Cycle 1
Health 2025-02-16 · Fire 2025-02-16
11 health deficiencies
Top issue: Environmental (2 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Rosemead, CA
Mission Care Center
5-star overall rating with 4-star inspections with 11 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
4800 Delta Avenue, Rosemead, CA
(626) 607-2400
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
59
Certified beds
Average residents
52
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2002-09-30
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.39
Registered nurse staffing · state 0.65 · national 0.68
LPN hours / resident day
1.55
Licensed practical nurse staffing · state 1.22 · national 0.87
Aide hours / resident day
2.30
Nurse aide staffing · state 2.64 · national 2.35
Total nurse hours
4.25
All reported nurse hours · state 4.51 · national 3.89
Licensed hours
1.95
RN + LPN hours · state 1.87 · national 1.54
Weekend hours
3.98
Weekend nurse staffing · state 4.08 · national 3.43
Weekend RN hours
0.35
Weekend registered nurse coverage · state 0.50 · national 0.47
Physical therapist
0.17
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.33
CMS adjusted RN staffing hours
Adjusted total hours
3.53
CMS adjusted total nurse staffing hours
Case-mix index
1.65
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 38% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,452
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.71
Composite VBP score used to determine payment impact.
Payment multiplier
0.9856
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.44
Baseline 21.10% · Performance 20.77% · Measure score 1.44 · Achievement 1.44 · Improvement 0.31
Healthcare-associated infections
3.96
Baseline 10.36% · Performance 7.97% · Measure score 3.96 · Achievement 0 · Improvement 3.96
Total nurse turnover
4.16
Baseline 58.73% · Performance 46.67% · Measure score 4.16 · Achievement 4.16 · Improvement 3.06
Adjusted total nurse staffing
2.32
Baseline 4.02 hours · Performance 3.74 hours · Measure score 2.32 · Achievement 2.32 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.67% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 237 · Observed rate 9.7% · Lower 95% interval 7.87% |
| Discharge to community | 55.94% |
50.57%
5.4 pts better
|
No Different than the National Rate · Eligible stays 277 · Observed rate 49.46% · Lower 95% interval 48.5% |
| Medicare spending per beneficiary | 1.41 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 153 · Denominator 153 |
| Falls with major injury | 0.65% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 153 |
| Discharge self-care score | 72% |
53.69%
18.3 pts better
|
Numerator 36 · Denominator 50 |
| Discharge mobility score | 60% |
50.94%
9.1 pts better
|
Numerator 30 · Denominator 50 |
| Pressure ulcers or injuries, new or worsened | 0.65% |
2.29%
1.6 pts better
|
Numerator 1 · Denominator 153 · Adjusted rate 0.55% |
| Healthcare-associated infections requiring hospitalization | 7.97% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 145 · Observed rate 8.97% · Lower 95% interval 5.01% |
| Staff COVID-19 vaccination coverage | 6.73% |
8.2%
1.5 pts worse
|
Numerator 7 · Denominator 104 |
| Staff flu vaccination coverage | 24.81% |
42%
17.2 pts worse
|
Numerator 32 · Denominator 129 |
| Discharge function score | 72% |
56.45%
15.5 pts better
|
Numerator 36 · Denominator 50 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 65 · Denominator 65 |
| Transfer of health information to patient | 97.14% |
96.28%
0.9 pts better
|
Numerator 68 · Denominator 70 |
| Resident COVID-19 vaccinations up to date | 15.38% |
25.2%
9.8 pts worse
|
Numerator 12 · Denominator 78 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
98.5%
1.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
1.6%
1.6 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.9% |
6.8%
4.9 pts better
|
11.4%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.9% |
| Percentage of long-stay residents who lose too much weight | 4.2% |
4.1%
0.1 pts worse
|
5.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.0% |
13.7%
2.3 pts worse
|
19.6%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.3% |
14.2%
4.9 pts better
|
16.7%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 9.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.4%
0.4 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 3.2% |
11.0%
7.8 pts better
|
16.3%
13.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.4% |
10.7%
0.3 pts better
|
14.9%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.0%
1 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
1.2%
0.6 pts worse
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 37.3% |
10.9%
26.4 pts worse
|
19.8%
17.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 37.3% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
4.7%
0.2 pts better
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.9% |
94.0%
5.9 pts better
|
81.7%
18.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.6% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 4.1% |
11.2%
7.1 pts better
|
12.0%
7.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 4.1% · Observed 4.0% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.5%
0.8 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.1% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.3% |
93.2%
6.1 pts better
|
79.7%
19.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.3% |
23.2%
1.1 pts worse
|
23.9%
0.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.3% · Observed 24.0% · Expected 23.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-18 · Fire 2024-02-18
10 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2023-02-16 · Fire 2023-02-16
15 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-02-16
