Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Nursing And Transitional Care during CMS and state inspections, most recent first.
Expired and undated medications were found on two med carts, including an opened bottle of Med Plus 2.0 without an open date, a blister pack of tamsulosin that had expired, and an OTC bottle of meclizine with an opened date and expiration date that were not current. An MA/CMA stated she or he was responsible for checking and dating medications, while the ADON and DON said staff were expected to monitor med carts for expired and improperly labeled meds.
Infection control failures occurred during medication administration and incontinent care. A medication aide placed clean gloves in her waistband and then used them for eye drops, an RN touched bed sheets and a bed remote before using the same gloves for G-tube medication administration, and staff failed to follow EBP for a resident with a stage 3 sacral wound and another resident with an indwelling catheter. A CNA also used contaminated gloves to remove and replace a brief without changing gloves or wearing a gown as required.
Incomplete OOH-DNR Form Lacked Physician Signature: A resident with severe cognitive impairment and DNR status had an OOH-DNR form in the chart that was signed by the resident/RP but not by the attending physician. SW and Medical Records staff confirmed the physician signature was missing, while the DON stated the facility still honored the DNR based on the EMR and prior RP signature.
Failure to maintain privacy during G-tube medication administration: An RN administered meds via a resident’s G-tube with the door and curtain open while others passed by and looked into the room. The resident was cognitively severely impaired and tube fed. The RN stated he forgot to close the door and curtain, and the ADON and DON confirmed that privacy should be provided during care.
A resident with moderate cognitive impairment and diagnoses including muscle weakness and hemiplegia/hemiparesis had an order allowing use of a sippy cup and plate guard with meals, but the care plan did not include goals or interventions for his refusal to use the plate guard. Staff observed the resident eating without the plate guard, and CNA, LVN, MDS nurse, and DON interviews confirmed the refusal was known but not reflected in the care plan.
A resident with vascular dementia, Parkinsonism, severe cognitive impairment, and a stage 3 sacral pressure ulcer with a wound vacuum did not have an EBP order in the clinical record. The care plan and order summary included wound treatment orders, but no EBP order was documented. Staff gave conflicting statements about whether EBP was needed, while the facility policy stated that residents with wounds such as pressure ulcers should have an EBP order.
Failure to Post Daily Nurse Staffing Information: The facility failed to ensure nurse staffing information was posted daily and in a prominent place for residents and visitors to view. Surveyors observed the posting was not updated on multiple days, and the DON stated she was responsible for posting it by 8:30 a.m. each day. The Administrator confirmed the DON’s responsibility, and the facility policy required the staffing sheet to be posted daily with the current date and made readily available.
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.
Expired and Undated Medications on Medication Carts
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in accordance with accepted professional principles on 2 of 4 medication carts reviewed. On the 400-Hall medication cart, a new bottle of Med Plus 2.0 was opened during medication pass, but the medication aide did not write an open date on the bottle. During interview, the medication aide stated she forgot to write the date and acknowledged that OTC liquids and Med Plus should be dated when opened because they can go bad and may upset residents' stomachs. The ADON and DON both stated that staff were responsible for dating opened OTC medications and Med Pass bottles when opened. The facility also had expired medications on the 400-Hall medication cart. A blister pack of tamsulosin 0.4 mg was observed with an expiration date of 1/25/2026. The medication aide stated she checked expiration dates before administering medications and acknowledged it was her responsibility to ensure no expired medications were in the cart. She also stated that Resident #23 had a history of refusing medication and that this was documented on the MAR. The ADON stated medication aides checked med carts each morning, the pharmacy consultant completed monthly audits, and he performed random spot checks for expired medications. On the 100/200 Hall medication cart, an OTC bottle of meclizine 12.5 mg was observed with an opened date of 1/16/2026 and an expiration date of January 2026. The medication aide stated he checked the med cart daily for expired medications and had opened and labeled the meclizine bottle. The DON stated medication aides checked med carts daily, ADONs performed random spot checks, and the pharmacy consultant completed monthly audits. Facility policy stated that medications must be administered in accordance with professional standards, opened fluids must be covered and dated, and expired medications must not be administered.
