remained locked when out of staff view, consistent with facility policy requiring medication carts to be secured during med passes and locked when not in use.
A facility failed to validate a resident's OOH-DNR order due to a missing physician signature, leading to the resident being considered full code despite her wishes. Staff interviews revealed a misunderstanding of the form's requirements, as they believed the physician's signature under the statement was sufficient. This oversight contravened the facility's policy, which requires a complete signature for validity.
A resident with respiratory conditions was observed receiving oxygen at rates higher than the prescribed 3 Lpm, contrary to the physician's order. Despite staff checks, the oxygen rate was inconsistently maintained, and a family member was found to have adjusted the settings. The facility's policies emphasized adherence to oxygen orders, yet the deficiency in maintaining the prescribed rate was evident.
A CNA failed to report a resident's rash promptly, delaying treatment. Despite in-service training, the CNA did not inform the charge nurse until the rash worsened. Other staff had reported the rash earlier, preventing negative outcomes.
A long-term care facility failed to provide adequate pharmaceutical services for two residents, leading to deficiencies in medication administration. One resident did not receive the prescribed dosage of Tramadol due to discrepancies between physician orders and medication records. Another resident did not receive a frozen nutritional treat as ordered, with the Med-Aide signing off without verifying its presence. The facility's policies on medication administration were not followed, resulting in these deficiencies.
A resident with an indwelling catheter and bowel incontinence received care from two CNAs who failed to follow proper infection control practices. The CNAs did not sanitize hands between glove changes and reused wipes during perineal care, contrary to facility protocols. The DON confirmed that these actions were against the established procedures meant to prevent cross-contamination and infection spread.
A resident with Alzheimer's and other conditions was observed crying while her family member rubbed her forehead, leading to concerns of potential abuse. Despite this, a CNA did not report the incident as suspected abuse according to facility policy, instead informing an LVN who noted discoloration but no distress. The facility's policy required immediate reporting to the Administrator, which was not followed, resulting in a deficiency.
A facility failed to ensure that an LVN maintained an active nursing license, resulting in the nurse working for 26 days with a delinquent license. The facility lacked a system for regularly checking nurses' licenses, relying on the nurses to manage their renewals. This deficiency was discovered during a survey, leading to the nurse's suspension until her license was renewed.
A facility failed to report an incident where a family member performed an inappropriate assessment on a resident, including opening the resident's labia, within the required timeframe. Despite concerns from nurses and involvement from APS, the facility did not recognize the incident as abuse due to the lack of sexual intent, leading to a deficiency in abuse prevention and reporting protocols.
Unattended Unlocked Medication Cart on 700 Hall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that drugs and biologicals were stored in locked compartments in accordance with professional standards. During an observation of the 700 hall medication cart, surveyors noted that the medication aide’s cart was left unlocked and unattended in the hallway while the medication aide was inside a resident room. No staff or other individuals were present near the cart at that time. When the medication aide returned to the cart, she found it unlocked and then secured it by locking it. In an interview immediately following the observation, the medication aide acknowledged she was responsible for that cart and confirmed she was expected to lock it whenever she walked away. She stated she forgot to lock the cart and recognized that, if left unlocked, a resident could open a drawer and take medications not intended for them or medications could be stolen. In a separate interview, the DON stated that she, the ADON, and numerous staff were responsible for ensuring medication carts were locked and that her expectation was that staff lock the cart whenever they walked away or when it was out of their view. The facility’s policy, “Security of Medication Cart,” stated that medication carts must be securely locked at all times when out of the nurse’s view and, when not in use, locked and parked at the nurses’ station or inside the medication room.
