Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 2027
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 Valley Nursing And Transitional Care during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of falls was left unattended in a wheelchair by a CNA, resulting in an unwitnessed fall and a hip fracture. After the fall, the CNA and a Med-Aide transferred the resident back to bed without notifying a nurse or having the resident assessed, and the incident was only discovered when the next shift was informed by the resident. Both staff members admitted to not following protocols for fall reporting and assessment.
A resident with dementia and other medical conditions was given Remeron, a psychotropic medication, without proper completion or signature of a consent form by the resident or responsible party. Facility staff confirmed that consent should have been obtained and documented before administration, but records showed the medication was given without this required step.
A resident's care plan was not promptly updated after a change from Full Code to DNR status, resulting in both statuses being reflected simultaneously for several days. Nursing staff and the DON confirmed that the required process for care plan revision was not followed, despite facility policy mandating immediate updates after status changes. The deficiency was identified through interviews and record reviews.
Two residents did not receive pharmaceutical services as ordered, including one who was given a lower dose of morphine than prescribed without prior physician or hospice notification, and another whose pain assessments were not properly documented using the required 0-10 scale. Nursing staff did not follow established procedures for medication administration and documentation, leading to incomplete and inaccurate records.
A resident with multiple medical conditions experienced a fall, and while the incident and immediate assessment were documented, there was no documentation that the physician or responsible party were notified as required by facility policy. Interviews with the PA, LVN, and DON confirmed that documentation of these notifications was expected but not completed, resulting in incomplete clinical records.
A deficiency was cited when a resident's care plan did not include all necessary components, such as measurable timetables and specific actions, resulting in incomplete planning and documentation of care.
A deficiency was cited when an area of the facility was not kept free from accident hazards and adequate supervision was not provided to prevent accidents. The environment and supervision protocols were found to be insufficient to minimize accident risks.
A facility failed to maintain an effective Infection Prevention and Control Program, as observed during incontinent care for a resident with urinary tract infection and cognitive impairment. The CNA did not sanitize hands between glove changes and reused wipes, contrary to facility policy. Interviews revealed inconsistencies in staff understanding of infection control protocols, despite clear guidelines requiring hand hygiene and proper wipe usage.
Failure to Provide Adequate Supervision and Timely Reporting After Resident Fall
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, hemiplegia, hemiparesis, a history of falls, and dependence for transfers was left unattended in his wheelchair in his room by a CNA. The CNA had wheeled the resident from the nurse's station to his room and left him there while seeking assistance for a transfer. During this time, the CNA was distracted by another resident's request and left the area. Upon returning, the CNA found the resident on the floor, having sustained an unwitnessed fall. Following the fall, the CNA, with the assistance of a Med-Aide, transferred the resident back to bed using a bed sheet, without notifying a nurse or having the resident assessed for injuries. The Med-Aide assumed the CNA had already reported the incident and that it was safe to move the resident. During the transfer, the resident was noted to be moaning, and after being placed in bed, continued to express pain, but neither staff member reported the incident to nursing staff at that time. The incident was only discovered when the incoming CNA for the next shift was informed by the resident that he had fallen and was experiencing pain. The incoming CNA immediately notified the LVN, who assessed the resident and initiated appropriate medical interventions. It was later confirmed that the resident had sustained a right hip fracture as a result of the unwitnessed fall. Both the CNA and Med-Aide involved admitted to not following facility protocols regarding fall reporting and resident assessment after a fall.
Failure to Obtain Consent Prior to Administration of Psychotropic Medication
Penalty
Summary
The facility failed to ensure that consent forms were properly completed or signed by a responsible party prior to administering a psychotropic medication, Remeron (Mirtazapine), to a resident. The resident, an adult male with diagnoses including a lumbar vertebra fracture, dementia, heart disease, and hypertension, was admitted with intact cognitive function as indicated by a BIMS score of 15. Despite this, review of the resident's records showed that Remeron was administered as an appetite stimulant over several days without obtaining the required signature or verbal consent from the resident or responsible party. Interviews with facility staff, including an LVN and the DON, confirmed that the established protocol required nurses to obtain either a written or verbal consent before administering psychotropic medications. The facility's policy also mandated that residents or their representatives be informed of the benefits, risks, and alternatives to the medication prior to initiation, and that this consent be documented. However, documentation revealed that the medication was given without the necessary consent, and staff acknowledged that this was not in accordance with facility policy or resident rights.
Failure to Timely Update Care Plan Following Change in Code Status
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for a resident following a change in code status from Full Code to Do Not Resuscitate (DNR). The resident, an elderly male with diagnoses including a lumbar vertebra fracture, dementia, heart disease, and hypertension, was admitted with Full Code status. Documentation showed that the resident was cognitively intact and required significant assistance with activities of daily living. The care plan initially reflected Full Code status, with interventions such as initiating CPR and calling 911 in the event of cardiac arrest. After a signed DNR order was obtained, the care plan was not promptly updated to reflect the new DNR status. Both Full Code and DNR statuses were present on the care plan for a period of time, and the DNR status was not added until several days after the order was signed. Interviews with nursing staff and the DON confirmed that the process for updating code status in the care plan was not followed in a timely manner. Staff described that the nurse receiving the code status change was responsible for updating the care plan, but this did not occur as required. The facility's policy required care plans to be updated immediately upon a change in status, with audits to ensure compliance. However, the care plan for this resident continued to reflect outdated information, and the DON acknowledged that the care plan should have been updated sooner. During this period, the resident experienced an unwitnessed fall, though no injury was noted. The deficiency was identified through interviews and record reviews, which demonstrated a lack of timely care plan revision following a significant change in the resident's code status.