Infection Control and EBP Failures During Medication Pass and Resident Care
Penalty
Summary
The facility failed to maintain infection prevention and control practices during medication administration and resident care for four residents. For one cognitively intact resident with diabetes, hypertension, Parkinsonism, peripheral vascular disease, muscle wasting, and quadriplegia, a medication aide placed clean gloves inside the waistband of scrub pants during a medication pass and then used those same gloves to administer eye drops. The aide stated the gloves became contaminated after touching the pants and acknowledged that the resident could get an infection. The ADON and DON both stated the gloves should not have been placed in the waistband and that clean gloves should have been kept on a clean surface. For another resident with a gastrostomy tube, diabetes, vascular dementia, Alzheimer’s disease, hypertension, and severe cognitive impairment, an RN donned gloves, touched the bed sheets and bed remote, and then used the same gloves to touch the resident’s G-tube and administer medication. The RN stated she should have removed the gloves and put on a new pair after touching the bed sheets and remote, and the ADON and DON stated gloves should be changed before touching the G-tube, syringe, and medication because the remote and sheets could be contaminated. The facility also failed to follow its own enhanced barrier precautions for two residents. One resident had a stage 3 sacral pressure ulcer with a wound vacuum and no EBP sign on the door; staff stated the resident did not need EBP because the wound was contained, while the DON stated the resident still needed to be under EBP. Another resident with an indwelling catheter and moderate cognitive impairment had an EBP care plan and order for gown and gloves, but during incontinent care a CNA did not wear a gown and used the same contaminated gloves to remove the brief and apply a clean brief after cleaning the posterior area. The CNA stated she should have worn a gown and changed gloves before placing the new brief, and staff stated EBP was needed for residents with catheters to prevent infection.
Incomplete OOH-DNR Form Lacked Physician Signature
Penalty
Summary
The facility failed to ensure that Resident #57 had a properly completed OOH-DNR form with a physician’s signature. Resident #57 was admitted with diagnoses including anemia, epilepsy, and atherosclerotic heart disease, and his 5-day MDS assessment showed a BIMS score of 02, indicating severely impaired cognition. His care plan identified him as a DNR and directed staff to ensure a signed DNR was in the medical record, and the order summary reflected an OOH-DNR order was in effect. Record review of the OOH-DNR form showed that the attending physician had not signed section E, which states the physician has noted the existence of the order in the person’s medical record and directs out-of-hospital health care professionals not to initiate or continue CPR and related interventions. The form also lacked the required signature in section F acknowledging the document had been properly completed. During interviews, the SW stated she handled code status discussions, obtained the resident’s or RP’s signature, updated the electronic medical record, and sent the form to medical records for notarization and physician signature. Medical Records staff confirmed the physician had not signed the form. The DON stated the resident’s RP had signed an OOH-DNR form during a prior admission and that the facility continued to honor the DNR status during the most recent admission without obtaining a new completed form. The DON also stated the form followed the resident and that the facility did not have a policy related to code status. Staff acknowledged that the OOH-DNR form on file had not been signed by the physician, even though the resident’s electronic record reflected DNR status.
Failure to Maintain Privacy During G-Tube Medication Administration
Penalty
Summary
The facility failed to provide the right to personal privacy during medication administration for Resident #116, a cognitively severely impaired female with a gastrostomy tube feeding. On 02/10/2026 at 4:36 p.m., RN K administered medication via the resident’s G-tube while the door and curtain remained open, and staff were seen passing by the room and looking in during the procedure. RN K also left the room a second time to obtain a new syringe and then returned to continue the medication administration, again with the door and curtain open. During an interview later that day, RN K stated that he was supposed to close the door and curtain before providing care, but he got nervous and forgot. He stated that he had been trained on resident privacy and dignity. The ADON and DON both stated that staff should provide privacy during medication administration and should close the door and curtain, with the ADON also stating that blinds should be closed when providing care. The facility policy on Promoting/Maintaining Resident Dignity stated that resident privacy must be maintained, and the Enteral Tube Medication Administration policy stated to establish the privacy of the patient.
