Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brighton Place Spring Valley during CMS and state inspections, most recent first.
Three residents experienced ongoing discomfort from cold temperatures when a broken HVAC unit was not repaired, leaving them unable to control room temperature. Residents with conditions such as fibromyalgia, COPD, and mobility issues reported being cold at night and relied on extra blankets or space heaters, which were not always available. The HVAC issue persisted for weeks while awaiting corporate approval for repairs.
A resident with moderate cognitive impairment and mobility issues was found with a space heater operating in her room, which staff had provided and operated for her comfort. Facility staff confirmed that space heaters are not allowed due to burn and fire risks, and facility policy restricts unauthorized electrical appliances in resident areas. This resulted in a failure to maintain a safe environment free from accident hazards.
Three residents were discharged without receiving the required written Notice of Transfer/Discharge, as confirmed by record review and staff interviews. The DON and SSD acknowledged that notices were not provided prior to discharge, citing workload issues. Facility policy mandates that such notices be given to residents or their representatives and documented in the medical record, but this was not done in these cases.
The facility did not develop or implement timely, person-centered discharge care plans for two residents, including one with chronic kidney disease and another with pneumonia. In both cases, discharge planning was either delayed until the day of discharge or not documented at all, contrary to facility policy and staff expectations. Interviews confirmed that this lack of timely planning could lead to uncoordinated and potentially unsafe discharges.
Two residents were prescribed psychotropic medications without specific behaviors or side effects being listed or monitored, as required by facility policy. Staff and pharmacy consultant interviews confirmed the lack of documentation in physician orders and MARs, and there was no consistent evidence to support the necessity of these medications. Facility policies required such monitoring, but it was not implemented for these residents.
Two residents' rooms were found with large areas of discoloration and peeling paint on the walls near their beds, which were visible to both residents and their visitors. Nursing and maintenance staff acknowledged the poor condition but had not documented or addressed the repairs, despite facility policy requiring maintenance issues to be logged and resolved.
A resident with dementia was admitted to hospice care, but the facility did not develop or implement a hospice care plan as required. Clinical record review and staff interviews confirmed the absence of such a plan, resulting in inconsistent staff interventions. Facility policy required collaboration with hospice and timely care plan updates, but these steps were not followed.
A resident with a history of severe sepsis, UTI, and bacteremia had a PIV catheter that was not changed according to the physician's order for site rotation and dressing change every 48 hours. Multiple observations confirmed the PIV and dressing remained unchanged beyond the scheduled intervals, and both nursing staff and the DON acknowledged the lapse, which was not in accordance with facility policy.
A resident with COPD was receiving oxygen therapy without a documented rationale or indication in the medical record, despite a physician's order requiring this information. The resident used oxygen in the facility but not during trips to medical appointments, and staff confirmed the omission of the required documentation. Facility policy and staff interviews indicated that all oxygen orders should include a reason for use.
A resident with brain cancer and weight loss did not receive recommended dietary changes after the RD advised discontinuing unwanted protein shakes and substituting with a frozen supplement and peanut butter. Despite clear documentation and communication, the dietary staff delayed updating the resident's meal plan, resulting in continued provision of unwanted supplements and failure to meet the resident's nutritional preferences within the facility's required timeframe.
A resident with dementia and schizoaffective disorder, under public conservatorship, was not offered influenza or pneumococcal vaccines as required. The facility failed to document any offer, education, or consent for these vaccinations, and staff interviews confirmed that the process was not completed according to policy.
A resident with dementia and schizoaffective disorder, under public conservatorship, was not offered the COVID-19 vaccine as required. The Infection Control Nurse did not follow up with the Social Services Director or the conservator's office to obtain consent, and there was no documentation of vaccine offer, education, or consent in the clinical record, contrary to facility policy and staff expectations.
A facility failed to provide a prescribed inhaler medication to a resident with COPD for eight days due to a lack of authorization from the pharmacy. A nurse confirmed the medication's unavailability, and the DON could not explain the delay. The facility also lacked a policy for medication dispensing.
