Health inspection·October 29, 2025

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete signatures of the doctor and RP. The DON stated the nurse was not to give the medication until signatures were on the consent form. She said the negative effect of not getting signatures on the consent form would be that it would not show the RP or resident was informed of the side effects of the medication and the consent to give the medication. She said it was a resident's right to accept the medication or refuse it. Review of facility's policy Use of Psychotropic Medication(s) dated 03/05/2025 revealed:Policy Explanation and Compliance Guidelines: 9. Prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, and alternatives for the medication, including any black box warnings for antipsychotic medications, in advance of such initiation or increase.10. The resident has the right to accept or decline the initiation or increase of psychotropic medication.11. The facility will document that the resident or resident representative was informed in advance of the risks and benefits of the proposed care, the treatment alternatives or other options and the preferred option to accept or decline in a format the facility deems to use (e.g., written consent form, narrative note, etc.). Event ID: Facility ID: 676446 If continuation sheet Page 2 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Valley Nursing and Transitional Care 1200 S Bryan Rd Mission, TX 78572 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to review and revise comprehensive care plans for 1 (Resident #3) of 5 residents reviewed for comprehensive care plan revisions. The facility failed to review and revise Resident #3's comprehensive person-centered care plan from Full Code Status to DNR Status in a timely manner reflecting both Full Code and DNR status on the care plan. This failure could affect residents and place them at risk of not receiving appropriate interventions to meet their current needs. Findings include: Record review of Resident #3's admission Record dated [DATE], revealed an [AGE] year-old male, admitted to facility on [DATE]. His diagnoses included: Wedge compression fracture of first lumbar vertebra (a type of spinal fracture where the front part of the vertebra collapses, creating a wedge-shaped deformity), dementia (a general term for a group of diseases that cause a loss of cognitive functioning, such as thinking, remembering, and reasoning, to the point that it interferes with daily life), heart disease, and hypertension (high blood pressure). Resident #3 was discharged from the facility to the hospital on [DATE] and did not return to the facility. Record review of Resident #3's Medicare 5-Day MDS dated [DATE] revealed Resident #3 had a BIMS score of 15, indicated cognitive function was intact. Resident #3 had clear speech, understood others and was able to be understood by others. Resident #3 was dependent on toileting hygiene and showers/baths requiring the assistance of two or more helpers. Record review of Resident #3's Care Plan dated [DATE], revealed: 1: FOCUS: Resident #3 is a full code Date Initiated: [DATE] Revision on: [DATE] Resolved Date: [DATE] GOALS: Facility will comply with resident/family wishes Date Initiated: [DATE] Revision on: [DATE] Target Date: [DATE] Resolved Date: [DATE] INTERVENTIONS/TASKS: If resident has a cardiac arrest, initiate CPR and call 911. Notify MD/RP and follow MD orders after notification. Date Initiated: [DATE] Revision on: [DATE] Resolved Date: [DATE] LN [DATE] Keep emergency cart well supplied and ready for use at all times Date Initiated: [DATE] Revision on: [DATE] Resolved Date: [DATE] LN [DATE] [NAME] chart and all pertinent documents with FULL CODE Date Initiated: [DATE] Revision on: [DATE] Resolved Date: [DATE] LN SS [DATE] FOCUS: Resident is a DNR Date Initiated: [DATE] Revision on: [DATE] Cancelled Date: [DATE] GOAL: Facility will comply with resident/family wishes Date Initiated: [DATE] Revision on: [DATE] Target Date: [DATE] Cancelled Date: [DATE] INTERVENTIONS/TASKS: Ensure signed DNR is in medical record Date Initiated: [DATE] Revision on: [DATE] Cancelled Date: [DATE] LN SS [DATE] If resident has a cardiac arrest, do not call 911 or initiate CPR. Notify MD/RP and follow instructions after notification Date Initiated: [DATE] Revision on: [DATE] Cancelled Date: [DATE] LN [DATE] [NAME] chart and all pertinent documents with DNR status Date Initiated: [DATE] Revision on: [DATE] Cancelled Date: [DATE] LN [DATE] Send copy of DNR paperwork upon transfer from facility Date Initiated: [DATE] Revision on: [DATE] Cancelled Date: [DATE] LN [DATE] Record review of Resident #3's OOH-DNR signed by RP, witnesses, physician, and notary was signed on [DATE]. In an interview on [DATE] at 12:52 pm, RN M stated that the admitting nurse was responsible for putting the code status of a resident in the care plan. She said if the resident code status changed to DNR after the admitting care plan, the nurse who was notified of the change of code status would put it in the Care Plan and remove the Full Code status. RN M stated she would want to see the signed DNR with signatures before she changed the code status on the Care Plan. RN M stated that usually the nurse who took the psychotropic order was the one who put the psychotropic or antipsychotic in the care plan. RN M stated for psychotropic medication orders, she would let the Care Team know, and they would put it in the care plan. In an interview on [DATE] at 01:40 pm, RN X stated that the admitting nurse was the one who completed the care plan on admission. She said (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676446 If continuation sheet Page 3 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Valley Nursing and Transitional Care 1200 S Bryan Rd Mission, TX 78572 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the admitting nurse adds the code status of a resident on admission and if their code status changed, the nurse who received the change in code status was the one who updated the care plan with the change in code status and discontinued the full code status to DNR. RN X stated that the nurse who received the order for a psychotropic was responsible for getting the signed consent for psychotropics. She said the medication