Invalid OOH-DNR Order Due to Missing Physician Signature
Penalty
Summary
The facility failed to ensure that a resident's Out of Hospital Do Not Resuscitate (OOH-DNR) order was valid due to the absence of a physician's signature at the bottom of the form. This oversight was identified during a review of the resident's records, which showed that the OOH-DNR form lacked the necessary physician signature in the section that required all signatories to acknowledge the document's completion. The resident in question, a female with severe cognitive impairment due to dementia and Crohn's disease, had an OOH-DNR order as part of her care plan, but the missing signature rendered the directive invalid. Interviews with facility staff, including the social worker (SW), medical records specialist, licensed vocational nurses (LVNs), and the Director of Nursing (DON), revealed a misunderstanding of the requirements for a valid OOH-DNR form. The staff believed that the physician's signature under the physician's statement was sufficient for validity, disregarding the need for a signature in the section acknowledging the document's completion. This misunderstanding led to the resident being considered a full code in the event of a medical emergency, contrary to her documented wishes. The facility's policy on Do Not Resuscitate orders, revised in April 2017, mandates that such orders must be signed by the attending physician and placed in the resident's medical record. However, the staff's misinterpretation of the policy requirements resulted in the failure to honor the resident's end-of-life wishes. This deficiency highlights a critical gap in the facility's processes for managing and validating advance directives, potentially affecting the quality of care provided to residents.
Failure to Maintain Prescribed Oxygen Rate for Resident
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident, identified as Resident #34, who required oxygen therapy. The resident, an 81-year-old male with diagnoses including acute and chronic respiratory failure, acute bronchitis, and chronic obstructive pulmonary disease (COPD), was observed receiving oxygen at rates higher than the prescribed 3 liters per minute (Lpm) via nasal cannula. Observations on multiple occasions showed the resident receiving oxygen at 4 Lpm and 3.5 Lpm, contrary to the physician's order. The resident reported that this was the rate he received at home and had informed the staff accordingly. Interviews with the facility's staff, including Licensed Vocational Nurses (LVNs) and the Assistant Director of Nursing (ADON), revealed inconsistencies in monitoring and maintaining the prescribed oxygen flow rate. LVN J stated that the oxygen rate should be checked every two hours, but observations indicated that the rate was not consistently maintained at the prescribed level. LVN K admitted to adjusting the oxygen setting to 3 Lpm during her checks but had not witnessed any changes made by the resident or his family. The ADON emphasized the importance of adhering to the physician's order and noted that any deviation without an order would be considered a medication error. Further investigation revealed that the resident's family member had been adjusting the oxygen rate, which was not permitted. The Director of Nursing (DON) confirmed that the family member was informed of the policy against adjusting the oxygen settings. Despite the deviations in oxygen administration, the DON stated that the resident did not exhibit signs of over-oxygenation or distress. The facility's policies and in-service records highlighted the need for strict adherence to oxygen therapy orders, yet the deficiency in maintaining the prescribed oxygen rate for Resident #34 was evident.
Failure to Report Change in Condition
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA D) had the appropriate competencies to communicate a resident's change in condition to the charge nurse, which is crucial for maintaining resident safety and well-being. The deficiency involved a resident with severe cognitive impairment and multiple diagnoses, including dementia and Crohn's disease. On 12/23/2024, CNA D noticed a rash on the resident's chest but decided not to report it immediately, intending to wait and see if it resolved on its own. The following day, the rash had spread, but CNA D again failed to report it due to being occupied with other residents. On 12/26/2024, CNA D finally reported the worsening rash to LVN A, who then assessed the resident and notified the nurse practitioner (NP). The NP prescribed Permethrin cream for dermatitis. Interviews with other staff members revealed that another CNA (CNA E) had noticed the rash on 12/24/2024 and reported it to the charge nurse, who then informed the treatment nurse. The treatment nurse had conducted a skin assessment and reported the findings to the resident's primary care provider (PCP), who recommended monitoring the condition. Despite the facility's in-service training on recognizing and reporting changes in residents' conditions, CNA D did not adhere to these protocols, resulting in a delay in addressing the resident's rash. The Director of Nursing (DON) confirmed that CNAs are trained to report changes immediately but acknowledged that there was no specific policy on the timeframe for reporting such changes. The report indicates that there were no negative outcomes for the resident due to the actions taken by other staff members who had reported the rash earlier.