Failure to Care Plan Resident Refusal of Plate Guard
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #73 that included measurable objectives and time frames to address his mental and psychosocial needs related to behavioral issues. Resident #73 was a 66-year-old male with diagnoses including muscle weakness and hemiplegia/hemiparesis following cerebral infarction affecting his right dominant side. His quarterly MDS assessment dated 12/2/25 showed moderate cognitive impairment, that he was able to make himself understood, and that he was usually able to understand others. Record review showed the comprehensive care plan dated 5/30/22 had no focus, goals, or interventions/tasks related to Resident #73's refusal to use the plate guard while eating, even though the order summary dated 2/9/26 stated he may use a sippy cup and plate guard with meals. During observation on 2/9/26, Resident #73 was in the dining room without the plate guard and stated that he did not want to use it. CNA I stated that Resident #73 refused to use the plate guard and that nurses were aware of the refusal. LVN C stated he had seen the refusal, that staff should have informed the DON to update the care plan, and that an alternative such as OT should have been considered. The MDS nurse stated she was not aware of the refusal, and the DON stated that when a resident refused to use the plate guard, it should have been care planned and the doctor informed.
Missing EBP Order for Resident with Stage 3 Sacral Pressure Ulcer
Penalty
Summary
The facility failed to maintain Resident #10’s clinical record in accordance with accepted professional standards because the record did not include an order for enhanced barrier precautions (EBP) even though the resident had a stage 3 sacral pressure ulcer with a wound vacuum. Resident #10’s record reflected diagnoses including vascular dementia, Parkinsonism, age-related physical debility, and a wound infection, and his quarterly assessment showed severe cognitive impairment. His care plan addressed the stage 3 pressure ulcer and included wound treatment orders, but there was no mention of EBP in the care plan or in the order summary. During interviews, the LVN, ADON, wound care nurse, and DON all discussed Resident #10’s sacral wound and wound vacuum. The LVN and ADON stated the resident did not need EBP because the wound was contained and CNAs wore gloves during peri-care, while the wound care nurse said he was not aware the resident was required to be under EBP since the wound was contained. The DON stated the resident had an open wound covered by a wound vacuum and needed to be under EBP, but she was not sure why he was not. The facility’s EBP policy stated that an order for EBP would be obtained for residents with wounds, including chronic wounds such as pressure ulcers.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure nurse staffing information was posted daily and readily accessible to residents and visitors with all required information for 3 of 3 days reviewed. Surveyors observed that the daily staffing information was not posted in a prominent place on 02/7/26, 02/8/26, and 02/9/26. During entrance to the facility on [DATE] at 8:39 a.m., a State Surveyor observed a clear frame on the right side of the extended care nurses station, on the wall next to the dining area of the transitional care, displaying the facility name and the total number of CNAs, LVNs, and RNs dated 02/6/26. During interview on 02/11/26 at 2:20 p.m., the DON stated she was responsible for posting the daily staff information and said it should be posted by 8:30 a.m. each day. She stated the negative outcome for not posting the staff information would be a lack of communication between residents, visitors, and staff. During interview on 02/11/26 at 2:45 p.m., the Administrator stated the DON was responsible for posting the nursing staffing information and that the daily postings should be up by 8:30 a.m. The facility policy dated 10/2022 stated that nurse staff information was to be readily available in a readable format to residents and visitors at any given time and that the staffing sheet would be posted on a daily basis and include the current date.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 154 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 9 | 0 |
| Village Healthcare And Rehabilitation | 3.5 mi | ★★★★★ | 2 | 0 |
| Briarcliff Nursing And Rehabilitation Center | 4.5 mi | ★★★★★ | 14 | 0 |
| Windsor Nursing And Rehabilitation Center Of Mcall | 4.9 mi | ★★★★★ | 5 | 0 |
| Grand Terrace Rehabilitation And Healthcare | 5.2 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Mission Valley Nursing And Transitional Care.
100% money-back within 48 hours.
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.