was not to be put in the computer until the family had signed consent for the psychotropic. She said that way, the order would not show up on the MAR and the medication would not be given until the consent was signed. In an interview on [DATE] at 03:16 pm, LVN GG stated that the admitting nurse completed the initial care plan and the RN reviewed the care plan then signed off on them. She said the admitting nurse was responsible for entering the code status on admission. LVN GG stated if the resident's code status changed, the Social Worker would let the nurse know of the change in code status and the nurse changed the status, discontinued the original code status, and in the comments, the nurse would document the resident's code status had been changed to DNR. LVN GG stated that the nurse who received the order for a psychotropic or antipsychotic was responsible for updating the care plan with goal and interventions. In an interview on [DATE] at 05:15 pm, the DON stated the Care Plan for Resident #3 showed his status code as Full Code on [DATE] which was the date his DNR was signed. She said the Care Plan was not updated with the DNR until [DATE]. She said it should have been updated sooner. The DON stated it would not have been clear if the resident was DNR if anything had happened to the resident between [DATE] and [DATE]. Resident #3 had an unwitnessed fall on [DATE] with no obvious injury. Record review of facility's policy Care Plan Revisions Upon Status Change dated [DATE] revealed: Policy: The purpose of this procedure is to provide a consistent process for reviewing and revising the care plan for those residents experiencing a status change. Policy Explanation and Compliance Guidelines: d. The care plan will be updated with the new or modified interventions. h. The Unit Manager or other designated staff member will conduct and audit on all residents experiencing a change in status, at the time the change in status is identified, to ensure care plans have been updated to reflect current resident needs. Event ID: Facility ID: 676446 If continuation sheet Page 4 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Valley Nursing and Transitional Care 1200 S Bryan Rd Mission, TX 78572 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents hazards and supervision:1.The facility failed to ensure Resident # 1 was not left unattended in his wheelchair in his room by CNA A, which resulted in an unwitnessed fall. Resident #1 sustained a hip fracture from the fall. 2.The facility failed to ensure CNA A and Med-Aide B notified a nurse of Resident #1's fall and transferred Resident #1 to bed without being assessed. The non-compliance for Resident #1 was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 04/21/2025 and ended on 04/23/2025. The facility corrected the non-compliance before the investigation began. This failure could place the residents at risk for injury or death. Findings included:Record review of Resident #1's admission sheet dated 10/21/25, reflected an [AGE] year-old male with an admission date of 05/03/25 and an initial admission date of 07/30/23. His relevant diagnoses included hemiplegia (a condition that causes paralysis or weakness on one side of the body), hemiparesis (weakness on one side of the body that can affect the arm, leg, and sometimes the face), displaced intertrochanteric fracture of right femur ( a break in the femur (thigh bone) just below the femoral head and above the lesser trochanter), pain to right hip, Alzheimer's disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline), lack of coordination, muscle weakness, and need for assistance with personal care. Record review of Resident #1's quarterly MDS assessment dated [DATE], reflected a BIMS score of 04, which indicated his cognition was severely impaired. Further review reflected Resident #1 was dependent ( helper does all of the effort. Resident does none of the effort to complete the activity. OR the assistance of 2 or more helpers is required for the resident to complete the activity) for transfers and used a wheelchair as a mobility device.Record review of Resident #1's quarterly care plan dated 09/23/25, reflected a:Problem: [Resident #1] is high risk for falls r/t unsteadiness on feet, other lack of coordination, other abnormalities of gait/mobility (dated initiated 07/30/23 and revised on 04/23/25)Interventions: in part included to anticipate and meet needs (date initiated 07/30/23 ad revised on 09/23/25), be sure the resident's call light is within reach and encourage/remind the resident to use call light for all assistance (dated initiated 07/30/23 and revised on 09/23/25), Ensure floor mats in place (dated initiated 08/25/25), provide resident with mobility device: WC, walker, or cane (date initiated 04/23/25), Pt evaluate and treat as ordered or PRN (date initiated 11/12/24)Problem: [Resident #1] has had an actual unwitnessed fall on: 03/26/25, 04/06/25, 04/09/25, 04/21/25 (date initiated 04/06/25 and revised on 04/23/25)Interventions: in part included, resident reminded to use call light for assistance when needed to avoid falls/injuries (date initiated 03/27/25), visual checks Q2 (date initiated 04/14/25), bed to lowest position w/safety pad on the floor (date initiated 04/22/25), and notify MD/RP of incident (date initiated 04/06/25)Record review of Resident #1's incident report dated 04/21/25 at 8:15 pm, reflected:Incident description: Around 8:00, CNA reported that upon entering the room, resident noted lying on the floor, left side of his bed, on his right-side position. Assisted X2 to bed, call light had not been triggered.Resident Description: [Resident #1] stated that he wants to walk. C/o pain to right hip/waist area when move/reposition. Denies of hitting his head.Record review on 10/21/25 of Resident #1's progress note dated 04/21/2025 at 8:24 pm, authored by LVN D reflected .notified NP. New orders for [pain medication], apply [pain gel] to affected area on right hip/waist, & x-ray hip/pelvis 2v in am. Will carry out orders.Record review on 10/21/25 of Resident #1's change in condition communication form dated 04/21/25 at 8:00 pm reflected: the change of condition was pain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676446 If continuation sheet Page 5 