Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Spring Valley Post Acute Llc during CMS and state inspections, most recent first.
Three justice-involved residents with complex medical conditions were kept in metal shackles attached to their beds, with removal only for toileting, showers, or physical therapy, and all restraint management handled by correctional officers. Facility staff did not assess, document, or obtain physician orders for the restraints, nor did they follow the facility's own restraint policy, resulting in a deficiency related to the lack of respectful and dignified treatment.
A resident in an LTC facility was mistakenly given medications intended for another resident, which she did not consume upon recognizing the error. The incident was reported, but the facility could not identify the responsible staff member or the exact time of the error. The facility's policy on resident identification before medication administration was not followed.
The facility failed to ensure accurate PASARR screenings for two residents, leading to deficiencies. One resident with schizophrenia and other mental health diagnoses was incorrectly documented as having no serious mental disorders. Another resident with mood disorder and psychosis also had an inaccurate PASARR. Interviews revealed a lack of responsibility and awareness regarding the accuracy of these screenings.
The facility's abuse policy was outdated, allowing a 24-hour window for reporting allegations of abuse, contrary to the mandated requirement of reporting within 2 hours. The Administrator confirmed reliance on this outdated policy, leading to a deficiency in abuse prevention and reporting procedures.
A resident with intact cognition reported verbal abuse by a CNA, who refused to provide a shower due to the resident's weight, citing staff safety concerns. The facility failed to report the allegation to the state agency immediately, as required by its policy, resulting in a deficiency.
A resident with a history of hemiplegia and hemiparesis was admitted with a right hand contracture, but the facility failed to develop a care plan to address this issue. Despite observations and staff acknowledgment of the contracture, no care plan was documented, contrary to facility policy requiring comprehensive care plans for residents' needs.
A facility failed to provide necessary care for a resident with a right hand contracture, despite the resident's documented need for range of motion interventions. Observations showed the absence of a splint or hand towel, and staff interviews confirmed the lack of these measures. The facility's administrator acknowledged the expectation for such care, highlighting a deficiency in meeting the resident's needs.
A facility failed to ensure proper infection control practices for a resident on contact isolation. An LVN entered the resident's room without wearing the required PPE and did not sanitize a multi-use glucometer after use, contrary to facility policy. The resident was on contact precautions for MRSA, and the facility's policies required PPE use and glucometer sanitization between uses.
A resident with an anxiety disorder experienced verbal abuse from a CNA who used profanity and confrontational language after the resident requested ice. The incident was overheard by another CNA and the resident's roommate. The facility's policy on abuse prevention was violated.
A facility failed to notify a resident's responsible party of a change in condition, including redness and irritation, due to reliance on outdated admission records. The LVN did not review the resident's H&P, which indicated the resident's incapacity to make decisions. The DON confirmed the oversight, which violated the facility's policy on notifying changes in condition.
Failure to Follow Restraint Policy for Justice-Involved Residents
Penalty
Summary
The facility failed to follow its own policy and procedure regarding the use of physical restraints for three justice-involved residents who were under the care of law enforcement and admitted to the facility in metal shackles. These residents were observed restrained with metal shackles on their ankles and, in some cases, wrists, which were attached to the bed frame or side rails. The shackles were only removed when the residents needed to use the restroom, shower, or participate in physical therapy, and the removal was performed by correctional officers, not facility staff. Facility staff, including CNAs and nurses, did not conduct regular assessments of the residents' skin integrity or document the use of restraints, as required by the facility's policy. Interviews with staff revealed that the facility considered itself a 'no-restraint' facility and did not classify the shackles as restraints, despite their definition in the facility's own policy. Staff were not trained in the use of restraints, did not perform or document pre-restraining assessments, and did not obtain physician orders for the use of restraints. There was no care plan in place for the use of restraints, and the use of shackles was not coded on the Minimum Data Set (MDS). Nursing progress notes did not include documentation of the placement or removal of restraints, nor were there assessments of skin integrity related to the use of shackles. The residents affected had significant medical conditions, including hemiplegia, hemiparesis, heart failure, hypotension, peripheral autonomic neuropathy, acute kidney failure, hand fracture, cellulitis, neuropathy, and hypertension. Despite these conditions, the facility did not provide the required monitoring or documentation for the use of restraints. The responsibility for monitoring and managing the restraints was placed solely on the correctional officers, and the residents did not participate in activities outside their rooms except for showers and physical therapy. The facility's failure to adhere to its own restraint policy and federal regulations resulted in a deficiency related to the respectful and dignified treatment of these residents.
