Mission Valley Post Acute

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the administrator who supervised and directed the facility operations was licensed according to state regulation when the unlicensed Operations Manager (OM) had the role of administrator for more than two years and five months. This failure resulted residents and staff being supervised and directed by unqualified administrative leadership. During an observation on 7/23/25 at 11:19 a.m. a facility post board near the nurses station was inspected. The post board had a nursing home administrator (NHA) license holder (NHAH) which indicated OM was not the licensed administrator of the facility. The post board also had a letter to residents and families which was signed Sincerely, ADMINISTRATOR [OM]'s signature. NHAH was not at the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure it kept accurate records of controlled medications (medication with a potential for abuse) as evidenced by: 1. The facility failed to ensure, for Residents 1-8, the scheduled (controlled medication, narcotic) medication system was complete (all documents available) and accurate (information matched). The record system included Shipping Manifests (pharmacy delivery receipt), Controlled Substance Accountability Sheets (CDR, Controlled Drug Record), Medication Administration Records (MAR, record of medication administration) and destruction logs. The facility records were incomplete. The facility records were inaccurate. These failures had the potential to result in undetected loss and diversion of scheduled medications. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide safe, clean, and homelike environment for five of six sampled residents (Residents 21, 23, 54, 73, and 75) when: 1. Resident 21 and 75's shared room had wet floor surfaces without a caution signage.2. Resident 54 and 73's shared room had wet floor surfaces without a caution signage and multiple items on the floor, including spilled white liquid, a yogurt cup, plastic spoon, toothbrush and plastic cup.3. Resident 23's oxygen concentrator (a medical device used to provide supplemental oxygen) had scattered white powder-like speckles on the top surface. These failures had the potential to result in slips, trips, falls, injury, exposure to unsanitary conditions and decreased resident comfort and well-being due to unsafe environmental hazards.1. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide ongoing assessment, monitoring, and implementation of physician orders for three of five sampled residents (Residents 1, 10, and 95) when: 1. Resident 1, who experienced a change in condition, did not receive timely nursing assessment and evaluation after Resident 1 was observed very sleepy and unresponsive despite multiple attempts by the licensed nurse to awaken Resident 1. 2. Resident 10, who had physician orders for daily weights, did not receive weight monitoring as ordered, and the physician was not notified of the refusals. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the provision of pharmaceutical services when: 1. A routine medication was not available for administration for 3 days for 1 out of 4 residents (Resident 67) observed during the medication pass. 2. Controlled substance (medications that can be easily abused and are under strict government control) medications were signed out of the Controlled Drug Record (CDR, an inventory document) but not documented on the Medication Administration Record (MAR) for 2 out of 6 sampled residents (Residents 49 and 95) 3. An as-needed pain medication was not administered as ordered by the physician for 1 out of 6 sampled residents (Resident 39) 4. A controlled medication was not accurately documented as given on two occasions for 1 out of 6 sampled residents (Resident 36). [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to store and prepare food in accordance with professional standards for safety when: Three boxes of 4-fluid-ounce milkshakes (74 pieces per box) were stored in Freezer chest 4, which was not kept at the required temperature (fluid-ounce is a form of measurement). A box of blueberry muffins and two unopened bags of frozen potato wedges were stored in the emergency storage room. Clean water pitchers were kept next to the dirty coffee drainpipes. These failures had the potential for contamination of food resulting in food borne illness for 84 residents who received food from the kitchen. An observation and interview with the Dietary Manager (DM) during the kitchen's initial tour, on 5/18/26, at 9:44 a.m., showed three boxes of 4-fluid-ounce milkshakes (74 pieces per box). [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement their infection prevention and control policies and procedures for five out of ten residents (Resident 9, 13, 16, 86, and 70) and a facility census of 84 when:For one of three sampled residents (Resident 9), Resident 9's clothing was on the floor and was returned to the closet without being laundered or cleaned prior to storage. For one of two sampled residents (Resident 86), Resident 86's urinal was stored directly on top of the trash receptacle without a lid and not placed in a protective bag. [...]

Inspectors wroteBased on observation, staff interview, and review of facility documents, the facility failed to ensure Freezer 3 was maintained in proper working condition, as evidenced by:1. The freezer's louvered panel was missing (a louvered panel is a cover located at the bottom of a freezer. It allows air to circulate freely for cooling, while keeping out direct light, dust, and debris).2. The freezer's right handle was missing. 1. During a concurrent observation and interview on 5/20/26 at 8:23 a.m., with Dietary Manager (DM), DM showed freezer 3's louvered panel was missing. As a result, the wiring, coils, and mechanical parts underneath were exposed. In addition, the mechanical components and wiring were coated in scattered black sticky dust and the DM described the area as dirty. DM stated the louvered panel had been missing for one year. [...]