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Valley Nursing and Transitional Care 1200 S Bryan Rd Mission, TX 78572 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few to right hip/waist area which started on 04/21/2025 Record review of Resident #1's x-ray results taken on 04/22/25 reflected a mildly displaced right hip fracture. This appears to be a inter trochanteric fracture.During a telephone interview on 10/21/25 at 1:04 pm, CNA A described Resident #1 as being a very anxious resident who frequently attempted to get up from his wheelchair and required constant supervision. She said when Resident #1 would be in his wheelchair, and he would be placed by the nurse's station so they could keep an eye on him. She said on 04/21/25 between 6:00 and 7:00 pm, she wheeled Resident #1 from the nurse's station back to his room. CNA A said she left him sitting in his wheelchair (wheels locked) while she went out to the hall to look for someone to help her transfer Resident #1 back to bed. She said while she was in the hall trying to motion for assistance from another CNA, the resident from across Resident #1's room asked her to take him to the restroom, and she did. CNA A said when she returned to Resident #1's room, she found him on the floor, lying on his right side between his bed and his wheelchair. She said she panicked and at that same moment, Med-Aide B walked into Resident #1's room. She said she asked Med-Aide B to help her transfer Resident #1 back to his bed. CNA A said Resident #1 did not complain of pain or had any facial grimacing during the transfer. CNA A said once Resident #1 was transferred back to bed, both she and Med-Aide B left his room. CNA A said Resident #1 looked ok. CNA A said she failed to notify Resident #1's charge nurse of the fall and Resident #1 was transferred back to bed without being assessed by a nurse. CNA A said she also forgot to notify anybody that Resident #1 had sustained an unwitnessed fall after she left his room. CNA A said that day, she had requested to leave early (8:00 pm) and CNA C had agreed to cover for her from 8:00 pm to 10 pm. CNA A said on her way home (not sure of the time) she received a telephone call from LVN D who told her Resident #1 was in pain and if she knew what had happened to him. CNA A said she told LVN D she did not know why Resident #1 was in pain and that nothing had happened to him during her shift. CNA A said around 9:30 pm, she called LVN D and told him Resident #1 had an unwitnessed fall in his room, was transferred back to bed by her and Med-Aide B, and that she had not reported it to anyone. CNA A said she had been regularly in-serviced on the topics of fall prevention which included notifying charge nurse of any falls and not moving a resident after they sustained a fall until they had been assessed by a nurse. She said a negative outcome of notifying a nurse that a resident had fallen and moving a resident before they were assessed could further injure a resident and cause more pain. CNA A said the next day, when she arrived at the facility to start her shift, she was called to the Administrator's office and was written up and suspended and days later was terminated. She said that it was the first time she had failed to report a fall.During a telephone interview on 10/21/25 at 3:31 pm, Med-Aide B said on 04/21/25 between 6:00 pm and 7:00 pm, she had been motioned by CNA A to assist her in transferring Resident #1 back to bed and at that moment she was busy. She said by the time she went into Resident #1's room to assist CNA A, Resident #1 on the floor. She said CNA A asked her to help transfer Resident #1 back to bed. She said they used a bed sheet to transfer Resident #1 back to bed and during the transfer, Resident #1 was moaning. Med-Aide B said after he was transferred back to bed, Resident #1 continued moaning but she and CNA A left his room, and she continued with her med-aide duties. Med-Aide B said she assumed CNA A had already notified Resident #1's charge nurse of the fall, had already been assessed, and it was safe to move him. Med-Aide B said her mistake was to assume CNA A had already notified Resident #1's nurse and that he had already been assessed. Med-Aide B said a negative outcome for not having a nurse assess Resident #1 before being transferred could have caused a fracture and made the pain worse. Med-Aide B said she had been in-serviced on the topic of fall preventions which included notifying a resident's nurse of a fall and not moving a resident after a fall until they had been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676446 If continuation sheet Page 6 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Valley Nursing and Transitional Care 1200 S Bryan Rd Mission, TX 78572 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few assessed by a nurse. Med-Aide B said she received a write-up and was in-serviced on the topics of ANE and fall prevention.During a telephone interview on 10/22/25 at 3:45 pm, CNA C said that on 04/21/25, CNA A had asked her if she could cover the last two hours of her 2 pm to 10 pm shift. She said she agreed and punched in at around 8:00 pm. CNA C said the facility's protocol required the outgoing CNA to give report to the incoming CNA, but on that day, CNA A had not reported anything on Resident #1. CNA C said the only thing CNA A asked her to do was to help her make her end of shift round on Resident #1. CNA C said soon after she walked into his room, Resident #1, immediately told her his right leg was hurting. She said she noticed he had facial grimacing. She said Resident #1 told her he had a fall earlier in the day and his leg had been hurting since then. She said she immediately went to tell LVN D Resident #1 had pain in his right leg and asked him if it was true that he had fallen earlier in the day. She said LVN D told her that he had not been told Resident #1 had fallen earlier in the day. She said she and LVN D rushed back to Resident #1's room where LVN D assessed him.During a telephone interview on 10/22/25 at 4:00 pm, LVN D said on 04/21/25 between 8:00 and 8:20 pm, CNA C had reported to him that Resident #1 complained of pain in his right leg. He said he and CNA C rushed back to Resident #1's room and he noticed he had facial grimacing and voiced that his right leg