A resident with right wrist drop did not have a splint applied as ordered by a physician, potentially worsening her condition. The DON confirmed that the resident did not receive daily RNA interventions, and documentation showed range of motion exercises were provided only 10 out of 26 days.
A resident with multiple diagnoses reported feeling violated by staff members and made several attempts to report the incidents to the social worker, DON, and administrator. Despite the facility's policy requiring immediate reporting to authorities, the administrator did not report the allegations, believing them to be false without proper investigation.
The facility failed to conduct a risk assessment for legionella in its water system and did not follow aseptic techniques during a catheter insertion for a resident with cognitive impairment. The Maintenance Supervisor and Infection Preventionist confirmed the absence of a risk assessment, while an LVN acknowledged using non-sterile gloves during the procedure, contrary to facility policy.
A facility failed to ensure the accuracy of an MDS assessment for a resident with schizophrenia, not reflecting the required PASARR Level II status. Despite a completed Level II evaluation recommending specialized services, the MDS did not indicate the resident's serious mental illness. Interviews with staff revealed expectations for accurate assessments, highlighting a lapse in regulatory compliance.
A resident with moderate cognitive impairment and a history of COPD was not properly supervised according to their care plan, which included interventions for smoking and elopement risk. The resident was observed leaving the facility unsupervised while smoking and was found in a non-designated smoking area. Staff interviews revealed lapses in following the care plan, with the Administrator acknowledging documentation errors.
A resident with moderate cognitive impairment and a history of elopement risk left the facility unsupervised and smoked in a non-designated area. Despite policies requiring supervision and sign-out procedures, staff were unaware of the resident's actions, indicating a failure to adhere to safety protocols.
The facility failed to ensure that psychotropic medications were ordered with a stop date for two residents, as per policy. The report highlights that the facility's policy is to ensure that as-needed psychotropic medications are ordered for a duration of 14 days, but this was not followed. The oversight in the documentation and monitoring of psychotropic medications represents a significant deficiency in the facility's care practices.
The facility failed to discard expired medications and improperly stored medications for three residents. An LPN found expired lorazepam in the refrigerator, and the DON confirmed expired medications should not be stored. A resident with multiple sclerosis had unauthorized supplements and analgesics at their bedside, while another with COPD had an inhaler left by a nurse. A third resident with cellulitis had unauthorized supplements and numbing agents at their bedside.
The facility failed to maintain an effective training program for two LVNs, as required by its policy. LVN #7, hired in 2021, had no competency documentation, and LVN #3, hired in 2023, had only one documented training. Both LVNs reported a lack of training, and the DSD confirmed the absence of documented shadowing or competency assessments. The DON and Administrator acknowledged non-compliance with the facility's training policy.
The facility failed to ensure that call cords were within reach for five residents, potentially preventing them from obtaining needed assistance. Observations and interviews confirmed that call cords were hanging out of reach, and the facility's policy indicated that call cords should be accessible. The current call cord system did not allow for adaptive devices.
The facility failed to ensure proper respiratory care for two residents. One resident received Bi-PAP treatment without a proper setting order from the physician, and another resident's change in condition was not documented or reported to the physician in a timely manner.
Failure to Maintain Comfortable Temperatures Due to Broken HVAC
Penalty
Summary
The facility failed to provide a safe, comfortable, and homelike environment for three of four sampled residents due to a broken HVAC unit that was not repaired in a timely manner. The HVAC malfunction affected the temperature control in several rooms, resulting in residents being unable to adjust the thermostat to a warmer setting. Observations and interviews revealed that residents consistently felt cold, especially during the night and early morning hours. Residents coped by using multiple blankets or relying on space heaters provided by staff, but these measures were insufficient or inconsistently available. Resident 1, who had fibromyalgia and moderate cognitive impairment, reported feeling extremely cold at night despite using several blankets and resorted to sleeping with her head under the covers. Resident 2, with chronic obstructive pulmonary disease and bradycardia, also experienced discomfort due to the cold and noted that the space heater was not always available for her use. Resident 3, who had difficulty walking and a history of falls, depended on a space heater to sleep comfortably. The Maintenance Supervisor confirmed that the HVAC unit had been broken for several weeks and that repairs were delayed pending corporate approval. The facility's policy emphasized the importance of maintaining comfortable temperatures for residents, which was not achieved in this instance.