Inspectors wroteBased on observation, interview and record review, for one of one sampled resident (Resident 70) reviewed for positioning and mobility, the facility failed to ensure Resident 70's reasonable accommodation of needs and preferences when the call light was left out of reach. This failure had the potential to impair the resident's ability to request help, placing the resident at risk for unmet care needs. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 out of 5 sampled residents (Resident 8) was free from unnecessary psychotropic medications (drugs that affects brain activities associated with mental processes and behavior). Resident 8 has been receiving Olanzapine (an antipsychotic medication) without staff monitoring target behaviors quantitatively. Quantitative measure of target behaviors would be helpful in monitoring the patient's progress, assessing effects of treatment, and a factor in considering whether to conduct gradual dose reduction (GDR, a tapering of a dose to determine if symptoms, conditions, or risks can be managed by a lower dose or if the dose or medication can be discontinued). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that continued nutritional care and services were provided to one of 20 sampled residents (Resident 68) when Resident 68, who had a weight loss of 11.2 pounds which yielded 11.8% weight loss from 4/6/26 to 5/1/26, was not reweighed after 5/1/26 for a total of 20 days (pounds or lbs. is a form of measurement which is also used to measure body weight). This deficient practice had the potential to result in Resident 68's further unplanned weight loss. During a review of Resident 68's admission Record (AR) dated 5/21/26, the AR indicated Resident 68 was admitted to the facility on [DATE] with diagnoses that included depression (a serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in daily activities) and malignant neoplasm of stomach (cancer of the stomach). [...]

Inspectors wroteBased on observation, interview and record review, for two of three sampled residents reviewed for respiratory care (Resident 16 and 23), the facility failed to ensure residents received respiratory care in accordance with professional standards of practice when:1. Resident 16's BiPAP (machine is a non-invasive that helps people breathe easier, it delivers pressurized air through a mask, providing a higher pressure when you inhale and a lower pressure when you exhale) equipment was not applied and not maintained as ordered nor did the staff follow required procedures for equipment monitoring and troubleshooting.2. Resident 23's oxygen via nasal cannula was not positioned correctly. These failures had the potential to result in inadequate ventilation support and increased respiratory distress. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure 2 out of 5 sampled residents (Residents 5 and 95) were free from unnecessary medications. Residents 5 had no hold parameters for an antihypertensive medication (medication to lower blood pressure); and Resident 95 had no monitoring for thyroid stimulating hormone (TSH) while receiving levothyroxine (medication to treat hypothyroidism, a condition where the thyroid gland does not produce enough thyroid hormone). The failure resulted in inadequate monitoring and had the potential for complications related to these medications such as severely low blood pressure or too low/too high TSH without dose adjustment, for the respective residents. 1. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure the accuracy of a Level I preadmission screening resident review (PASARR) screening for 1 (Resident #74) of 1 sampled resident reviewed for PASARR screening.

Inspectors wroteBased on observation and interview, the facility failed to ensure residents' rooms measured at least 80 square (sq) feet (ft) per resident in 8 (Rooms 27 - 34) of 13 residents' rooms on 1 (Station 3) of 3 units in the facility.

Inspectors wroteBased on interview and record review the facility failed to provide services which met professional standards for one resident (Resident 1) of three sampled residents when nursing staff did not document physician's orders were carried out. This failure contributed to formation and worsening of Resident 1's sacrococcyx (the backside area between a person ' s hips and down to the tailbone) wound.

Inspectors wroteBased on observation, interview and record review, the facility had a score of 11.43% medication error rate when four medication errors of 35 opportunities were observed during medication pass observation as follows: 1. Eliquis tablet 5 mg (milligram) also known as Apixaban- used to prevent serious blood clots due to irregular heartbeat) was not administered as prescribed by the physician. 2. Metformin HCL (hydrochloride) 500 mg (oral diabetes medicine that helps control blood sugar levels ) was given on an empty stomach. 3. Reglan 10 mg (metoclopramide-use to treat nausea,vomiting) was not administered as prescribed by the physician. 4. Peridex solution (Chlorhexidine gluconate, used as an oral rinse to treat the symptoms of gingivitis-gum disease) 5 ml.(milliliters) was not administered as prescribed by the physician. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the nutritive value, flavor, and appearance of the food prior to serving. This failure had the potential to decrease the nutrition status of the residents in promoting recovery from illness or injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare, store, and serve food under sanitary conditions when they were using unpasteurized eggs and proper hand washing was not done. These failures had the potential to expose residents who received nutritional services from the kitchen to food borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow infection control practices when; 1. The staff did not wash hands between residents during medication pass for Resident 54 and Resident 7. 2. The staff did not change gloves between residents when obtaining blood pressures (BP) or sanitize the BP cuff for Residents 63 and 22. 3. In the medication room specimen refrigerator, there was a urine specimen dated 10/15/2021 and unlabeled [NAME] - [NAME] (JP- drain is a closed- suction medical device for collecting body fluids from surgical sites) with 30 ml (milliliter) of brown color liquid. These failures increased the potential for cross contamination.

