Mission Valley Post Acute

In the surveyor’s words

From the most serious findings on record at Mission Valley Post Acute, in the surveyor’s own words.

• Immediate jeopardy, patternF610Jul 21, 2022

  Based on observation, interview and record review, facility failed to protect residents by allowing CNA 1 to continue to work as a direct care giver before completion of an investigation of Resident 1's physical abuse allegation against CNA 1. The facility failed to thoroughly investigate physical abuse allegations by two of two sampled residents (Resident 1 and Resident 2) against Certified Nursing Assistant (CNA1). Theses failures had the potential to result in repeated physical abuse of Resident 1 and Resident 2 and placed other 56 residents residing at the facility at potential risk for abuse. […]

• No harm, potential for more than minimal, widespreadF839Jun 11, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF755Jun 11, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF584May 21, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF684May 21, 2026

  Based 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. […]