Unauthorized Space Heater in Resident Room Creates Safety Hazard
Penalty
Summary
A deficiency was identified when a resident with moderate cognitive impairment, difficulty walking, and a history of falls was found in her room with a space heater turned on. The resident reported that staff provided her with the space heater and would turn it on for her in the mornings, as she felt too cold at night without it. The space heater was observed on the floor across the room while the resident was in bed. Interviews with facility staff, including the Maintenance Supervisor and the Director of Nursing, confirmed that space heaters are not permitted in resident rooms due to the risk of burns and fire hazards. A review of the facility's policy on electrical appliances indicated that only authorized electrical appliances are allowed in resident living areas, but did not specifically address the use of space heaters. The presence and use of the space heater in the resident's room constituted a failure to provide a safe environment free from accident hazards.
Failure to Provide Written Notice of Transfer/Discharge
Penalty
Summary
The facility failed to provide a written Notice of Transfer/Discharge to three residents and their responsible parties prior to their discharge, as required by both facility policy and federal regulations. Record reviews for three residents revealed that none had documented evidence of receiving the required written notice before being transferred or discharged to lower levels of care, such as assisted living or independent living facilities. Interviews with the Director of Nursing (DON) and the Social Service Director (SSD) confirmed that the notices were not provided, with the SSD citing being overwhelmed with workload as a reason for not issuing the notices in advance. The DON and a licensed nurse both acknowledged the importance of these notices in preparing residents and their families for discharge and reducing anxiety. The facility's own policies specify that a Notice of Proposed Transfer and Discharge must be given to the resident or their representative prior to discharge, with a copy placed in the medical record and sent to the Ombudsman. Despite these requirements, the review of clinical records and interviews with staff confirmed that the notices were not provided for the three residents in question. The absence of these notices meant that residents and their families were not formally informed in writing about the upcoming discharge, nor were they given the opportunity to appeal the decision, as required by regulation.
Failure to Develop and Implement Timely Discharge Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered care plans related to resident discharges for two of three residents reviewed. For one resident with chronic kidney disease and a responsible party, the discharge care plan was created by the Social Service Director on the day of discharge, rather than at admission as required. The resident had a moderately impaired cognitive score, and the discharge was to an assisted living facility via medical transport. The care plan listed interventions such as establishing a pre-discharge plan and coordinating discharge, but was not developed in a timely manner. For another resident with pneumonia and intact cognition, there was no documented evidence that a discharge care plan had been developed or implemented prior to discharge to an assisted living facility. Interviews with the DON and staff confirmed that discharge care plans should be developed at admission to allow for collaboration and preparation, and that the absence or late development of such plans could result in disorganized or unsafe discharges. The facility's policy also stated that discharge planning should begin at admission and be documented by social services.
Failure to Monitor and Document Behaviors for Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs by not listing and monitoring specific behaviors for the use of psychotropic medications for two residents. For one resident with diagnoses including dementia and suicidal ideations, multiple psychotropic medications were prescribed without specific behaviors or side effects being listed for monitoring in the physician’s orders, Medication Administration Record (MAR), or care plans. Staff interviews confirmed that there was no documentation of behaviors or side effects, and the pharmacy consultant acknowledged missing this omission during the monthly medication regimen review. Another resident with diagnoses including encephalopathy and major depressive disorder was prescribed an antipsychotic medication for schizophrenia without specific behaviors being documented for staff monitoring. Interviews with staff, family, and the psychiatric nurse practitioner revealed a lack of observed or documented behaviors such as delusions, hallucinations, or violence that would justify the use of the medication. The DON and medical director both stated that there was no consistent documentation of behaviors to support the diagnosis or the use of the antipsychotic medication. Facility policies required that orders for psychoactive medications include specific behaviors to be monitored and that staff document these behaviors and any side effects. Despite these policies, the facility did not ensure that such documentation was present or that staff were monitoring and recording the necessary information to determine the continued need for psychotropic medications for the affected residents.