Removal Plan
- Residents identified as affected by the deficient practice involving the use of physical restraints were discharged in coordination with the Federal Correctional Complex (FCC) Victorville and attending physician and transferred to [NAME] Valley Global Medical Center.
- The attending physician declined to issue orders for the continued use of restraints.
- Residents affected by the deficient practice will be discharged in coordination with FCC as follows: Room # 9A Resident 1 to [Name of the hospital], Room # 9C Resident 2 to [Name of the hospital], Room # 16C Resident 3 to [Name of the hospital].
- A comprehensive review of records for 107 residents was completed. In addition, direct observations were conducted across all shifts by charge nurses and Registered Nurses. Alert residents were interviewed by staff. No additional residents were found to be affected by the deficient practice.
- Ongoing in-service training was provided by Director of Staff Development with an emphasis on the distinction between medical and correctional restraints.
- Resident's requiring physical restraints will be observed for 72 hours, during which non-pharmacological interventions will be attempted in collaboration with Activities, Social Services, Nursing, and Rehab.
- Physicians and family members will be notified, and nursing staff will follow up on all physician orders.
- Social Services, in coordination with the interdisciplinary team (IDT), will provide information regarding the resident's behavior and the effectiveness of the treatment plan to the resident and, as appropriate, to the family or responsible party.
- Licensed nurses will conduct weekly skin integrity checks and document daily progress notes. Any concerns will be escalated to the Primary Care Provider (PCP) and family.
- Residents will be repositioned per facility protocol.
- Monthly psychosocial-emotional assessments will be conducted by Social Services, with documentation of observations, interviews, and reviews involving residents, families, and staff.
- Recapitulation of findings will be presented and reported by the Director of Nursing (DON) or designee to the Quality Assessment and Assurance Committee on a monthly basis for three months, or until 100% compliance has been sustained. The Committee will review the findings and take action as indicated.
- The facility will not admit justice-involved individuals until it has confirmed substantial compliance with all applicable statutes and regulations governing the care of justice-involved individuals.
Medication Error Involving Incorrect Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors when a nurse administered medications intended for another resident. On February 26, 2025, a resident was given a medication cup labeled 52B containing six different types of medication, which she did not consume because she recognized they were not hers. The resident, who was cognitively intact with a BIMS score of 15, reported the incident. A review of her Medication Administration Record for February 2025 showed she was prescribed several medications, none of which matched the ones she was given. The Director of Nursing was informed of the incident on February 28, 2025, and confirmed that the medications given to the resident belonged to another resident who had been admitted to the hospital on the same day. The facility's incident report acknowledged the medication error but could not identify the staff member responsible or the exact time it occurred. Interviews with the nursing staff revealed that the night nurse denied administering the incorrect medications, as they were given in the morning. The facility's policy requires residents to be identified before drug administration, which was not followed in this case.