Medication Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for two residents, leading to deficiencies in medication administration. For one resident, the nursing staff did not administer Tramadol as prescribed by the physician. The resident, who had severe cognitive impairment and a history of Alzheimer's disease, heart failure, and type 2 diabetes, was supposed to receive two tablets of Tramadol every eight hours as needed for pain. However, the Control Drug Administration Record showed that only one tablet was administered on multiple occasions. Interviews with the Director of Nursing (DON) and Licensed Vocational Nurses (LVNs) revealed discrepancies between the physician's orders, the electronic Medication Administration Record (e-MAR), and the blister pack labels. The nursing staff failed to verify the correct dosage and did not contact the physician to clarify the orders, resulting in the resident not receiving the intended therapeutic benefit of the medication. Another resident, who had severe cognitive impairment and a history of dementia, hypothyroidism, and Crohn's disease, did not receive a frozen nutritional treat as ordered. The resident's care plan included a daily frozen nutritional treat to address unintended weight loss. However, on a specific date, the facility ran out of the frozen nutritional treats, and the dietary staff failed to provide a substitute. The Med-Aide signed off on the administration of the treat without verifying its presence on the resident's lunch tray. Interviews with the Dietary Manager and Med-Aide confirmed that the treat was not available, and the Med-Aide did not physically check the tray before signing off on the MAR. This oversight could have impacted the resident's nutritional intake, although the facility's dietician noted no negative effects due to the provision of pudding as a supplement. The facility's policies on medication and treatment orders, as well as medication administration, were not followed, leading to these deficiencies. The policies require that medications be administered as prescribed and documented accurately. The nursing staff and Med-Aides failed to adhere to these policies, resulting in discrepancies in medication administration and documentation. The DON acknowledged the responsibility of the nursing staff to verify and document medication administration accurately, and the facility's failure to do so led to the identified deficiencies.
Inadequate Infection Control Practices During Resident Care
Penalty
Summary
The facility failed to establish an effective infection prevention and control program, as evidenced by improper hand hygiene and incontinent care practices observed during care for a resident. The resident, a female with a history of cerebral infarction, muscle weakness, and neuromuscular dysfunction of the bladder, was dependent on staff for toileting hygiene and had an indwelling catheter. During an observation, two CNAs were seen performing incontinent care without following proper hand hygiene protocols, such as sanitizing hands between glove changes and using a new wipe for each swipe. The CNAs involved, CNA F and CNA G, admitted to not being aware of the correct procedures for hand hygiene and wipe usage during perineal care. CNA F used a single wipe multiple times by folding it, contrary to the facility's protocol, which requires a new wipe for each swipe. Additionally, CNA G did not sanitize her hands between glove changes, and both CNAs failed to change gloves and sanitize hands at appropriate times during the care process. The Director of Nursing (DON) stated that hand hygiene should be performed before and after resident care, between glove changes, and after each wipe during incontinent care. The facility's policies and procedures, including the Clinical Skills Checklist and Handwashing/Hand Hygiene policy, were not adhered to by the CNAs, leading to a risk of cross-contamination and infection spread among residents.