Failure to Maintain Clean and Homelike Resident Room Walls
Penalty
Summary
The facility failed to maintain a clean, homelike, and visually appealing environment in the rooms of two residents, as evidenced by large areas of discoloration and peeling paint on the walls near the heads of their beds. These deficiencies were observed during initial tours and confirmed by both nursing and maintenance staff, who acknowledged the poor condition of the walls and agreed that repairs were needed. The issues were visible to residents and their visitors, with one resident's family member regularly sitting in a position where the damaged wall was in clear view. Despite the facility's policy requiring staff to document maintenance needs in a log at the nurse's station, a review of the maintenance book showed no entries for the needed repairs in these rooms over a five-month period. The Director of Maintenance admitted that although repairs had been made in other units, the required repairs for these rooms had not been documented or addressed. The Director of Nursing also confirmed that all rooms were expected to be presentable and homelike, and that staff were responsible for reporting such issues.
Failure to Develop Hospice Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a hospice care plan for a resident who had been admitted to hospice care, as evidenced by observation, interviews, and record review. The resident, who had a diagnosis of dementia, was admitted to the facility and subsequently had a physician's order for hospice admission. Despite this order, there was no documented evidence that a hospice care plan was created or implemented for the resident. This omission was confirmed through review of the clinical record and interviews with licensed nursing staff, who acknowledged the absence of a hospice care plan and recognized its importance for consistent and coordinated care. Further, the Director of Nursing confirmed that both the hospice agency and the facility are responsible for developing care plans to ensure staff provide consistent care, but acknowledged that this was not done for the resident in question. Facility policies reviewed also required the development and updating of comprehensive, person-centered care plans based on assessed needs, and specifically called for collaboration between the hospice and facility on care planning when a resident elects hospice care. The lack of a hospice care plan meant that staff interventions were not being implemented consistently for the resident.
Failure to Change Peripheral IV Catheter and Dressing per Physician Order
Penalty
Summary
A peripheral intravenous (PIV) catheter was inserted into a resident's left arm on 4/29/25, as documented on the dressing. The resident had a physician's order to change the PIV line and dressing every 48 hours, with scheduled changes on 5/1/25, 5/3/25, and 5/5/25. Observations conducted on 5/5/25, 5/6/25, and 5/7/25 confirmed that the PIV catheter and dressing had not been changed since the initial insertion date. Licensed nurses interviewed during these observations acknowledged that the PIV should have been changed according to the physician's order to prevent infection and ensure the line remained functional. The resident involved had been admitted with severe sepsis, urinary tract infection, and bacteremia, conditions that require careful infection control. The Director of Nursing confirmed that the facility's protocol is to follow physician orders for IV site rotation and dressing changes, and that the failure to change the PIV as ordered placed the resident at risk for further infection. Review of facility policy indicated that all IV dressing changes should be labeled and documented, and that site rotation is a required component of complete orders.
Failure to Document Rationale for Oxygen Therapy
Penalty
Summary
The facility failed to document a rationale for the use of oxygen therapy for a resident with a diagnosis of chronic obstructive pulmonary disease (COPD). The resident was observed using oxygen in bed and reported using it most of the time due to COPD, but did not use oxygen during trips outside the facility for medical appointments. The physician's order for oxygen required staff to specify a diagnosis or reason for use, but the electronic health record and Medication Administration Record did not include documentation of the indication for oxygen therapy. Oxygen saturation levels for the resident were consistently above 92% both on oxygen and on room air. Licensed nursing staff and the Director of Nursing confirmed that all oxygen orders require a rationale for use and that the omission was a mistake. Facility policy also required oxygen to be administered as prescribed, with a documented purpose. The lack of documentation for the reason for oxygen use meant that staff would not know the intended purpose of the therapy, and the resident was not provided with oxygen during transportation to appointments, contrary to the physician's order.