was hurting. LVN D said he conducted a head-to-toe assessment, pain assessment (3/10) and notified Resident #1's NP/RP. LVN D said Resident #1's NP ordered pain medication and an x-ray of his right leg, stat. LVN D said after he had administered pain medication, called for an x-ray, and he called CNA A to ask her what happened to Resident #1. He said at first CNA A told him she did not know why Resident #1 was in pain and that nothing had happened to him during her shift. LVN D said CNA A called him 2 hours later and reported that Resident 1 had an unwitnessed fall and that she had failed to report it to anybody. LVN D said by the time CNA A called him back, he had already assessed Resident #1, called his NP, administered pain medication, and ordered x-rays to his right hip. LVN D said Resident #1's x-ray results showed he had sustained a right hip fracture as a result of the unwitnessed fall he had earlier that day. LVN D said a negative outcome for Resident #1 not having his unwitnessed fall reported and assessed before being moved could have worsened his fracture.During an interview on 10/22/25 at 4:20 pm, the DON said on 04/21/25, she had been informed by LVN D that Resident #1 had an unwitnessed fall sometime between 6:00 pm and 7:00 pm and was complaining of right hip pain. She said from what was reported to her, CNA A had wheeled Resident #1from the nurse's station back to his room to transfer him back to bed. She said while CNA A stood by Resident #1's door trying to motion another staff member to assist her in transferring Resident #1 back to bed, the resident directly across Resident #1's room called her to take him to the restroom. The DON said by the time CNA A came back to Resident #1's room, Resident #1 sustained an unwitnessed fall. The DON said Resident #1 was found on the floor and that's when CNA A and Med-Aide B transferred him back to his bed without him being assessed by a nurse or notifying anyone of the fall. She said that on 04/21/25, she had been informed by LVN D that between 8:00 pm and 8:15 pm, CNA C reported to him that Resident #1 had complained of right hip pain. She said LVN D immediately assessed Resident #1 and had notified his NP by 8:20 pm. She said LVN D later discovered CNA A had discovered Resident #1 lying on the floor in his room between 6:00 pm and 7:00 pm and that he had been transferred back to his bed by CNA A and Med-Aide B without being assessed by a nurse. She said the following day, CNA A was written up, suspended, and later terminated. The DON said it was her lapse in judgment that worried the facility's management that led to her termination. The DON said Med-Aide had received a write up for not reporting Resident #1's fall. The DON said the following interventions had been initiated between 04/21/25 through 04/23/25:100% of staff were in-serviced on the topic of ANE, timely reporting of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676446 If continuation sheet Page 7 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Valley Nursing and Transitional Care 1200 S Bryan Rd Mission, TX 78572 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few incidents, direct care staff were in-serviced on the topic of fall prevention; the months of May 2025 to October 2025, direct care staff had been in-serviced on the topic of ANE, ADL accuracy, safe transfers, notification of changes, and fall prevention; ADONs had conducted weekly CNA observations of ADLs level assistance to ensure they followed proper procedures (started 08/2025 to present), nursing staff and CNAs had random check-offs performed from 08/2025 to 09/2025. The DON said the facility had what they called a watchlist which was a communication tool for nursing staff to communicate any changes in residents in their hall. She said during their morning and afternoon meetings, each charge nurse was called to attend and give report of any changes/concerns with any resident or CNAs not following protocols. The DON said CNAs have what they called handoff which meant the outgoing CNAs were supposed to relay any changes, and special instructions to the in-coming CNAs. She said the handoffs were supposed to occur at every shift. The DON said a negative outcome to Resident #1 of being moved without being assessed by a nurse or reporting the fall would be pain.Record review of the facility's Fall Prevention Program policy dated 08/15/22 reflected:Policy:Each resident will be assessed for fall risk and will receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls.Definitions:A fall is an event in which an individual unintentionally comes to rest on the ground, floor, or other level, but not as a result of an overwhelming external force (e.g., resident pushes, another resident). The event may be witnessed, reported, or presumed when a resident is found on the floor or ground and can occur anywhere.Policy Explanation and Compliance Guidelines:8. When any resident experiences a fall, the facility will:Assess the residentComplete a post-fall assessmentComplete an incident reportRecord review of the facility's Safe Resident Handling/Transfers policy dated 02/19/25 reflected:Policy:It is the policy of this facility to ensure that residents are handled and transferred safely to prevent or minimize risk for injury and provide and promote a safe, secure, and comfortable experience for the resident while keeping the employees safe in accordance with current standards and guidelines. Policy Expectations:All residents require safe handling when transferred to prevent or minimize the risk of injury to themselves and the employees that assist them. While manual lifting techniques may be utilized dependent upon the resident's condition and mobility, the use of mechanical lift or other assistive devices could be used.Compliance Guidelines:13. Staff members are expected to maintain compliance with safe handling/transfer practices. Record review of the facility's Incidents and Accidents policy dated 08/15/22 reflected: It is the policy of this facility for staff to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident.Definitions: Accident refers to any unexpected or unintentional incident, which results or may result in injury or illness to a resident.Policy Explanation:The purpose of incident reporting can