Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around September 2026
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 At Community Living Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that immunization histories were missing from the medical records of several residents with complex medical conditions. The DON reported that these records were kept separately in a pharmacy file rather than in the official medical records, and both the Administrator and DON were unsure about the process for accessing this information when needed.
The facility did not ensure proper infection control practices, as clean laundry was transported uncovered through hallways and sometimes delivered to incorrect resident rooms. Additionally, staff lacked knowledge and implementation of Enhanced Barrier Precautions for a resident with a wound vacuum, and no EBP signage was posted. Interviews confirmed that staff were unaware of EBP requirements and did not consistently use isolation signage.
Staff members were alleged to have consumed alcohol and transported residents while under the influence during an outing, but the incident was not documented in the medical records or reported to the State Survey Agency as required. The residents involved had complex medical conditions, and the facility administrator confirmed that the event should have been reported.
Allegations that a staff member drove residents while intoxicated were not investigated or documented by the facility. Despite policies prohibiting staff alcohol use during resident outings, no evidence of an investigation or reporting to the State Agency was found for three residents with complex medical needs.
Two residents did not have all required laboratory results filed in their medical records, including a missing urine culture and a missing urine microalbumin result. The ADON confirmed that these results were not present in the records and had to be obtained from external sources.
Surveyors found that chemicals were stored with food in the dry storage area, a freezer lacked a functional thermometer and backup temperature monitoring, and the Dietary Manager wore a hairnet that did not fully contain hair, all in violation of professional food service standards.
Following an incident where a staff member was arrested for drinking while transporting residents, the facility did not provide required training on dementia care, abuse, neglect, exploitation, or substance abuse to staff. Staff interviews confirmed a lack of formal education, audits, or checklists related to safe transportation and abuse prevention, despite facility policies mandating such training.
Incomplete Medical Records: Missing Immunization Documentation
Penalty
Summary
Surveyors determined that the facility failed to maintain complete and accurately documented medical records for four out of twenty-four sampled residents. Specifically, the immunization histories for these residents, who had various diagnoses including dementia, osteoporosis, macular degeneration, chronic pain, congestive heart failure, chronic kidney disease, morbid obesity, anxiety, type II diabetes, hyperkalemia, and neuropathy, were not found in their medical records. During interviews, the Administrator was unable to identify where the immunization records were stored if not in the medical record, and the DON stated that the records were kept in a pharmacy file in her office rather than in the residents' medical records. The DON also expressed uncertainty about what would happen if the immunization information was needed and not available in the medical record.
Failure to Implement Infection Control Measures and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement and maintain an effective infection prevention and control program, as evidenced by multiple observations and staff interviews. Laundry staff were seen transporting clean resident laundry throughout the facility without any covering, exposing the laundry to potential contamination as it was moved past residents and staff in the hallways. Additionally, the laundry staff sometimes carried laundered clothing on their shoulder and delivered bundles of clothing to multiple resident rooms, occasionally resulting in residents' clothing being placed in the wrong rooms. The supervisor of the laundry department confirmed that clean laundry was not covered during transport and was unaware of the requirement to do so. For one resident with significant medical conditions, including a stage 3 pressure ulcer and a wound vacuum, there was no evidence of Enhanced Barrier Precautions (EBP) being implemented or posted outside the resident's room. Staff interviews revealed a lack of knowledge about EBP among nursing and support staff, with some staff stating they did not know what EBP were and that isolation signage was not routinely used. The Director of Nursing also acknowledged unfamiliarity with EBP and recognized that some residents, including the one with a wound vacuum, would qualify for such precautions. No EBP signage was observed in the facility, and staff communication about precautions was inconsistent.
Failure to Timely Report Alleged Staff Misconduct Involving Alcohol Use During Resident Outing
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately, but not later than two hours after the allegation was made, to the State Survey Agency. Specifically, a staff member was arrested for driving under the influence (DUI) and had alcohol in the facility vehicle while transporting residents during a rafting trip. Additionally, it was alleged that maintenance, activities, and nursing staff consumed alcohol during the outing with residents. The incident was not documented in the medical records of the involved residents, and the State Survey Agency was not notified as required. The residents involved included individuals with significant medical conditions such as dementia, osteoporosis, macular degeneration, chronic pain, cerebral palsy, contracture, muscle weakness, cramp and spasm, major depressive disorder, Lupus, anxiety, and a history of falling. Despite the serious nature of the allegations and the vulnerability of the residents, there was no evidence in their records regarding the incident, and the required reporting procedures were not followed. The facility administrator confirmed that there was a zero-tolerance policy for alcohol and that the incident should have been reported, but acknowledged that it was not.
