Spring Valley Post Acute LLC

Inspectors wroteBased on interview and record review, the facility failed to ensure that Discharge Minimum Data Set (MDS- computerized assessment instrument) assessments were initiated, completed and submitted within the required 14 day timeframe following resident discharge, in accordance with Centers for Medicare & Medicaid Services (CMS) requirements, for three of three sampled residents reviewed for resident assessments (Residents 35, 78, and 104). This failure had the potential to result in incomplete resident assessment discharge status information, which may affect continuity of care, follow up services, and compliance with federal reporting requirements.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that pressure injury (the type wound [open sore on the skin] caused by sitting or lying in one position too long) treatment and services were consistent with the residents' current wound conditions and with the facility's own treatment protocol for one out of three sampled residents (Resident 3) reviewed for pressure injury care. This failure resulted in delays in appropriate treatment, slowed the healing process, and increased the risk of further deterioration of Resident 3's right ischium (the lower, back part of the hip bone) pressure injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement its smoking safety policy for one of three sampled residents reviewed for smoking safety (Resident 47), when Resident 47 was found to have smoking materials in his possession on March 4, 2026. This failure had the potential to place the residents and others at risk for fire-related injury or other smoking-related accidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their dialysis policy for one resident (Resident 130) when staff did not monitor and complete Resident 130's Post Access Site Assessment (checking the dialysis access site after treatment to make sure it is safe and there are no problems like bleeding, swelling, infection). This failure had potential to cause complications at the access site for Resident 130.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were administered in accordance with the physician's orders and policy for one of six residents reviewed for Medication Administration (Resident 103) when a Licensed Vocational Nurse (LVN 1) administered an anti-hypertensive (used to treat high blood pressure) to Resident 103. This failure had the potential to result in poor blood pressure control and increased risk of hypertension-related complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a sanitary and safe environment for one of five residents reviewed for infection control when a License Vocational Nurse (LVN 2) entered Resident 130's room, which was a contact isolation precautions resident room ( prevent the spread of infections transmitted through direct or indirect contact with a patient or their environment), without wearing personal protection equipment (PPE-such as gloves and gown). This failure had the potential for cross contamination and infection (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) which can jeopardize the health and safety of residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its own policy and procedure concerning the use of physical restraints when three of three Justice-Involved Residents (residents under the care of law enforcement, community supervision, in custody, held involuntarily through operation of law enforcement authorities [Residents 1, 2, and 3]) did not receive respectful and dignified treatment. This includes the right to be free from physical restraints, which was not necessary to address residents' medical conditions. The facility, instead, placed sole responsibility on the correctional officers for the application, removal, and monitoring of potential complications associated with the use of restraints. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of five sampled residents (Resident 1) was free of any significant medication errors (administration of medications which was not in accordance with accepted professional standards and principles), when Resident 1 was given medications that belongs to another resident. These failures had the potential to jeopardize the health and well-being of medically compromised Resident 1.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to ensure the accuracy of a preadmission screening and resident review (PASARR) for 2 (Resident #34 and Resident #74) of 3 sampled residents reviewed for PASARRs.

Inspectors wroteBased on interview and facility policy review, the facility failed to update their abuse policy and procedure related to 1 of the 7 components of abuse prohibition. Specifically, the facility policy did not reflect the reporting of all allegations of abuse within the mandated timeframe of immediately, but not later than 2 hours after the allegation was made.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to timely report an allegation of abuse to the state survey agency for 1 (Resident #27) of 1 sampled resident reviewed for abuse.

Inspectors wroteBased on observation, interview, record review, facility policy review, the facility failed to develop a care plan to address a resident's right hand contracture for 1 (Resident #185) of 1 sampled resident reviewed for limited range of motion.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to implement services for the treatment of a right hand contracture for 1 (Resident #185) of 1 sampled resident reviewed for limited range of motion.

Inspectors wroteBased on observation, interview, record review, document review, and facility policy review, the facility failed to ensure staff donned personal protective equipment (PPE) before they entered the room of a resident who was on contact isolation and failed to ensure staff cleaned a multi-use glucometer after use before it was placed back on the medication cart for 1 (Resident #75) of 3 sampled residents reviewed for infection control.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to protect the resident ' s right to be free from abuse (the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish), for one of five sampled residents (Residents 1), when a Certified Nursing Assistant (CNA 1) was witnessed using profanity towards Resident 1, on November 6, 2024. This failure had the potential for Resident 1 to experience psychosocial harm.

Inspectors wroteBased on interview, and record review, the facility failed to notify the resident's designated responsible party for one of three sampled resident (Resident 1) when Resident 1's change of condition when Resident 1 developed redness, irritation to right side of throat and right ear with pain and itching. This failure prohibited Resident 1's representative to be actively involved in participating with Resident 1's comprehensive Plan of care.

Inspectors wroteBased on interview, and record review, the facility failed to follow their policy and procedure (P&P) when it did not administer regular insulin (a medication that helps your body use sugar for energy) that was readily available in their emergency kit (e-kit- small quantity of medications that can be dispensed when pharmacy services are not available) and instead used the insulin brought to the facility by resident's family. This had the potential to administer a medication that could have been tampered, contaminated or unsafe for use for one of three sampled residents (Resident 1).