Inaccurate PASARR Screenings for Residents
Penalty
Summary
The facility failed to ensure the accuracy of the Preadmission Screening and Resident Review (PASARR) for two residents, leading to deficiencies in the screening process. Resident #74 was admitted with a medical history that included schizophrenia, unspecified psychosis, impulse disorder, mood disorder, depressive episodes, and anxiety disorder. However, the PASARR Level I Screening for this resident incorrectly indicated that there were no serious mental disorders such as schizophrenia or symptoms of psychosis. Interviews with the Minimum Data Set/Resident Coordinator and the Director of Nursing Services (DNS) confirmed that the resident's diagnosis of schizophrenia should have been included in the PASARR. Similarly, Resident #34 was admitted with a history of mood disorder and psychosis, and the Minimum Data Set (MDS) indicated moderate cognitive impairment and active diagnoses of psychotic disorder. Despite this, the PASARR Level I Screening for Resident #34 also failed to capture the diagnosis of psychosis. The MDS/Resident Coordinator stated she was not responsible for ensuring the accuracy of the PASARR and was unaware of why the diagnosis was omitted. These inaccuracies in the PASARR screenings for both residents highlight a failure in the facility's process to accurately document and review mental health diagnoses upon admission.
Failure to Update Abuse Reporting Policy
Penalty
Summary
The facility failed to update its abuse policy and procedure to comply with the mandated timeframe for reporting allegations of abuse. The existing policy, effective since October 2014, required reporting of alleged and substantiated violations to the state agency and other relevant agencies within 24 hours of knowledge of the incident. However, the policy did not align with the requirement to report all allegations of abuse immediately, but not later than 2 hours after the allegation was made. This discrepancy was identified during a review of the facility's policy titled 'Policy and Procedure on Patient Abuse and Prevention.' During an interview, the Administrator, who assumed the role in July 2023, confirmed that the facility was operating under the outdated policy, which allowed for a 24-hour reporting window unless the incident involved serious bodily injury. This failure to update the policy to reflect the current reporting requirements constituted a deficiency in the facility's abuse prevention and reporting procedures.
Failure to Timely Report Allegation of Verbal Abuse
Penalty
Summary
The facility failed to timely report an allegation of abuse involving a resident to the state survey agency. The facility's policy on patient abuse and prevention requires that all alleged and substantiated violations be reported to the state agency within 24 hours of knowledge of the incident. However, the facility did not adhere to this policy in the case of a resident who reported verbal abuse by a certified nursing assistant (CNA). The resident, who had a medical history including morbid obesity, chronic obstructive pulmonary disease, type 2 diabetes mellitus, muscle weakness, and chronic heart failure, reported that a CNA refused to provide a shower due to the resident's weight, citing concerns for staff safety and potential legal repercussions. The resident, who had intact cognition as indicated by a Brief Interview for Mental Status (BIMS) score of 15, reported the incident to the surveyor on November 18, 2024. The surveyor then informed the facility's Administrator and Director of Nursing Services. The Administrator reported the allegation to the state agency later that day, but the report was not made immediately upon knowledge of the incident, as required by the facility's policy. The delay in reporting the allegation of verbal abuse constituted a deficiency in the facility's adherence to its own policies and regulatory requirements.
Failure to Develop Care Plan for Resident's Contracture
Penalty
Summary
The facility failed to develop a care plan to address a resident's right hand contracture, which was identified during a survey. The resident, who was admitted on 10/21/2024, had a medical history of hemiplegia and hemiparesis following cerebrovascular disease affecting the right dominant side. An admission Minimum Data Set (MDS) assessment indicated that the resident was severely impaired in cognitive skills for daily decision-making and had a range of motion limitation in both upper and lower extremities. Despite these findings, the resident's medical record showed no evidence of a care plan to address the right hand contracture. Observations on multiple occasions confirmed the presence of the right hand contracture. Interviews with facility staff, including a Licensed Vocational Nurse and the MDS/Resident Coordinator, confirmed the absence of a care plan for the contracture. The MDS/Resident Coordinator, who was responsible for completing care plans with the Director of Nursing Services, acknowledged the oversight. The facility's policy requires comprehensive care plans to meet residents' medical, nursing, and psychological needs, including addressing limited range of motion, but this was not adhered to in this case.