include:Assuring the appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of the resident care.Conducting root cause analysis to ascertain causative/contributing factors as part of the Quality Assurance Performance Improvement (QAPI) to avoid further occurrences.Alert administration of occurrences that could result in reporting requirements.Meeting regulatory requirements for analysis and reporting of incidents and accidents. Compliance Guidelines:6. Any injuries will be assessed by a licensed nurse or practitioner, and the affected individual will not be moved until safe to do so.Record review on 04/21/25 of Resident #1's change in condition dated 04/21/25 at 8:18 pm was done.Record review on 10/21/25 of Resident #1's progress notes dated 04/21/25 at 8:20 pm, reflected he had a head-to-toe assessment, pain assessment, NP notified, pain medication administered, and x-rays ordered.Record review on 10/22/25 of the facility's in-services reflected the following in-services were conducted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676446 If continuation sheet Page 8 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Valley Nursing and Transitional Care 1200 S Bryan Rd Mission, TX 78572 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete on with staff after the incident on 04/21/25, 04/22/25, and 04/23/25 on the topics of ANE, timely reporting of an incident, and fall prevention.Record review on 10/22/25 of CNA A's Employee Counseling Report dated 04/21/25 reflected that she was written up on a Level two offense: Failure to report an incident.: On April 21, 2025, at approximately 8:00 pm, Resident #1 was found on the floor next to his bed. Staff member, CNA A failed to follow the appropriate incident reporting procedures. Upon further inquiry, the employee admitted to providing inaccurate information regarding the incident. This conduct constitutes violations of our Code of Conduct policy and proper reporting procedures.Record review on 10/22/25 of Med-Aide B's employee counseling report dated 04/23/25 reflected, she was counseled on a level two offense for failure to report an incident. On April 21, 2025, at approximately 8:00 PM, Resident #1 was found on the floor next to his bed. Staff member, [NAME] B. [NAME], was called by CNA A, to aid in transferring the resident from the floor to the bed. Employee failed to follow the appropriate incident reporting procedures. This conduct constitutes violations of our Code of Conduct policy and proper reporting procedures. Record review on 10/22/25 of the facility's in-service logs reflected during the months of May 2025 to October 2025, direct care staff had been in-serviced on the topics of ANE, ADL accuracy, safe transfers, notification of changes, and fall prevention program.Record review on 10/22/25 of the facility's Observation binder reflected weekly CNA observations conducted by the facility's ADONs from August 2025 to present, all CNAs had been observed on ADLs level of assistance to ensure they followed proper procedures.In interviews on 10/21/25 and 10/22/25, with CNAs B, C, E, F, G, H, I, J, K, P, Q, R, S, U, V, W, Y, Z, AA reflected all had been in-serviced on the topics of ANE, fall prevention, timely reporting of incidents, and fall prevention. All said they had been observed by ADONs during ADLs and random checkoffs had been done. All knew of the facility's protocol to give report to the in-coming CNA of any special instructions or changes with resident in their hall.In interviews on 10/21/25 and 10/22/25, with LVNs D, T, BB, and DD and RNs l, M, N, O, X, and CC reflected all had been in-serviced on the topics of ANE, fall prevention, timely reporting of incidents, and fall prevention. All knew of the facility's protocol to give report to the in-coming nurse to notify them of any special instructions or changes with resident in their hall. All said the facility had what they called watchlist which was a dashboard used as a communication tool for all nurses to report any change in conditions, special instructions, anything that is going on with a certain resident in their hall. They said the watchlist was updated as needed and they went over it during the morning and afternoon meetings. They all said that was a time also in which they were Event ID: Facility ID: 676446 If continuation sheet Page 9 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Valley Nursing and Transitional Care 1200 S Bryan Rd Mission, TX 78572 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to provide Accuracy in service delivery. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 (Resident #2 and Resident #3) of 5 residents reviewed for medication.1.The facility failed to administer Morphine Sulfate as ordered by the physician on two different occasions.2.The facility failed to document the pain level 0-10 on the physician's order to monitor for pain every shift for Resident #3. These deficient practices could place residents at risk of not receiving therapeutic doses of their medication.The Findings included:1.Review of Resident #2's face sheet reflected a [AGE] year-old female with an initial admission date of 07/14/2018 with a diagnosis of Parkinsonism (Umbrella term for conditions that cause symptoms similar to Parkinson's disease, including tremors, stiffness, and slow movement), Alzheimer's Dementia (Brain disorder that causes memory loss, confusion, and other cognitive decline), Atherosclerotic Heart Disease (Plaque buildup in arterial walls), Atrial Flutter (a heart rhythm problem where two upper chambers of the heart beat too fast, causing them to flutter instead of beating in a strong steady rhythm).Review of Resident #2's MDS dated [DATE] reflected a Brief Interview for Mental Status (BIMS) of 99 (Resident was unable to complete the interview).Review of Resident #2's Care Plan dated 7/28/2025 reflected resident was under hospice care with listed interventions as: medications as ordered and notify physician immediately if there is breakthrough pain. Work cooperatively with hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs are met.Review of Resident #2's active orders as of 8/01/2025 OK to admit resident to hospice under physician DX: Alzheimer's / DementiaReview of Resident #2's active orders as of 8/01/2025 for Morphine Sulfate (Concentrate) Solution 20 MG/ML Give 0.5 mL by mouth every 4 hours as needed for Pain.Review of Resident #2's Individual Resident's Controlled Substance Record dated 8/2/25 reflected Morphine Sulf 100 MG/5 ML administer 0.5 ML by mouth as needed every 4 hours for shortness of breath or pain.Review of Resident #2's Individual Resident's Controlled Substance Record reflected Morphine Sulfate 0.25 mL was given on 8/10/20 at 10:00 PM by LVN EE and the same dose of 0.25 mL given on 8/11/25 at 7:00 AM by LVN FF.Review of Resident #2's Medication Administration Record reflected Morphine Sulfate 0.5 mL was given on 8/10/25 at 10:00 PM by LVN EE.Review of Resident #2's Medication Administration Record reflected Morphine Sulfate 0.5 mL was given on 8/11/2025 at 7:01 AM by LVN FF.Review of Resident #2's Nursing Progress Note reflected an entry made on 8/10/2025 at 10:00 PM by LVN EE Note Text: Morphine Sulfate (Concentrate) Solution 20 MG/ML Give 0.5 ML by mouth every 4 hours as needed for painReview of Resident #2's Nursing Progress Note reflected an entry made on 8/10/2025 at 10:39 PM by LVN EE Note Text: Morphine Sulfate (Concentrate) Solution 20 MG/ML Give 0.5 ML by mouth every 4 hours as needed for Pain PRN Administration was: Effective Follow-up Pain Scale was: 0Review of Resident #2's Nursing Progress Note reflected an entry made on 8/11/2025 at 6:17 AM by LVN FF Note Text: Received shift with resident in bed with irregular breathing between 24-32 per minute with Pulse of 110. Patient not on O2 per family request as endorsed by LVN EE. At 7 AM administered Morphine Sulfate 0.25 ML only per family due to patient moaning when repositioned. Kept HOB elevated and comfort measures provided. Family at bedside.Review of Resident # 2's Nursing Progress Note reflected an entry make on 8/11/2025 at 8:50 AM by LVN FF Note Text: Morphine Sulfate (Concentrate) solution 20 MG/ML Give 0.5 ML by mouth every 4 hours as needed for Pain Patient moaning and having SOB.In an interview on 10/21/2025 at 3:41 PM with LVN FF stated he had received a report from LVN EE not to give the whole dose (Morphine) as family (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676446 If continuation sheet Page 10 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Valley Nursing and Transitional Care 1200 S Bryan Rd Mission, TX 78572 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few requested. LVN FF said I asked the family member out of respect and gave 0.25 mL of morphine as the family requested. LVN FF said he had not called the doctor to inform him of the request made by the family to decrease the dosage of the morphine because he was busy and he knew he should have called. LVN FF said he documented on his progress notes the dose of 0.25 ML given as requested by the family.In a phone interview on 10/22/2025 at 11:42 AM with the Branch Manager of hospice, she stated Coordination of Care is done between hospice and facility staff upon admission and facilities are good in communicating with us. She said the facility did inform hospice of a lowered dose requested by the family after the medication was given. She said The facility was supposed to notify hospice of a request for a lowered dose so that we can document and let the doctor know. We would have to maybe send out our nurse to speak to the family and provide re-education.In a phone interview on 10/23/2025 at 1:14 PM with the pharmacy consultant, she said she was not informed that the nurses had given a lesser dose of the prescribed medication (morphine) to resident #2. She said administering a lesser dose of morphine may cause less drowsiness and may not manage pain as effectively.In an interview on 10/23/2025 at 3:42 PM with LVN BB stated if there are any changes to a resident's condition or meds, I would coordinate with hospice. If a family decided to give less or more of a medicine, we would have to coordinate with hospice and let them know so they can give us an order and speak to the family for further assessment. He said he would notify the family of the need to coordinate with hospice for changes in dosage. LVN BB said his last in-service on medication administration was about 2 weeks ago and an in-service from hospice was about 2 weeks ago.In an interview on 10/23/2025 at 3:57 PM with LVN ADON GG stated Resident # 2's pain was being managed because she was noted to be calm and there was no distress that he noted as he would make his rounds. He said a lesser dosage of morphine given than what was ordered would possibly affect pain management. In an interview on 10/23/2025 at 4:22 PM with the DON, she said 2-3 weeks ago hospice training was done by the hospice. We spoke to all staff and reminded them to provide compassionate care. We also communicated and met with the hospice DON and Administrator for training. Re-education and in-services were started and were still ongoing.In an interview on 10/23/2025 at 4:39 PM with the Administrator, she said there is a communication binder that hospice nurses and aides use when they check in and out after the visit was completed. She said the pharmacy consultant comes in every month and does entrance and exit with the DON and the Administrator. She said the facility's QAPI is reviewed for trends monthly. The administrator said reeducation and mandatory meetings were held continuously. She said daily morning meetings are held Monday-Friday that consisted of 3 different types. The first meeting held was and IDT (Interdisciplinary Team) meeting which consisted of all departments to discuss problems and resolutions, 2nd meeting was a clinical meeting held with the charge nurse to discuss all nursing related topics and reviewed the 24 hour. The 3rd meeting was a discharge planning meeting which involved the clinical care team and social services to review long-term/short-term residents and what residents may need upon discharge.2.Record review of Resident #3's admission Record dated 10/21/2025, revealed an [AGE] year-old male, admitted to facility on 06/06/2025. His diagnoses included: Wedge compression fracture of first lumbar vertebra (a type of spinal fracture where the front part of the vertebra collapses, creating a wedge-shaped deformity), dementia (a general term for a group of diseases that cause a loss of cognitive functioning, such