Failure to Implement Dietitian's Dietary Recommendations for Resident
Penalty
Summary
The facility failed to implement the Registered Dietitian's (RD) recommendations for a resident with brain cancer who was experiencing weight loss and had a low albumin level. The RD had assessed the resident and recommended discontinuing protein shakes, which the resident found too sweet and refused, and substituting them with a frozen supplement (Magic Cup) and adding peanut butter to all meals. The RD also recommended updating the resident's nighttime snack to a preferred tuna sandwich. These recommendations were documented and communicated to the Dietary Services Supervisor (DSS) via email, with the expectation that changes would be implemented within three days, as per facility policy. Despite these recommendations, observations and interviews revealed that the resident continued to receive the unwanted protein shakes and did not receive the Magic Cup supplement in a timely manner. The DSS acknowledged receiving the RD's recommendations but admitted to not entering the changes into the dietary software promptly due to being busy. As a result, the resident's dietary preferences and nutritional needs were not met as recommended by the RD, and the facility exceeded its own policy timeframe for implementing dietary changes. The resident, who had moderately impaired cognition, repeatedly expressed dissatisfaction with the provided supplements and meals, stating a preference for the frozen supplement and disliking the protein shakes. Multiple observations confirmed that the resident continued to receive the unwanted items, and staff interviews corroborated the delay in updating the dietary plan. Facility policy required dietary recommendations to be implemented within three days, but this was not followed, resulting in the resident not receiving preferred and recommended foods and supplements.
Failure to Offer and Document Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer influenza and pneumococcal vaccinations to one resident upon admission, as required by both facility policy and CDC recommendations. The resident in question had diagnoses including dementia and schizoaffective disorder and was under the legal care of a public conservator. Review of the clinical record revealed no documentation that the resident or their responsible party had been offered the vaccines, nor that the risks and benefits had been explained verbally or in writing. The Infection Control Nurse (ICN) acknowledged that she had asked the Social Services Director to assist in contacting the conservator for consent but did not follow up, resulting in no action being taken. Interviews with the ICN and the Director of Nursing confirmed that all residents should be offered these vaccines, with proper documentation of acceptance or refusal and education on risks and benefits. The facility's own policies require annual influenza vaccination offers and pneumococcal vaccination offers for eligible adults, with informed consent or refusal documented in the medical record. In this case, the process was not completed, and there was no evidence of an offer or consent for the resident, constituting a failure to follow established procedures.
Failure to Offer and Document COVID-19 Vaccination for Resident Under Conservatorship
Penalty
Summary
The facility failed to offer a COVID-19 vaccine to one resident who was under the care of a public conservator, as required by facility policy and CDC recommendations. The resident, who had diagnoses including dementia and schizoaffective disorder, was admitted under conservatorship, with the public conservator's office acting as the responsible party for medical decisions. Upon review of the resident's clinical record, there was no documentation that the COVID-19 vaccine had been offered, nor that the risks and benefits had been explained to the resident or the responsible party. The Infection Control Nurse (ICN) acknowledged that she had asked the Social Services Director to contact the conservator's office for consent but did not follow up, resulting in no action being taken. Interviews with facility staff, including the ICN and the Director of Nursing (DON), confirmed that the expectation was for all residents to be offered the COVID-19 vaccine, with proper documentation of acceptance or refusal and education on risks and benefits. The facility's policy also required that educational materials be sent to responsible parties and that general consent be obtained. The lack of documentation and follow-up meant that the resident was not offered the vaccine, and there was no evidence that the required education or consent process occurred.
Failure to Provide Prescribed Inhaler Medication
Penalty
Summary
The facility failed to ensure that an inhaler medication ordered by a physician was available for administration to a resident diagnosed with Chronic Obstructive Pulmonary Disease (COPD). The resident was admitted with a diagnosis of COPD and was prescribed an inhaler medication to be taken once daily. However, the medication was unavailable for eight days, as indicated in the Medication Administration Record. During interviews, a Licensed Nurse confirmed the unavailability of the medication and mentioned that the pharmacy required authorization to deliver it. The Director of Nursing was unable to explain the delay in authorization and acknowledged that the resident did not receive the medication as ordered. Additionally, the facility could not provide a policy and procedure related to medication dispensing.