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) when there were missing documentation for bowel and bladder elimination for one of three sampled residents (Resident 1). These failures had the potential to cause unsafe conditions and poor quality of life for Resident 1.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. Ice machine was not kept in sanitary condition and put residents at risk for foodborne illness (stomach illness acquired from ingesting contaminated food). 2. The handwashing sink in dish washing area was not providing enough hot water pressure to wash hands effectively, which had the potential to cause foodborne illness. 3. The microwave was not kept in sanitary condition which could transfer to residents' foods during reheating. This had the potential to contaminate the food and cause foodborne illness. 4. The floor under the stainless-steel counters and center island had food crumbs and trashes that had the potential to attract pests. 5. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of garbage and refuse properly when trash, and opened boxes were found outside on the floor surrounding the dumpster and the lids of the dumpsters did not close properly. This failure had the potential to attract pests and rodents.

Inspectors wroteBased on interview and record review, the facility failed to accurately document the Minimum Data Set (MDS- facility assessment tool) for three ( Residents 38, 81, and 155) of seven residents reviewed for MDS accuracy when: 1. Resident 38's Clopidogrel- an antiplatelet (medication that prevents blood cells from sticking together forming a clot) was coded as anticoagulant (medication that prevents the formation of blood clots) in Resident 38's MDS, dated [DATE]. 2. Resident 81's Clopidogrel- an antiplatelet was coded as anticoagulant in Resident 81's MDS, dated [DATE]. 3. Resident 155's MDS assessment for Active Diagnoses was left blank. These failed practices had the potential to result in unmet care needs for Residents 38, 81 and 155, which can affect the health and safety of the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy on Food Temperature to provide appetizing food at appropriate temperatures according to residents' preferences for three of 91 sampled residents (Resident 17, 70, 104). This failure placed residents at potential risk to decrease nutritional intake and affect the resident's nutrition status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the appropriate food textures was provided when 13 of 13 residents (Residents 50, 39, 102, 16, 14, 25, 30,10, 63, 55, 28, 355, 33) with pureed texture (a diet with food texture of smooth like pudding or mashed potatoes that requires no chewing for one who has difficulty chewing and/ or swallowing) received a bowl of Peanut Butter and Chocolate Swirl Pie pureed dessert with runny, watery consistency, had lumpy and chunk for lunch on February 2 2022. This failure had the potential to place the residents at risk of choking and aspiration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their infection control and prevention program by not following their policy and procedures when: 1. Resident 70's urinal (a container used to collect urine) was unlabeled and had brownish orange stain on the bottom of the container. 2. For one out of six residents, (Resident 100) nasal cannula (oxygen tubing) was not changed as per the facility's policy and procedure. 3. A Licensed Vocational Nurse (LVN 1) failed to wear appropriate personal protective equipment (PPE- equipment such as gloves, masks, and gowns worn by people who are at risk of injury or infection) and perform hand hygiene when she entered room [ROOM NUMBER] in the yellow zone (a designated area for symptomatic, suspected COVID-19, and residents awaiting test results; COVID-19 exposed residents; [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR- a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) was re-evaluated after a Significant Change in Status Assessment (SCSA- a comprehensive Minimum Data Set (MDS- a facility assessment tool) assessment done for a resident that must be completed when a resident meets the significant change guidelines for either improvement or decline), for one resident reviewed for PASRR (Resident 51). This failure had the potential for Resident 51 not to receive the care and services most appropriate for her needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed nurses performed glucometer (a machine that monitors how much sugar is in the blood) calibration (the process of setting up an instrument to provide a result for a sample within an acceptable range) in accordance with the facility policy and manufacturer's guidelines. This deficient practice had the potential to cause a wrong blood sugar reading in a vulnerable population of 28 residents who gets their blood sugar monitored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were properly labeled, dated, and stored when opened for Over the Counter (OTC- are medicines sold directly to a consumer without a requirement for prescription) medication bottles were available for use in one of three Medication Storage Rooms. This failure had the potential to cause unsafe and/or inappropriate storage and administration of medications for a highly vulnerable population of 92 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Food and Nutrition Services staff had appropriate competencies to carry out the functions of the food and nutrition services when two Dietary Aide (Dietary Aide 1 and Dietary Aide 2) did not know how to check the sanitation concentration on the dish machine. These failures had the potential to cause foodborne illness (stomach illness acquired from ingesting contaminated food) to all residents, in a medically compromised population of 91 out of 92 residents who received foods from the kitchen.

Inspectors wroteBased on observation, and interview, the facility failed to ensure trash can lids were functioning and ready to use when the footstep was not functioning in multiple residents' isolation rooms (residential care needs Personal Protective Equipment (PPE- gown gloves and face masks to provide care to control the source of infection). This failure had the potential to spread the source of infection and to compromise the health and wellbeing from a universe of 92 residents who were on isolation precautions (use PPE while providing care to the residents).