Mission Valley Nursing: DNR Not Updated After Signing - TX
That is what inspectors found at Mission Valley Nursing and Transitional Care following a complaint inspection completed October 29, 2025. The facility, on South Bryan Road in Mission, failed to update the care plan for a resident identified in records as Resident 3 after he signed a DNR. His care plan continued to list him as Full Code on the same date the DNR was executed. It was not corrected until days later.
During that window, he fell.
The fall was unwitnessed. Inspectors noted no obvious injury was recorded. But the director of nursing, interviewed during the inspection, acknowledged directly what the delay meant. She said it would not have been clear whether the resident was DNR if anything had happened to him between the date he signed the order and the date the care plan was finally updated. She said it should have been updated sooner.
That is the institution's own assessment of its own failure.
The care plan is not a bureaucratic formality. It is the document staff consult when a resident's condition changes suddenly, when seconds matter and there is no time to search through admission paperwork or call a family member. If a resident collapses and the care plan says Full Code, staff resuscitate. If the resident had already decided, in writing, that he did not want that, the care plan's error does not just create confusion. It creates the conditions for overriding a person's final medical wishes.
The facility's own policy, titled "Care Plan Revisions Upon Status Change," required that care plans be updated with new interventions when a status change was identified and that a unit manager audit all residents experiencing a change in status at the time the change was identified. The DNR was a status change. The audit did not happen in time.
The inspection also surfaced a separate documentation concern involving psychotropic medications. A licensed vocational nurse told inspectors that when a nurse received an order for a psychotropic or antipsychotic, the medication was not to be entered into the computer system until the family had signed consent. The logic offered was that keeping the order out of the system would prevent the medication from appearing on the medication administration record, which would in turn prevent it from being given before consent was obtained.
Another LVN told inspectors that the nurse who received the psychotropic order was also responsible for updating the care plan with goals and interventions for that medication.
Inspectors also documented how code status changes were supposed to work at the facility. According to an LVN interviewed during the inspection, the social worker would notify the nurse of any change, the nurse would then update the status, discontinue the original code status order, and document in the comments that the resident's code status had changed to DNR. That process existed. It was not followed in time for Resident 3.
The deficiency was cited at a level of minimal harm or potential for actual harm, affecting few residents. That classification reflects what inspectors could document, not what could have happened. Resident 3 fell while his care plan was wrong. He was not injured in a way inspectors could record. But the director of nursing said it herself: if something had happened to him during those days, nobody looking at his chart would have known what he wanted.
He had already told them. He had signed the paper. The facility just had not written it down where it counted.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mission Valley Nursing and Transitional Care from 2025-10-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Mission Valley Nursing and Transitional Care in Mission, TX was cited for violations during a health inspection on October 29, 2025.
That is what inspectors found at Mission Valley Nursing and Transitional Care following a complaint inspection completed October 29, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.