as thinking, remembering, and reasoning, to the point that it interferes with daily life), heart disease, and hypertension (high blood pressure). Record review of discharge revealed Resident #3 was discharged from the facility to the hospital on [DATE] and did not return to the facility. Record review of Resident #3's Medicare 5-Day MDS dated [DATE] revealed Resident #3 had a BIMS score of 15, indicated cognitive function was intact. Resident #3 had clear (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676446 If continuation sheet Page 11 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Valley Nursing and Transitional Care 1200 S Bryan Rd Mission, TX 78572 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few speech, understood others and was able to be understood by others. Resident #3 was dependent on toileting hygiene and showers/baths requiring the assistance of two or more helpers. Record review of Resident #3's Care Plan dated 06/07/2025, revealed: FOCUS: Resident #3 is on pain medication therapy (Tylenol) r/t pain. Date Initiated: 06/09/2025 Revision on: 07/17/2025 Cancelled Date: 07/17/2025.GOAL: Resident #3 will be free of any discomfort or adverse side effects from pain medication through the review date. Date Initiated: 06/09/2025 Revision on: 07/17/2025 Target Date: 09/17/2025 Cancelled Date: 07/17/2025.INTERVENTIONS/TASKS: Administer ANALGESIC medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT. Date Initiated: 06/09/2025 Revision on: 07/17/2025 Cancelled Date: 07/17/2025 LN RN 07/17/2025 Ask physician to review medication if side effects persist. Date Initiated: 06/09/2025 Revision on: 07/17/2025 Cancelled Date: 07/17/2025 LN RN 07/17/2025. Record review of Resident #3's 06/01/2025 to 07/01/2025 Order Summary revealed Monitor for pain every shift use 0-10 scale (A) for alert residents use pain ad (B) for confused residents document which pain scale used to assess residents pain rating. Every shift. Record review of Resident #3's June 2025 Medication Administration Record revealed check marks only for monitoring dayshift pain level and nightshift pain level from 06/07/2025 through 06/26/2025 and a check mark only for dayshift pain level 06/27/2025 with no pain level documented.In an interview on 10/28/25 at 12:52 pm, RN M stated Resident #3 always had complaints of pain to his back. She said they always had to be gentle moving him. She said he was almost always in like a fetal position. In an interview on 10/28/25 at 02:45 pm, LVN GG stated Resident #3 was always in pain. She said his pain level would go from a 3 to where he was yelling at times. LVN GG stated Resident #3 was alert but then there were times when he was confused. She said he was a fragile man. LVN GG stated he had to be turned every so often. LVN GG stated Resident #3 would complain of pain when he was turned here and there. She said pain medication was always offered because he was always had pain. During an interview on 10/28/25 at 05:15 pm, the DON stated Resident #3 had an order to monitor for pain every shift and for them to document the pain scale using 0 out of 10. She said Resident #3's June 2025 MAR showed check marks with no documentation of pain level. The DON stated the MAR should have had the pain level documented on the monitoring order. She said the PRN Tylenol order had pain levels on administration, but that was not the pain monitoring order. The Tylenol order was another order. She said if the pain level number was not there, they would not know if the resident's pain was being controlled. Record review of facility policy titled: Medication Administration, Revised Date 10/01/19 reflected 2. Administration B. Medications are administered in accordance with written orders of the prescriber.Record review of facility policy titled: Pain Management, Date Implemented: 8/15/22 reflected 1. In order to help a resident attain or maintain his/her highest practicable level of physical, mental, and psychosocial wee-being and to prevent or manage pain, the facility will: c. Manage or prevent pain, consistent with the comprehensive assessment an plan of care, current professional standards of practice, and the resident's goals and preferences.Record review of Hospice Service Agreement dated June 1, 2018, reflected Article IV. Services to be provided by Nursing Facility. 4.3 Coordination with Hospice regarding Plan of Care. (ii) Modification. The Nursing Facility will assist with periodic review and modification of the Plan of Care. Nursing Facility will consult with Hospice, as reasonably necessary, with respect to any modification of the Plan of Care. Hospice retains the sole authority for determining the appropriate level of hospice care provided to each Hospice Patient. Any modification to the Plan of Care must be approved by Hospice.Record review of facility's policy Pain Management dated 08/15/2022 revealed: Policy:The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676446 If continuation sheet Page 12 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Valley Nursing and Transitional Care 1200 S Bryan Rd Mission, TX 78572 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete person-centered care plan, and the residents' goal and preferences.Policy Explanation and Compliance Guidelines:The facility will utilize a systematic approach for recognition, assessment, treatment and monitoring of pain.Recognition:1. In order to help a resident attain or maintain his/her highest practicable level of physical, mental and psychosocial well-being and to prevent or manage pain, the facility will:a. Recognize when the resident is experiencing pain and identify circumstances when the pain can be anticipated.b. Evaluate the resident for pain upon admission, during ongoing scheduled assessments, and when a significant change in condition or status occurs (e.g., after a fall, change in behavior or mental status, new pain or an exacerbation of pain).c. Manage or prevent pain, consistent with the comprehensive assessment and plan of care, current professional standards of practice, and the resident's goals and preferences. Event ID: Facility ID: 676446 If continuation sheet Page 13 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Valley Nursing and Transitional Care 1200 S Bryan Rd Mission, TX 78572 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 resident (Resident #3) of 5 residents reviewed for medical records accuracy, in that: The facility failed to document the doctor and RP had been notified of Resident #3's fall on 06/16/2025 at 05:07 am. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment.Findings included: Record review of Resident #3's admission Record dated 10/21/2025, revealed an [AGE] year-old male, admitted to facility on 06/06/2025. His diagnoses included: Wedge compression fracture of first lumbar vertebra (a type of spinal fracture where the front part of the vertebra collapses, creating a wedge-shaped deformity), dementia (a general term for a group of diseases that cause a loss of cognitive functioning, such as thinking, remembering, and reasoning, to the point that it interferes with daily life), heart disease, and hypertension (high blood pressure). Record review of Resident #3's Medicare 5-Day MDS dated [DATE] revealed Resident #3 had a BIMS score of 15, indicated cognitive function was intact. Resident #3 had clear speech, understood others and was able to be understood by others. Resident #3 was dependent on toileting hygiene and showers/baths requiring the assistance of two or more helpers. Record review of Resident #3's Care Plan dated 06/07/2025, revealed: FOCUS: Resident #3 has had an actual fall -06/16/25 UW fall Date Initiated: 06/16/2025 Revision on: 07/17/2025 Cancelled Date: 07/17/2025GOAL: The resident will resume usual activities without further incident through the review date. Date Initiated: 06/16/2025 Revision on: 07/17/2025 Target Date: 09/17/2025 Cancelled Date: 07/17/2025INTERVENTIONS/TASKS: 06/16/25 Encourage and educate resident on importance of using call light for all assistance. Date Initiated: 06/16/2025 Revision on: 07/17/2025 Cancelled Date: 07/17/2025 RN LN 07/17/2025 Monitor/document /report PRN x 72h to MD for s/sx: Pain, bruises, Change in mental status, New onset: confusion, sleepiness, inability to maintain posture, agitation. Date Initiated: 06/16/2025 Revision on: 07/17/2025 Cancelled Date: 07/17/2025 LN RN 07/17/2025 Neuro-checks x (72 hours) Date Initiated: 06/16/2025 Revision on: 07/17/2025 Cancelled Date: 07/17/2025 LN RN 07/17/2025 Notify MD/RP of incident Date Initiated: 06/16/2025 Revision on: 07/17/2025 Cancelled Date: 07/17/2025 RN LN 07/17/2025. Record review of Resident #3's Progress Notes on 06/16/2025 at 05:07 am written by LVN GG revealed, PATIENT WAS FOUND ON THE FLOR NEXT TO THE BED WITH PILLOW UNDER HIS HEAD. PATIENT STATES THAT HE WAS REACHING FOR THE BED SIDE TABLE WHEN THE AIR MATTRESS SHIFTED, CAUSING HIM TO LOSE BALANCE AND FALL ONTO THE FLOOR. PT DENIES HITING HIS HEAD AND DENIES PAIN AT THIS MOMENT. NEURO CHECKS PERFORMED AND WNL. PATIENT ASSISTED BACK TO BED WITH 3 STAFF AND STATED HE WAS COMFORTABLE WHEN FIXED INTO BED. EDUCATED THE PATIENT ON THE IMPORTANCE OF USING THE CALL LIGHT WHEN IN NEED OF ASSISTANCE. Record review of Resident #3's Progress Notes on 06/16/2025 at 04:35 pm written by PA HH revealed, No issues per nurse. During an interview on 10/21/2025 at 05:19 pm, PA HH stated she could not remember if she had been notified of Resident #3's fall on 06/16/2025, but she was pretty sure the nurse notified her of the fall. PA HH stated, If there are no notes on the fall, that's on me. I must have forgotten. PA HH stated she should have mentioned the fall in her notes. She stated again, If there are no notes on the fall or orders written in my notes, that is on me. I have a lot of patients I see. During an interview on 10/22/2025 at 02:36 pm, the DON stated the nurse should have documented the NP and RP were notified. The DON stated she did not know why PA HH did not document in her notes she was notified of the fall for Resident #3 when she came to see him that day of the fall (06/16/2025). During an interview on 10/28/2025 at 03:16 pm, LVN GG (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676446 If continuation sheet Page 14 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 676446 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/29/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mission Valley Nursing and Transitional Care 1200 S Bryan Rd Mission, TX 78572 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete stated when a resident had a fall, she would notify the doctor, notify family, notify DON, and start the neuro checks. She said she did not know why her Progress Note did not show the notifications to the doctor and RP when Resident #3 fell on [DATE]. During an interview on 10/28/2025 at 05:15 pm, the DON stated the nurses should put all information in the Progress Notes when there was a fall. She said the nurse (LVN GG) should have documented the NP/PA and RP were notified. The DON stated she did not know why the PA did not document in her notes she had been notified of the fall for Resident #3 when she came to see him that day. During an interview on 10/29/2025 at 11:40 am, Doctor II stated it was their practice to document unwitnessed falls of residents. He stated Resident #3's unwitnessed fall should have been documented by his PA (PA HH). Doctor II stated he was looking at the notes from his PA who had seen Resident #3 the same day as his fall (06/16/2025). He stated PA HH would be counseled for not documenting that Resident #3 had an unwitnessed fall, the evaluation she had done, and orders she had given. Record review of facility's policy Physician Visits and Physician Delegation policy dated 10/24/2022 revealed: PolicyIt is the policy of this facility to ensure the physician takes an active role in supervising the care of residents.Policy Explanation and Compliance Guidelines:1.The Licensed Nurse should:h. Write a note to reflect the date and time of the physician visit, and indication as to whether new orders were written or no new orders were received and any special discussions between the resident and/or family and physician during the visit. Record review of facility's policy Documentation in Medical Record policy dated 10/24/2022 revealed: Policy:Each resident's medical record shall contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress through complete, accurate, and timely documentation. Event ID: Facility ID: 676446 If continuation sheet Page 15 of 15