Spring Valley Post Acute LLC

In the surveyor’s words

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

• Immediate jeopardy, widespreadF812Feb 4, 2022

  Based 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. […]

• Immediate jeopardy, patternF604Sep 26, 2025

  Based 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. […]

• Actual harm, isolatedF689Jan 27, 2022

  Based on observation, interview, and record review the facility failed to ensure for one of nine residents (Resident 1) with a diagnosis of dementia and periods of forgetfulness was being properly monitored and supervised when the following occurred: 1. The facility failed to implement 1:1 monitoring and supervision of care after Resident 1 left the building on February 1, 2021, without staff's knowledge. 2. Staff failed to monitor and properly supervise Resident 1 on June 26, 2021, when he eloped (leaving building without permission from the physician) and was hit by a car causing his death. These failures resulted in Resident 1 not being monitored or supervised resulting in Resident 1 eloping on February 1, 2021, and June 26, 2021. […]

• No harm, potential for more than minimal, widespreadF814Feb 4, 2022

  Based 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. Findings: During an observation on February 1, 2022, at 9:48 AM, outside facility in front of the laundry area, the dumpster was overflow with trash and opened boxes. Lids of the dumpster was unable to fully close. Surrounding the dumpster on the floor there was trash and piles of opened boxes. During an observation on February 1, 2022, at 9:52 AM, outside facility in front of laundry, three recycle dumpster lids were not close. […]

• No harm, potential for more than minimal, patternF645Nov 21, 2024

  Based 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. Findings included: A facility policy titled, Pre-admission Screening and Resident Review (PASARR), revised 12/2006, indicated All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) per the Medicaid Pre-Admission Screening and Resident Review process. Policy Interpretation and Implementation 1. […]