Inspectors wroteBased on interview and record review, the facility failed to complete the Comprehensive Minimum Data Set (MDS, an assessment tool used to direct care) within 14-calendar days of admission for two of five sampled residents (Resident 1 and 56). This failure had the potential to delay the development of a comprehensive care plan necessary to provide the appropriate individualized care and services for each resident related to the care areas identified on their Comprehensive MDS.

Inspectors wroteBased on interview and record review, for three of five (Resident 56, 57, and 58) sampled residents, the facility failed to complete Quarterly Minimum Data Set (MDS, an assessment tool used to direct care) Assessments in the regulatory specified manner. This failure had the potential for Residents 56, 57, and 58 to not receive care and services based on their current health status.

Inspectors wroteBased on record review and interview, the facility failed to ensure one of two sampled residents (Resident 11) was accurately assessed using the Minimum Data Set (MDS - an assessment tool), when Resident 11's MDS was inaccurately assessed as not being a hospice patient. This deficient practice had the potential for Resident 11 to not receive hospice care due to incorrect data entered and receive planned care not consistent with the resident's condition.

Inspectors wroteBased on interview and record review, the facility failed to provide care that met the professional standards of care for one resident out of 20 sampled (Resident 170) when she was cleaned after being incontinent of feces with Chlorox bleach wipes. This deficient practice had the potential to cause pain and chemical burns to Resident 170.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care for two (Resident 55 and 65) of four residents that required oxygen therapy when Resident 55 and 65 were given oxygen without doctor's orders. These deficient practices had the potential to result in Resident's 55 and 65's inadequate monitoring of Resident 55 and 65's safe use of oxygen and response to oxygen therapy.

Inspectors wroteBased on record review and interview, the facility failed to provide care for three (Resident 44, 45 and 118) of three residents that required dialysis (artificial kidney machine that rids your blood of unwanted toxins, waste products and excess fluids by filtering your blood). Staff did not do a complete assessment before Resident 45 and Resident 118's dialysis treatment or complete the dialysis communication record for Resident 45 and 118 before they went to their dialysis treatments. This deficient practice resulted in an inaccurate assessment of Resident 45 and 118's dialysis access site and functionality and failure to communicate potential changes in the resident's physical condition prior to receiving dialysis care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the pharmacist's medication regimen review (MRR) was promptly acted upon for two (Residents 63 and 66) of 20 sampled residents. This failure had the potential for a delay in treatment and risk for serious side effects for Residents 63 and 66.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (Resident 66) of 20 sampled residents was free from unnecessary psychotropic (drugs that affect the brain activities associated with mental processes behavior) medications when Resident 66 received: 1. Zyprexa ( used to treat certain mental/mood conditions (such us schizophrenia, bipolar disorder) without a gradual dose reduction (GDR, a tapering of a dose to determine if symptoms, conditions, or risk can be managed by a lower dose or if the dose medication can be discontinued) attempt or resident -specific clinical rationale for continuing the medication since 7/30/2020. 2. Ativan (used to treat anxiety) without a GDR attempt or resident -specific clinical rationale for continuing the medication since 6/25/2020. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one (Resident 45) of 20 sampled residents was free of significant medication errors when Eliquis tablet 5 mg (Apixaban- used to prevent serious blood clots due to an irregular heartbeat) was not administered as prescribed by the physician. This failure had the potential for an increased risk of stroke (not enough blood flow and oxygen to the brain due to a clot) when the medication was not provided.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure safe medication storage when: 1. In the Medication Room, there were multiple unlabeled, discontinued intravenous (administered into the vein) solution in a medium size plastic bin. 2. Station 3-Medication Cart 3 was dirty with small pieces of aluminum paper and multiple loose tablets in the bottom of the cart. 3. Station 2-Medication Cart 2 was dirty with small pieces of aluminum paper and multiple loose tablets in the bottom of the cart. Discontinued medication was still stored in Medication Cart 2 and had multiple opened eyedrops, an unlabeled bottle of nitroglycerine (used for heart/chest pain), and bisacodyl suppositories (laxative) were stored together in a small plastic bin. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the accuracy of the electronic medical record for one of 20 sampled residents (Resident 2), when Resident 2's medical record had information scanned into it belonging to Resident 171. This deficient practice did not ensure the medical record contained records specifically for Resident 2. For Resident 171, the resident's confidential record was not protected and the Preadmission Screening and Resident Review (PASRR), a screening tool to ensure individuals with mental illness are not inappropriately placed and receive specialized services if indicated) was not readily available to the healthcare team.

Inspectors wroteBased on observation and interview, the facility failed to provide 22 of 22 residents in the following multiple resident rooms (27, 28, 29, 30, 31, 32, 34) with at least 80 square feet per resident. This failure had the potential to result in a lack of sufficient space for the provision of care by facility staff and for the lack of sufficient space for residents to have personal belongings at the bedside. After observation and interview, there was adequate space for residents and staff to move about without obstruction. Recommend granting waiver.