Failure to Apply Splint as Ordered
Penalty
Summary
The facility failed to apply a splint to a resident's right hand as ordered by a physician, which had the potential to worsen the resident's wrist drop condition. The resident was admitted with a diagnosis of right wrist drop and had a provider order for the daily application of a splint to her right wrist, except during exercise or showering. However, during an observation, the resident was found not wearing the splint, and she confirmed that it was often not applied. The Director of Nursing (DON) acknowledged that the resident did not receive the daily interventions as ordered. A review of the Restorative Nursing Assistant (RNA) documentation revealed that range of motion exercises were provided only 10 out of 26 possible days. Despite documentation indicating the splint should be applied daily, the resident was observed without it during a joint observation with the DON, who confirmed the resident was neither exercising nor showering at the time.
Failure to Report Allegations of Abuse
Penalty
Summary
The Facility failed to report allegations of abuse by staff members against a resident, despite the resident's multiple attempts to report the incidents. The resident, who had diagnoses including acute osteomyelitis, anxiety, alcohol abuse, and unspecified psychosis, reported feeling violated while in the Facility. The resident described an incident where a nurse allegedly ran her finger up the resident's inner thigh to wake them up during the night shift. The resident communicated these allegations to the social worker, Director of Nursing (DON), and the administrator, and also spoke to the ombudsman in the presence of the administrator and social worker. Despite these reports, the administrator did not take appropriate action, believing the allegations to be false without conducting a proper investigation or reporting the incidents to the authorities as required by the facility's policy. The resident provided emails as evidence of their attempts to report the abuse. In one email, the resident expressed frustration over the lack of incident reports being filed despite repeated requests. Another email detailed an incident where a nurse allegedly touched the resident inappropriately and threatened to withhold medications. The facility's policy mandates that the administrator or a designated representative notify law enforcement immediately or within two hours of the initial report and send a written report to the Ombudsman, Law Enforcement, and CDPH Licensing and Certification within twenty-four hours. However, the administrator admitted to not reporting the allegations, thus failing to comply with the facility's abuse reporting and investigation policies.
Deficiencies in Water Management and Catheter Insertion Procedures
Penalty
Summary
The facility failed to implement a comprehensive water management program, as evidenced by the lack of a risk assessment to identify potential areas for legionella and other waterborne pathogens in the facility's water system. Despite having a policy in place that required the development and utilization of water management strategies, the Maintenance Supervisor admitted to not having completed a risk assessment and was unaware of the water flow through the facility. The Infection Preventionist and the Administrator also confirmed that no risk assessment had been conducted, and the water management plan had not been customized for the facility. Additionally, the facility did not adhere to proper aseptic techniques during the insertion of an indwelling catheter for a resident with moderate cognitive impairment and a history of obstructive and reflux uropathy. During the procedure, an LVN used non-sterile gloves to set up the catheter supplies, which violated the facility's policy requiring sterile equipment and techniques. The LVN acknowledged the mistake and expressed a need for further training. The DON stated that if sterile technique was compromised, the procedure should be restarted with new supplies, and the Administrator was unaware of the specific process staff should follow.