Failure to Report Suspected Abuse
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents, specifically concerning a resident who was observed crying while her family member was rubbing her forehead. The resident, a female with a history of Alzheimer's disease, hypertension, functional quadriplegia, peripheral vascular disease, and schizoaffective disorder, was noted to have discoloration on her forehead. Despite the observation of the resident crying, the facility staff member, CNA A, did not report the incident as suspected abuse according to the facility's policy. CNA A observed the resident's family member rubbing the resident's forehead while the resident was crying, which she interpreted as a sign of potential abuse. However, CNA A did not report this suspicion to the Administrator or Director of Nursing as required by the facility's policy. Instead, she reported the incident to LVN B, who assessed the resident and noted the discoloration but did not observe any signs of pain or distress. The failure to report the incident directly to the Administrator delayed the investigation and reporting of the potential abuse. Interviews with facility staff, including LVN B, LVN C, the DON, and the Administrator, revealed inconsistencies in the reporting and assessment of the incident. The DON and Administrator were not made aware of the resident crying until several days after the incident, and CNA A's initial statement did not include details about the resident crying. The facility's policy required immediate reporting of suspected abuse to the Administrator, which was not followed in this case, leading to a deficiency in the facility's handling of potential abuse situations.
Failure to Ensure Active Nursing Licenses
Penalty
Summary
The facility failed to ensure that a Licensed Vocational Nurse (LVN A) maintained an active nursing license in accordance with Texas state laws. LVN A's nursing license was found to be delinquent, and she continued to work and provide nursing care to residents for a total of 26 days after her license had expired. This was discovered during a survey when the Director of Nursing (DON) and Human Resources (HR) were unaware of the delinquency. The facility's system for verifying and monitoring nursing licenses was inadequate, as HR only tracked nurse aides' certifications and did not regularly check the nurses' licenses. Interviews with the DON, HR, and the Administrator revealed that there was no established process for regularly checking the licensure status of nurses. The responsibility for license renewal was placed on the nurses themselves, and no reminders or checks were conducted by the facility. The DON and HR both confirmed that LVN A had been working with a delinquent license and had provided care to residents during this period. The facility's handbook stated that employees were responsible for maintaining current licenses, but there was no active oversight to ensure compliance. The deficiency was identified when Surveyor B discovered LVN A's delinquent license. The DON and HR acknowledged that LVN A was not allowed to work with a delinquent license, and she was subsequently suspended until her license was renewed. The Administrator confirmed that no other nursing staff had delinquent licenses after conducting an audit. Despite the lack of complaints or observed effects on resident care, the facility's failure to ensure active licensure for LVN A posed a risk to the quality of care provided to residents.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to report allegations of resident abuse within the required timeframe to the State Survey Agency. Specifically, an incident occurred where a family member was observed performing an inappropriate assessment on a resident, which included opening the resident's labia and attempting to scoop out what she believed to be a yeast infection. This incident was not reported to the State Survey Agency within the mandated two-hour window for allegations involving abuse or serious bodily injury. The facility's Director of Nursing (DON) and Administrator did not recognize the incident as abuse, leading to a failure in timely reporting. The resident involved was an elderly female with Alzheimer's disease, cognitive communication deficit, muscle weakness, osteoporosis, and other medical conditions. She was dependent on staff for activities of daily living, including toileting hygiene. On the day of the incident, the resident had just received perineal care from a Licensed Vocational Nurse (LVN), who applied cream to the resident's groin area. Shortly after, the family member arrived, removed the resident's brief, and conducted an inappropriate assessment, which was witnessed by the LVN and another nurse. Despite the nurses' concerns and the subsequent involvement of Adult Protective Services (APS), the facility did not report the incident to the State Survey Agency. The DON and Administrator believed that the family member's actions did not constitute abuse because there was no sexual intent. However, the facility's policy clearly states that residents have the right to be free from abuse by anyone, including family members. The failure to report this incident within the required timeframe constitutes a deficiency in the facility's abuse prevention and reporting protocols.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Mission
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mission Valley Nursing And Transitional Care | 0.2 mi | — | 12 | 1 |
| Village Healthcare And Rehabilitation | 3.4 mi | — | 2 | 0 |
| Briarcliff Nursing And Rehabilitation Center | 4.4 mi | — | 5 | 0 |
| Windsor Nursing And Rehabilitation Center Of Mcall | 4.9 mi | — | 5 | 0 |
| Grand Terrace Rehabilitation And Healthcare | 5.2 mi | — | 6 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.