Mission Valley Nursing and Transitional Care

Inspectors wroteBased on observation, interview and record review, the facility failed to review and revise the comprehensive care plan for 1 of 4 (Resident #1) residents reviewed for comprehensive care plan revisions. The facility failed to review and revise Resident #1's care plan to reflect his refusal to use his call light. This failure could place residents at risk of not receiving the appropriate care, service, or treatment needed in a timely manner.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 2 of 4 medication carts (400 Hall medication cart and 100/200 Hall medication cart) reviewed for pharmacy services.1. The facility failed to properly label the Med Plus 2.0 that was on the 400-Hall medication cart with an open date. 2. The facility failed to dispose of the medication from 400-Hall medication cart a blister pack of tamsulosin 0.4 MG (medication used to treat an enlarged prostate) capsules which had expired on 01/25/2026.3. The facility failed to dispose of the medication from Hall 100/200 Med-Cart a bottle of Over-the-Counter meclizine 12.5 MG (medication used to treat dizziness, nausea, and vomiting) tablets which had expired on January 2026 and had an opened date of 1/16/2026. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 (Resident #13, Resident #116, Resident #10, Resident #79) of 8 residents observed for infection control. 1. The facility failed to ensure MA use proper infection control during her medication administration for Resident #13 on 02/10/2026. 2. The facility failed to ensure RN J changed gloves after touching the bed sheets and the bed remote during medication administration via Gastrostomy tube for Resident #116 on 02/11/2026. 3. The facility failed to ensure Resident #10 was placed under EBP due to a stage 3 sacral wound that started on 02/04/26. 4. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure residents had the right to formulate an advance directive for 1 (Resident #57) of 6 residents reviewed for Advance Directives. The facility failed to ensure Resident #57's OOH-DNR form included a physician's signature. This failure could affect all residents who have implemented Advance Directives and established their choice not to be resuscitated at risk of receiving CPR against their wishes.

Inspectors wroteBased on interviews, observations and record review, the facility failed to provide the right to personal privacy, which includes accommodations during medication administration for 1 (Resident #116) of 6 Residents reviewed for Privacy. The facility failed to ensure RN K closed the door or the curtain during medication administration via gastrostomy tube for Resident #116 on 02/10/2026. This failure could place the residents at risk of not having their personal privacy maintained during medical treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet resident's mental and psychosocial needs, for 1 Residents (Resident#73) of 3 residents reviewed for care plans. The facility did not develop and implement a comprehensive person-centered care plan to address Resident#73's behaviors. These failures could residents at risk for their mental and psychosocial needs not being met.

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #10) of 6 residents reviewed for administration. The facility failed to ensure Resident #10 had an order for EBP (refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloved use during high contact resident care activities). This failure could place residents at risk of not receiving nursing services by adequately trained nurses and could result in a decline in health.

Inspectors wroteBased on observation and interview, the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for 3 of 3 days reviewed (02/7/26, 02/8/26, and 02/9/26) for nurse staffing posting. The facility failed to post the daily staffing information in a prominent place on 02/7/26, 02/8/26, and 02/9/26. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents hazards and supervision:1. The facility failed to ensure Resident # 1 was not left unattended in his wheelchair in his room by CNA A, which resulted in an unwitnessed fall. Resident #1 sustained a hip fracture from the fall. 2. The facility failed to ensure CNA A and Med-Aide B notified a nurse of Resident #1's fall and transferred Resident #1 to bed without being assessed. The non-compliance for Resident #1 was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 04/21/2025 and ended on 04/23/2025. The facility corrected the non-compliance before the investigation began. This failure could place the residents at risk for injury or death.

Inspectors wroteBased on interview and record review, the facility failed to inform residents in advance about any care and treatment for 1 of 5 residents (Resident #3) reviewed for resident rights, in that: The facility failed to ensure consent forms were properly completed or signed by a responsible party prior to administration of a psychotropic medication (Remeron) for Resident #3. This failure could place residents at risk of not being aware of changes related to their care/treatment.

Inspectors wroteBased on interviews and record reviews, the facility failed to review and revise comprehensive care plans for 1 (Resident #3) of 5 residents reviewed for comprehensive care plan revisions. The facility failed to review and revise Resident #3's comprehensive person-centered care plan from Full Code Status to DNR Status in a timely manner reflecting both Full Code and DNR status on the care plan. This failure could affect residents and place them at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide Accuracy in service delivery. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 (Resident #2 and Resident #3) of 5 residents reviewed for medication.1. The facility failed to administer Morphine Sulfate as ordered by the physician on two different occasions.2. The facility failed to document the pain level 0-10 on the physician's order to monitor for pain every shift for Resident #3. These deficient practices could place residents at risk of not receiving therapeutic doses of their medication.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 resident (Resident #3) of 5 residents reviewed for medical records accuracy, in that: The facility failed to document the doctor and RP had been notified of Resident #3's fall on 06/16/2025 at 05:07 am. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that described the services to be provided to attain or maintain the residents' highest practicable physical, mental, and psychosocial needs, for 1 of 4 residents (Resident #1) reviewed for care plans in that: The facility failed to ensure an individualized care plan to address Resident #1's level of assistance that was required for ADLs by a 1 or 2 person assist. The CNA made the determination to provide perineal care by herself, resulting in Resident #1 to fall and was discharged to the hospital on [DATE]. This failure could place residents at risk of injuries and their individual medical, physical and psychosocial needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to ensure adequate supervision was provided for 1 of 4 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure Resident #1 was provided with adequate supervision and assistance while provided incontinent care on 08/20/25. Resident#1 suffered a fall that resulted in a subdural hematoma (a collection of blood that forms on the surface of the brain, between the brain and its outermost protective covering). Resident#1 was discharged to hospital on [DATE] and passed away on 08/21/25. The facility did not have consistent procedures for floor staff to establish level of need for residents requiring 1-2 person assist for ADLs. This failure could prevent residents from receiving appropriate supervision which could lead to resident sustaining serious injury, harm, or death.

Inspectors wroteBased observations, interviews, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #115) of 3 residents observed for Infection Control. CNA A failed to follow proper hand hygiene and cleansing of perineal area while providing incontinent care to Resident #115. These failures could place the residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that all alleged violations involving exploitation were thoroughly investigated and results reported of all investigations to the State Survey Agency, within 5 working days of the incident for 1 (Resident #49) of 5 residents reviewed for exploitation. The facility Abuse Coordinator/Administrator failed to thoroughly investigate a reported allegation of exploitation of Resident #49 by CNA A. This failure could place residents at risk of exploitation.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that include measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one of eight residents (Resident #48) reviewed for comprehensive care plans, in that: Resident #48's last fall was not reflected in her comprehensive care plan. This failure could place residents at risk for not receiving necessary care and services.

Inspectors wroteBased on observation, and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 kitchen reviewed in that; Air conditioner vent near the food preparation area had condensation that was dripping a clear liquid onto the floor Air conditioner vent had brown stains around the edges and in the middle Ceiling tiles (2) adjacent to the air condition vent had brown stains This failure could place staff at risk of injury while preparing meals for residents.