Inaccurate MDS Assessment for PASARR Level II
Penalty
Summary
The facility failed to ensure the accuracy of the annual Minimum Data Set (MDS) assessment for a resident regarding the Preadmission Screening and Resident Review (PASARR) Level II. The resident, who was admitted with a medical history of schizophrenia and schizoaffective disorder, had a Level II PASARR evaluation completed, which recommended specialized services. However, the MDS assessment conducted later did not reflect the resident's status as having a serious mental illness, as required by the PASARR process. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing (DON), revealed that the MDS should have been marked for Level II PASARR, as the resident's condition had not changed. The MDS Coordinator, who was new to the facility, stated that she would have triggered the Level II PASARR on the MDS if she had been present at the time of the assessment. The DON and the Administrator both expressed that their expectation was for the MDS to be accurate, timely, and true, indicating a lapse in the facility's adherence to regulatory requirements.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to implement the comprehensive care plan for a resident identified as an elopement risk and smoker. The resident, who had a history of chronic obstructive pulmonary disease and moderate cognitive impairment, was admitted to the facility with a care plan that required supervision while smoking and interventions for elopement risk. However, the resident was observed exiting the facility unsupervised while smoking and was later seen smoking in a non-designated area. The facility's policy required residents to sign out when leaving the premises, but there was no record of the resident signing out on one of the observed occasions. Interviews with facility staff, including the Infection Preventionist and the Director of Nursing, revealed a lack of adherence to the care plan. The Infection Preventionist indicated that the resident was allowed outside alone if signed out, while the Director of Nursing acknowledged the resident's independence but noted a failure to sign out on the observed date. The Administrator admitted that the care plans were expected to be correct but suggested that staff errors occurred due to haste. These actions and inactions led to the deficiency in implementing the resident's care plan, specifically regarding smoking supervision and elopement risk management.
Resident Elopement and Smoking Policy Violation
Penalty
Summary
The facility failed to prevent a resident from leaving the premises without staff knowledge and allowed the resident to smoke in a non-designated area. The resident, who had a history of chronic obstructive pulmonary disease and moderate cognitive impairment, was identified as an elopement risk and required supervision while smoking. Despite these precautions, the resident was observed exiting the facility in a wheelchair while smoking and proceeded down the street until out of sight. The resident later confirmed they went to a store without notifying staff or signing out, as required by facility policy. Interviews with staff revealed a lack of awareness regarding the resident's departure and smoking activities. The LVN and DON were unaware of the resident's unsupervised exit, and the Infection Preventionist noted that the resident was allowed outside alone only if they signed out. The Director of Staff Development and the Administrator were not aware of any incidents of the resident smoking in non-designated areas, although the resident was observed doing so. These lapses indicate a failure to adhere to facility policies regarding resident supervision and safety measures for smoking.
Psychotropic Medication Management Deficiency
Penalty
Summary
The report identifies a deficiency in the management of psychotropic medications for two residents at the facility. The first resident, admitted on April 17, 2024, was diagnosed with schizophrenia and other mental health conditions. The care plan for this resident was initiated on April 19, 2024, and included the administration of psychotropic medications. However, the order for the medication did not include a stop date, which is a requirement for as-needed medications. The second resident, admitted on February 19, 2024, was diagnosed with anxiety and depression. The care plan for this resident also lacked a stop date for the prescribed psychotropic medication, which is a violation of the facility's policy. The report highlights that the facility's policy is to ensure that as-needed psychotropic medications are ordered for a duration of 14 days, after which the resident's condition should be re-evaluated. The report also notes that the facility's administrator expects that the use of psychotropic medications should be minimized. Despite these policies, the report identifies that the orders for the psychotropic medications were not properly documented, and the required stop dates were not included. This oversight in the documentation and monitoring of psychotropic medications represents a significant deficiency in the facility's care practices.
Medication Storage and Expiration Deficiencies
Penalty
Summary
The facility failed to ensure expired medications were discarded and medications were properly stored, as observed in the medication storage room and involving three residents. During an observation, an LPN acknowledged the presence of expired lorazepam in the refrigerator, which should have been discarded after 90 days. The Director of Nursing confirmed that expired medications, including pantoprazole and lorazepam, should not be stored in the refrigerator. Interviews with the DON and the Administrator reiterated that expired medications should be removed and disposed of appropriately. Resident #7, admitted with a history of multiple sclerosis and pain, was found to have dietary supplements and a topical analgesic at their bedside without a care plan or physician's order to self-administer or store medications. The resident admitted to self-administering the supplement but could not reach the analgesic. An RN confirmed that the resident was not permitted to self-administer medications and removed the analgesic from the bedside. Resident #12, with a history of COPD, was observed with an inhaler at their bedside, which was left by a medication nurse from the previous shift. The resident was not care planned to self-administer medications. An RN admitted to forgetting the inhaler at the bedside. Similarly, Resident #116, admitted with cellulitis, had a supplement and a topical numbing agent at their bedside without authorization to self-administer medications. The resident was unaware of the restriction, and an LPN confirmed the resident's inability to self-administer medications.