Failure to Administer and Document Medications as Ordered
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with physician orders and established procedures for two residents. In the first case, a female resident with diagnoses including Parkinsonism, Alzheimer's dementia, atherosclerotic heart disease, and atrial flutter was under hospice care and had an active order for Morphine Sulfate 0.5 mL by mouth every 4 hours as needed for pain. On two occasions, nursing staff administered only 0.25 mL of morphine instead of the prescribed 0.5 mL dose, based on a family request, without notifying the physician or hospice prior to the change. Documentation in the controlled substance record and progress notes reflected the lower dose, and interviews confirmed that the nurse did not contact the physician due to being busy, despite knowing it was required. Hospice and pharmacy consultants were not informed of the dose change until after administration, and the facility's own staff acknowledged that any change in medication dosage should be coordinated with hospice and the physician. In the second case, a male resident with a history of lumbar vertebra fracture, dementia, heart disease, and hypertension had an order to monitor pain every shift using a 0-10 scale and to document which pain scale was used. Review of the medication administration record for June showed that, instead of documenting the actual pain level, staff only placed check marks for pain monitoring on most days, with no numerical pain level recorded. Interviews with nursing staff indicated that the resident frequently complained of pain, and the DON confirmed that the pain level should have been documented as per the order. The absence of pain level documentation meant there was no clear record of whether the resident's pain was being effectively managed. Both cases demonstrate failures in following physician orders for medication administration and documentation. The facility's policies require medications to be administered as ordered and pain to be assessed and documented systematically. However, staff did not adhere to these requirements, resulting in incomplete or inaccurate service delivery for the residents involved.
Failure to Document Physician and Responsible Party Notification After Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to maintain complete and accurate clinical records for a resident who experienced a fall. The resident, an elderly male with diagnoses including a lumbar vertebra fracture, dementia, heart disease, and hypertension, was found on the floor next to his bed after attempting to reach for his bedside table. The progress note documented the fall, the resident's denial of pain or head injury, and the completion of neuro checks, but did not include documentation that the physician or responsible party (RP) had been notified of the incident, as required by facility policy and the resident's care plan. Further review of the resident's care plan and facility policies confirmed that staff were expected to notify the physician and RP following a fall and to document these notifications in the medical record. Interviews with the physician assistant (PA), licensed vocational nurse (LVN), and director of nursing (DON) revealed that the notifications may have occurred, but were not documented in the resident's progress notes. The PA acknowledged that she should have documented the fall and any related evaluation or orders, while the LVN and DON both stated that all relevant information, including notifications, should be recorded in the progress notes. The facility's own policies on physician visits and medical record documentation require that all significant events, such as falls, and any resulting physician notifications or orders, be accurately and timely documented in the resident's medical record. In this case, the lack of documentation regarding physician and RP notification following the resident's fall constituted a failure to maintain clinical records in accordance with accepted professional standards and practices.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care. This omission was observed during the survey and was based on a review of the resident's records and care planning documentation. The deficiency was directly related to the facility's inaction in ensuring that the care plan was comprehensive and included all necessary elements to meet the resident's needs.
Failure to Maintain Accident-Free Environment and Provide Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Infection Control Deficiency Due to Improper Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by the improper hand hygiene and cleansing techniques observed during incontinent care provided to a resident. The resident, a male with a history of urinary tract infection and benign prostatic hyperplasia, required assistance with personal care due to moderate cognitive impairment and incontinence. During the care, the CNA did not sanitize her hands between glove changes and used the same wipe multiple times instead of using one wipe per swipe, which is against the facility's infection control policy. Interviews with the CNA and other staff members revealed inconsistencies in the understanding and application of infection control protocols. The CNA admitted to not recalling any mistakes during the care and expressed confusion about the hand hygiene requirements. Other staff members, including CNAs and LVNs, provided varying accounts of the infection control training they received, with some unable to recall the last in-service training. The facility's policies clearly outlined the need for hand hygiene between glove changes and the use of one wipe per swipe during incontinent care, but these were not consistently followed. The facility's Infection Control Policy and Hand Hygiene policy were reviewed, indicating that all staff should assume residents could be infected and perform hand hygiene according to established procedures. The policies emphasized the importance of hand hygiene before and after glove use and during resident care. Despite these guidelines, the observed practices during the resident's care did not align with the facility's standards, leading to a deficiency in infection control practices.
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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 Nursing & Rehabilitation Center | 0.2 mi | — | 1 | 0 |
| Village Healthcare And Rehabilitation | 3.5 mi | — | 2 | 0 |
| Briarcliff Nursing And Rehabilitation Center | 4.5 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.