Failure to Investigate Alleged Staff Intoxication During Resident Outing
Penalty
Summary
The facility failed to provide evidence that all alleged violations of abuse, neglect, or mistreatment were thoroughly investigated for three residents. Specifically, allegations were made that a staff member drove residents while being intoxicated, but there was no documentation in the medical records of the involved residents regarding the incident, nor was there any investigation provided by the facility. The residents involved had significant medical conditions, including dementia, osteoporosis, macular degeneration, chronic pain, cerebral palsy, muscle weakness, major depressive disorder, Lupus, anxiety, and a history of falling. Interviews with the Administrator and CEO revealed that the incident involved a staff member being stopped by authorities due to alcohol containers found in the facility vehicle while transporting residents on an outing. Both the Administrator and CEO confirmed that staff are not permitted to consume alcohol or have alcohol in facility vehicles while on duty. Despite these policies, the incident was not reported to the State Agency, and no investigation was conducted or documented by the facility.
Incomplete Filing of Laboratory Results in Resident Records
Penalty
Summary
The facility failed to maintain complete, dated laboratory records in the clinical records of two residents. For one resident with diagnoses including Lupus, major depressive disorder, dementia, anxiety, and a history of falls, a physician's order was placed for a urine analysis with culture. While the urine analysis result was present in the medical record, the urine culture result was missing. The Assistant Director of Nursing (ADON) confirmed that the culture results had not been filed in the medical record and had to be obtained by calling the laboratory. Similarly, another resident with Alzheimer's disease, type 2 diabetes, major depressive disorder, and anxiety disorder had a physician's order for multiple laboratory tests, including a urine microalbumin. Although most test results were documented, the urine microalbumin result was not found in the medical record. The ADON stated that she had to request the hospital to send the missing result so it could be attached to the medical record. In both cases, the required laboratory reports were not filed in the residents' clinical records as required.
Food Safety Deficiencies in Kitchen Storage, Temperature Monitoring, and Staff Hygiene
Penalty
Summary
Surveyors observed multiple failures to adhere to professional standards for food service safety within the facility's kitchen. Chemicals, including peroxide, multi-surface cleaner, glass cleaner, mop cleaner, table top cleaner, vinegar, and mop heads, were stored in the dry storage room alongside food items. Specifically, a mop handle was found touching an open bag of tortilla chips, which was also in contact with a bottle of vinegar. The Dietary Manager confirmed that some frequently used chemicals were kept in the dry storage room, despite most being stored elsewhere. Additionally, the freezer's temperature monitoring was inadequate. The external display for the freezer temperature was not functioning, and there was no backup thermometer inside the freezer to verify the temperature. Although temperature logs indicated a consistent reading, the accuracy could not be confirmed due to the lack of a working thermometer. Furthermore, the Dietary Manager was observed wearing a hairnet that did not fully contain all hair, with several strands exposed, contrary to professional standards for food safety.
Failure to Provide Required Staff Training After Substance Abuse Incident
Penalty
Summary
The facility failed to provide staff training on dementia care, abuse, neglect, exploitation, and the procedures for reporting such incidents, as well as ongoing substance abuse training following a significant event. Specifically, after a staff member was arrested for drinking while driving residents in the facility van, there was no formal training or education provided to staff regarding substance abuse, safe transportation, or abuse prevention. Multiple staff interviews confirmed that no additional training or audits were conducted after the incident, and staff were only verbally informed that drinking while working would result in termination. The facility's own policies require education on abuse, neglect, and exploitation during orientation and periodically thereafter, but this was not followed after the incident. Record review and staff interviews revealed that staff involved in resident transportation did not receive formal training on safe transport or abuse prevention, and there were no checklists, audits, or ongoing education provided. The administration could not recall any specific training or follow-up after the alcohol-related incident, and the only action taken was the removal of driving privileges from the involved staff member. Facility policies reviewed indicated a requirement for ongoing education on abuse prevention and a drug-free workplace, but these were not implemented as required.
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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 Centerfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mission At Richfield Nursing And Rehabilitation | 27.2 mi | — | 0 | 0 |
| Stonehenge Of Richfield | 27.5 mi | — | 0 | 0 |
| San Rafael Health And Rehabilitation | 36.5 mi | — | 0 | 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.