Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mission Valley Post Acute during CMS and state inspections, most recent first.
A facility failed to ensure the accuracy of a Level I PASARR screening for a resident with a history of psychological disorders and receiving antipsychotic medication. The PASARR inaccurately indicated no serious mental disorder, contrary to the resident's documented diagnoses. Staff interviews revealed the MDS Coordinator was responsible for verifying PASARR accuracy, and the facility policy required screening for mental disorders, with further evaluation if necessary.
The facility was found non-compliant with room size requirements, as rooms on Station 3 were below the 80 sq ft per resident standard. Staff reported no care issues due to room size, but the Administrator and DON acknowledged the importance of meeting these standards.
A facility failed to meet professional standards when nursing staff did not document or follow physician's orders for a resident, leading to the worsening of a sacrococcyx wound from Stage 1 to Stage 4. The DON confirmed the deficiency, noting that proper documentation and adherence to orders were not maintained.
Inaccurate PASARR Screening for Resident with Mental Disorder
Penalty
Summary
The facility failed to ensure the accuracy of a Level I Preadmission Screening and Resident Review (PASARR) for a resident admitted with a medical history that included unspecified disorder of psychological development, unspecified psychosis, and depression. Upon admission, the resident's Minimum Data Set (MDS) indicated moderate cognitive impairment and active diagnoses of depression, psychotic disorder, and unspecified disorder of psychological development. The resident was also receiving antipsychotic medication, Risperdal, for unspecified psychosis. However, the PASARR Level I screening inaccurately indicated that the resident did not have a serious mental disorder, which was contrary to the resident's documented diagnoses and medication regimen. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing (DON), revealed that the MDS Coordinator was responsible for verifying the accuracy of the PASARR upon a resident's admission. Both the MDS Coordinator and the DON acknowledged that the resident's diagnosis of psychosis should have been reflected in the Level I PASARR screening. The facility's policy required that all new admissions be screened for mental disorders, and if the Level I screen indicated potential criteria for a mental disorder, a Level II evaluation should be conducted. The failure to accurately complete the Level I PASARR screening could result in the omission of necessary evaluations and services for the resident.
Non-compliance with Resident Room Size Requirements
Penalty
Summary
The facility failed to ensure that residents' rooms met the minimum size requirements, with several rooms measuring less than the required 80 square feet per resident. Specifically, rooms 27 to 34 on Station 3 were found to be non-compliant, with each room providing only 70 to 78.75 square feet per resident. This deficiency was confirmed by the Maintenance Director during measurements conducted on 10/10/2024. Interviews with staff, including CNAs and a Licensed Vocational Nurse, revealed that they did not experience any issues providing care due to the room sizes. However, the Administrator acknowledged the importance of adhering to room size requirements to ensure that care is not impeded. The Director of Nursing also expressed an expectation that the facility should comply with the regulatory standards for room sizes, indicating awareness of the 80 to 100 square feet requirement.
Failure to Document and Follow Physician's Orders
Penalty
Summary
The facility failed to provide services that met professional standards for one resident when nursing staff did not document that physician's orders were carried out. This failure contributed to the formation and worsening of the resident's sacrococcyx wound. The resident was admitted with diagnoses including mitral valve insufficiency and traumatic hemorrhage of the cerebrum. The resident's Braden Scale assessment indicated a very high risk for developing a pressure injury, and the physician's orders included the application of barrier cream, foam dressing, and position changes to prevent further skin deterioration. Despite these orders, the Treatment Administration Records (TAR) for February through June 2023 showed numerous instances where the prescribed treatments were not documented as carried out. Specific orders such as cleansing the coccyx area, applying barrier cream, and using an air mattress were frequently not followed across multiple shifts. This lack of documentation and adherence to physician's orders was confirmed by the Director of Nursing (DON), who acknowledged that if it was not documented, it was not done. The resident's condition worsened over time, with the sacrococcyx area developing from a Stage 1 pressure injury to an unstageable wound and eventually a Stage 4 pressure ulcer. The facility's policies on medication and treatment orders, as well as the prevention of pressure injuries, were not followed, leading to the resident's deteriorating condition. The DON confirmed the deficiency, stating that it was the licensed nurse's responsibility to ensure orders were carried out and documented properly.
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What surveyors actually found near you
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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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Fremont
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| We Care Skilled Nursing - Fremont | 0.1 mi | ★★★★★ | 3 | 0 |
| Country Drive Post Acute | 0.1 mi | ★★★★★ | 4 | 0 |
| Crestwood Treatment Center | 0.2 mi | ★★★★★ | 1 | 0 |
| Niles Canyon Post Acute | 0.9 mi | ★★★★★ | 6 | 0 |
| Fremont Healthcare Center | 1.2 mi | ★★★★★ | 30 | 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 July 2026) and official state health department websites.