Failure to Implement Care for Resident's Hand Contracture
Penalty
Summary
The facility failed to implement necessary services for the treatment of a right hand contracture for Resident #185, who was admitted with a medical history of hemiplegia and hemiparesis following cerebrovascular disease affecting the right dominant side. The resident's admission Minimum Data Set (MDS) indicated severe cognitive impairment and a range of motion limitation in both upper and lower extremities. Despite these documented needs, there was no evidence of a care plan addressing the resident's right hand contracture. Observations over several days revealed that Resident #185 had a right hand contracture without the use of a splint or hand towel, which are measures typically used to prevent further contractures and infections. Interviews with staff, including a registered nurse and a certified nursing assistant, confirmed the absence of these interventions. The facility's administrator acknowledged that range of motion should be provided based on the resident's assessment, and a hand roll would be a measure to prevent contractures, indicating a lapse in the expected standard of care.
Infection Control Deficiency: Improper PPE Use and Glucometer Sanitization
Penalty
Summary
The facility failed to ensure proper infection prevention and control measures were followed for a resident on contact isolation. A Licensed Vocational Nurse (LVN) entered the room of a resident who was on contact isolation for methicillin-resistant Staphylococcus aureus (MRSA) without donning the required personal protective equipment (PPE), which included a gown and gloves. The LVN believed that PPE was unnecessary as long as there was no physical contact with the resident, despite a sign on the resident's door indicating the need for PPE. This action was contrary to the facility's policy on transmission-based precautions, which mandates the use of appropriate PPE upon entering the room of a resident on contact isolation. Additionally, the LVN failed to sanitize a multi-use glucometer after checking the resident's blood sugar, placing it back on the medication cart without cleaning it. The facility's policy and the glucometer's user manual both require that the device be sanitized between uses with an EPA-registered disinfectant. The LVN acknowledged the oversight, citing a lack of disinfectant wipes on the medication cart as the reason for not cleaning the glucometer. Interviews with the Infection Preventionist and the Director of Nursing Services confirmed that staff were expected to wear PPE when entering the room of a resident on contact precautions and to clean glucometers after each use.
Verbal Abuse Incident Involving CNA and Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from abuse when a Certified Nursing Assistant (CNA) was witnessed using profanity towards a resident. The incident occurred when the resident requested ice from the CNA, who left the room to get gloves without informing the resident. The resident, feeling confused and thinking he had done something wrong, expressed frustration verbally. Upon returning, the CNA confronted the resident in a confrontational manner, using inappropriate language and demanding the resident to sit down. The resident involved had been admitted to the facility with a diagnosis that included an unspecified anxiety disorder, and his cognitive status was intact as indicated by a Brief Interview for Mental Status (BIMS) score of 15. The incident was corroborated by another CNA who overheard the altercation and the resident's roommate, who heard the exchange but could not see it. The facility's policy on abuse prevention clearly states the residents' right to be free from any form of abuse, which was violated in this instance.
Failure to Notify Responsible Party of Resident's Condition Change
Penalty
Summary
The facility failed to notify the designated responsible party of a resident's change in condition, which included redness, irritation, pain, and itching on the right side of the throat and right ear. This failure occurred despite the resident's primary physician indicating that the resident did not have the capacity to understand and make decisions. The Licensed Vocational Nurse (LVN) involved did not review the resident's History and Physical (H&P) documentation, which clearly stated the resident's incapacity, and instead relied solely on the admission record that inaccurately listed the resident as self-responsible. The Director of Nursing (DON) confirmed that the responsible party was not notified on two separate occasions, as indicated on the Change of Condition (COC) form. The facility's policy requires notifying the resident, their attending physician, and any interested family member or legal representative of changes in the resident's condition, except in medical emergencies. The failure to update the admission record to reflect the physician's assessment contributed to the oversight in notifying the responsible party.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Victorville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Knolls West Post Acute Llc | 1.7 mi | — | 1 | 0 |
| Desert Ridge Transitional Care Center, Lp | 2.9 mi | — | 7 | 0 |
| Apple Valley Care Center | 5.1 mi | — | 15 | 0 |
| Mountains Community Hosp Dp/snf | 19.2 mi | — | 0 | 0 |
| Hillcrest Nursing Home | 24.1 mi | — | 6 | 0 |
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