Deficiency in Staff Training and Competency Documentation
Penalty
Summary
The facility failed to maintain an effective training program for two Licensed Vocational Nurses (LVNs) out of five staff members reviewed for training and competencies. According to the facility's policy, competency assessments should be conducted upon hire, during the first 90 days of employment, annually, or when new equipment or procedures are introduced. However, for LVN #7, who was hired on 09/16/2021, there was no competency documentation in the employee file. The Director of Staff Development (DSD) confirmed the absence of a completed orientation checklist and skills training documentation for LVN #7. LVN #7 also stated that she had not completed a competency checklist during orientation and had not received hands-on training since nursing school. Similarly, LVN #3, hired on 09/03/2023, had no documented competencies or skill checks in her personnel file, except for an in-service training on the facility's blood glucose monitoring system. LVN #3 did not recall receiving any training from the facility. The DSD acknowledged that while newly hired staff were expected to shadow other nurses, there was no evidence of this training for LVN #3. The Director of Nursing (DON) and the Administrator both confirmed that the facility was not in compliance with its policy regarding nursing competency, which requires competency forms to be completed within the first 90 days of employment and annually thereafter.
Inaccessible Call Cords for Residents
Penalty
Summary
The facility failed to ensure that call cords were within reach for five sampled residents, potentially preventing them from obtaining needed assistance from staff. Observations revealed that the call cords for Residents 1 through 5 were hanging from the wall to the floor, out of reach. Resident 1, who had diagnoses including tremor, encephalopathy, generalized weakness, and was admitted to hospice care, did not have an accessible type of call system appropriate for his functional level. Interviews with Licensed Nurses and the Director of Nursing confirmed that call cords should be within residents' reach, and the facility policy indicated that call cords should be placed within reach in residents' rooms and clipped to the bedspread for wheelchair-bound residents. On 4/3/24, observations showed that Resident 1's call cord was out of reach, and similar issues were noted for Residents 2 through 5. Interviews with Licensed Nurses 1 and 2, as well as the Director of Nursing, confirmed that call cords should be accessible to residents. The facility's policy, revised in January 2012, stated that call cords should be within residents' reach and adaptive call bells should be provided as needed. However, a telephone interview with the Administrator revealed that the current call cord system did not allow for switching to adaptive devices such as a soft touch call button.
Failure to Ensure Proper Respiratory Care and Documentation
Penalty
Summary
The facility failed to ensure proper respiratory care and treatment for two residents. For Resident 1, the licensed nurses applied a Bi-PAP machine without a proper setting order from the physician. The medical record showed an incomplete order for the Bi-PAP, and the Director of Nursing (DON) confirmed that the order should have been clarified with the physician. The facility's policy requires oxygen to be administered as prescribed, which was not followed in this case. For Resident 2, the facility failed to document a change in condition and notify the physician. The resident's oxygen saturation dropped significantly, and despite being placed on oxygen, the condition did not improve. The licensed nurse did not document the change in condition or notify the physician in a timely manner. The DON confirmed that the physician should have been notified and the event documented according to the facility's policy on change of condition.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 518 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Spring Valley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Amaya Springs Health Care Center | 1.1 mi | ★★★★★ | 9 | 0 |
| Lemon Grove Care And Rehabilitation Center | 1.2 mi | ★★★★★ | 27 | 0 |
| Community Care Center | 1.4 mi | ★★★★★ | 12 | 0 |
| Grossmont Hospital D/p Snf | 2 mi | ★★★★★ | 0 | 0 |
| Bella Vista Health Center | 2.1 mi | ★★★★★ | 11 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.