Inspection Reports for Mission Valley Nursing and Transitional Care

The facility was found deficient in multiple areas including failure to obtain proper consent for psychotropic medication, failure to timely update care plans reflecting code status changes, inadequate supervision leading to an unwitnessed fall causing a hip fracture, failure to administer medications as ordered and document pain levels, and failure to maintain complete and accurate medical records including notification of falls.

The complaint investigation was triggered by an incident on 08/20/2025 where Resident #1 fell during perineal care provided by a CNA who determined the level of assistance unilaterally. The resident suffered a subdural hematoma and was hospitalized, later passing away on 08/21/2025. The facility was found to have inconsistent procedures for determining assistance levels and inadequate supervision. Immediate Jeopardy was identified on 08/22/2025 and removed on 08/23/2025 after corrective actions.

The facility failed to ensure an individualized care plan addressing the level of assistance required for Resident #1, leading to a fall during care. The facility also failed to provide adequate supervision, resulting in a subdural hematoma and the resident's death. Immediate Jeopardy was identified but later removed after corrective actions. The facility remained out of compliance with a severity of harm and scope of isolated due to the need for continued monitoring.

The facility failed to maintain an effective infection prevention and control program, as evidenced by CNA A's improper hand hygiene and cleansing techniques during incontinent care for Resident #115, potentially placing residents at risk of cross-contamination and infection.

The complaint involved Resident #49 alleging CNA A owed her money from a personal loan. Multiple interviews with Resident #49, CNA A, CNA B (former employee), social worker, and administrator revealed conflicting accounts about money owed and purchase of perfume bottles. The administrator did not obtain written statements from key witnesses and did not interview other staff who purchased perfume from Resident #49's sister. The investigation was incomplete and not reported timely to the State Survey Agency.

The facility failed to thoroughly investigate and report an allegation of exploitation involving Resident #49 and CNA A within the required timeframe. Interviews and record reviews revealed inconsistent handling of the allegation, lack of written statements, and incomplete investigation by the administrator. The administrator in-serviced staff on abuse, neglect, and exploitation but did not fully investigate or interview all relevant parties.

The complaint involved an allegation that CNA A owed money to Resident #49. Interviews revealed a disputed loan and purchase of perfume bottles between Resident #49, CNA A, and Resident #49's sister. The facility's investigation was incomplete, lacking written statements and interviews with all involved parties. The administrator did not interview other staff or verify purchases. The investigation was closed without full resolution, and CNA A was counseled and moved to a different hall.

The facility failed to thoroughly investigate and report allegations of exploitation involving a CNA and Resident #49 within the required timeframe. The investigation was incomplete, lacking written statements and interviews with all relevant staff. Additionally, the facility failed to update Resident #48's care plan to reflect a recent fall, and the kitchen environment had a maintenance issue with an air conditioner vent dripping liquid.

The facility failed to update Resident #11's care plan and physician orders to reflect the upsized Foley catheter, failed to ensure treatment orders and monitoring for Residents #8 and #103, and failed to maintain accurate medical records. Additionally, infection control practices were deficient as a CNA did not change gloves appropriately during incontinent care for Resident #48, increasing infection risk.