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-02-20
D · Potential for more than minimal harm
2025-02-16
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-02-20
D · Potential for more than minimal harm
2025-02-16
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-02-20
F · Potential for more than minimal harm
2024-02-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-18
E · Potential for more than minimal harm
2024-02-18
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-03-18
D · Potential for more than minimal harm
2024-02-18
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-03-18
F · Potential for more than minimal harm
2023-02-16
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-02-15
F · Potential for more than minimal harm
2023-02-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-02-18
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-12
D · Potential for more than minimal harm
2025-12-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-12-12
E · Potential for more than minimal harm
2025-02-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-03-11
E · Potential for more than minimal harm
2025-02-16
F926 · Environmental Deficiencies
Health
Have policies on smoking.
Corrected 2025-03-11
D · Potential for more than minimal harm
2025-02-16
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-03-11
D · Potential for more than minimal harm
2025-02-16
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-03-11
D · Potential for more than minimal harm
2025-02-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-11
D · Potential for more than minimal harm
2025-02-16
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-03-11
D · Potential for more than minimal harm
2025-02-16
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-03-11
D · Potential for more than minimal harm
2025-02-16
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-03-11
D · Potential for more than minimal harm
2025-02-16
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2025-03-11
E · Potential for more than minimal harm
2025-01-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-03
D · Potential for more than minimal harm
2024-11-25
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-12-04
E · Potential for more than minimal harm
2024-02-18
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-03-21
E · Potential for more than minimal harm
2024-02-18
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-03-21
E · Potential for more than minimal harm
2024-02-18
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2024-03-21
E · Potential for more than minimal harm
2024-02-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-03-21
E · Potential for more than minimal harm
2024-02-18
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-03-21
E · Potential for more than minimal harm
2024-02-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-21
D · Potential for more than minimal harm
2024-02-18
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-03-21
D · Potential for more than minimal harm
2024-02-18
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-03-21
E · Potential for more than minimal harm
2024-02-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-02-05
D · Potential for more than minimal harm
2023-10-25
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-11-13
E · Potential for more than minimal harm
2023-07-03
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-07-31
D · Potential for more than minimal harm
2023-07-03
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-07-31
E · Potential for more than minimal harm
2023-02-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-03-09
E · Potential for more than minimal harm
2023-02-16
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-03-09
D · Potential for more than minimal harm
2023-02-16
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-03-09
D · Potential for more than minimal harm
2023-02-16
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-03-09
D · Potential for more than minimal harm
2023-02-16
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-03-09
D · Potential for more than minimal harm
2023-02-16
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-03-09
D · Potential for more than minimal harm
2023-02-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-03-09
D · Potential for more than minimal harm
2023-02-16
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-03-09
D · Potential for more than minimal harm
2023-02-16
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-03-09
D · Potential for more than minimal harm
2023-02-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-09
D · Potential for more than minimal harm
2023-02-16
F881 · Infection Control Deficiencies
Health
Implement a program that monitors antibiotic use.
Corrected 2023-03-09
Penalties and ownership
What sits behind the stars
Ownership
Flagstone Healthcare Central LLC
5% Or Greater Direct Ownership Interest · Organization
The Ensign Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Nelson, Timothy
Operational/Managerial Control · Individual
Nelson, Timothy
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
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Broadway Healthcare Center
San Gabriel, CA
4-star overall rating with 3-star inspections with $3,145 in total fines with 14 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Pine Grove Healthcare & Wellness Centre, LP
San Gabriel, CA
3-star overall rating with 3-star inspections with 17 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Royal Vista Care Center
San Gabriel, CA
1-star overall rating with 1-star inspections with $2,818 in total fines with 35 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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