Victorville, CA

Spring Valley Post Acute LLC

1-star overall rating with 1-star inspections with $82,963 in total fines with 8 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle

14973 Hesperia Road, Victorville, CA

(760) 245-6477

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

1 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

1 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

126

Certified beds

Average residents

105

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

David & Frank Johnson

Operator or chain grouping

Approved since

1971-02-19

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

45 facilities

Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.35

Registered nurse staffing · state 0.65 · national 0.68

LPN hours / resident day

1.41

Licensed practical nurse staffing · state 1.22 · national 0.87

Aide hours / resident day

2.97

Nurse aide staffing · state 2.64 · national 2.35

Total nurse hours

4.73

All reported nurse hours · state 4.51 · national 3.89

Licensed hours

1.76

RN + LPN hours · state 1.87 · national 1.54

Weekend hours

4.18

Weekend nurse staffing · state 4.08 · national 3.43

Weekend RN hours

0.26

Weekend registered nurse coverage · state 0.50 · national 0.47

Physical therapist

0.09

Reported PT staffing · state 0.10 · national 0.07

Adjusted RN hours

0.36

CMS adjusted RN staffing hours

Adjusted total hours

4.79

CMS adjusted total nurse staffing hours

Case-mix index

1.35

Higher values indicate more complex resident acuity

RN turnover

33%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

38%

Annual nurse turnover · state 38% · national 46%

SNF VBP

Value-based purchasing

Program rank

11,265

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

17.47

Composite VBP score used to determine payment impact.

Payment multiplier

0.9818

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

1.82

Baseline 22.30% · Performance 21.08% · Measure score 1.82 · Achievement 0.77 · Improvement 1.82

Healthcare-associated infections

0

Baseline 8.10% · Performance 10.43% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Adjusted total nurse staffing

3.42

Baseline 3.83 hours · Performance 4.05 hours · Measure score 3.42 · Achievement 3.42 · Improvement 0.65

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 8.36%
10.72%
2.4 pts better
No Different than the National Rate · Eligible stays 170 · Observed rate 6.47% · Lower 95% interval 5.56%
Discharge to community 42.94%
50.57%
7.6 pts worse
No Different than the National Rate · Eligible stays 106 · Observed rate 36.79% · Lower 95% interval 35.43%
Medicare spending per beneficiary 1.42
1.02
0.4 pts worse
Drug regimen review with follow-up 98.85%
95.27%
3.6 pts better
Numerator 259 · Denominator 262
Falls with major injury 0%
0.77%
0.8 pts better
Numerator 0 · Denominator 262
Discharge self-care score 24.77%
53.69%
28.9 pts worse
Numerator 27 · Denominator 109
Discharge mobility score 18.35%
50.94%
32.6 pts worse
Numerator 20 · Denominator 109
Pressure ulcers or injuries, new or worsened 2.29%
2.29%
About the same
Numerator 6 · Denominator 262 · Adjusted rate 1.72%
Healthcare-associated infections requiring hospitalization 10.43%
7.12%
3.3 pts worse
No Different than the National Rate · Eligible stays 157 · Observed rate 15.29% · Lower 95% interval 7.09%
Staff COVID-19 vaccination coverage 3.5%
8.2%
4.7 pts worse
Numerator 7 · Denominator 200
Staff flu vaccination coverage 51%
42%
9 pts better
Numerator 102 · Denominator 200
Discharge function score 18.35%
56.45%
38.1 pts worse
Numerator 20 · Denominator 109
Transfer of health information to provider 98.43%
95.95%
2.5 pts better
Numerator 125 · Denominator 127
Transfer of health information to patient 95.74%
96.28%
0.5 pts worse
Numerator 45 · Denominator 47
Resident COVID-19 vaccinations up to date 32.58%
25.2%
7.4 pts better
Numerator 43 · Denominator 132

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 3.8
2.3
1.5 pts worse
1.9
1.9 pts worse
Long Stay · 20240701-20250630 · Adjusted 3.8 · Observed 6.2 · Expected 3.2 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 1.5
1.6
0.1 pts better
1.8
0.3 pts better
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 2.1 · Expected 2.3 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 100.0%
98.5%
1.5 pts better
93.4%
6.6 pts better
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 82.4%
98.2%
15.8 pts worse
95.5%
13.1 pts worse
Long Stay · 2024Q3-2025Q2 · 4Q avg 82.4%
Percentage of long-stay residents experiencing one or more falls with major injury 1.3%
1.6%
0.3 pts better
3.3%
2 pts better
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.3% · Q3 1.2% · Q4 1.3% · 4Q avg 1.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 0.0%
6.8%
6.8 pts better
11.4%
11.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents who lose too much weight 2.6%
4.1%
1.5 pts better
5.4%
2.8 pts better
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.8% · Q3 1.8% · Q4 1.5% · 4Q avg 2.6%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 34.0%
13.7%
20.3 pts worse
19.6%
14.4 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 38.2% · Q2 31.5% · Q3 31.6% · Q4 34.7% · 4Q avg 34.0%
Percentage of long-stay residents who received an antipsychotic medication 17.2%
14.2%
3 pts worse
16.7%
0.5 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 16.7% · Q3 20.3% · Q4 16.7% · 4Q avg 17.2% · Used in QM five-star
Percentage of long-stay residents who were physically restrained 0.0%
0.4%
0.4 pts better
0.1%
0.1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened 21.1%
11.0%
10.1 pts worse
16.3%
4.8 pts worse
Long Stay · 2024Q4-2025Q3 · Q4 9.7% · 4Q avg 21.1% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 18.7%
10.7%
8 pts worse
14.9%
3.8 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 19.4% · Q3 12.3% · Q4 22.1% · 4Q avg 18.7% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 5.4%
1.0%
4.4 pts worse
1.0%
4.4 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 7.0% · Q3 4.0% · Q4 3.5% · 4Q avg 5.4% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 13.5%
1.2%
12.3 pts worse
1.7%
11.8 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 21.1% · Q2 7.1% · Q3 13.6% · Q4 12.5% · 4Q avg 13.5% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 16.4%
10.9%
5.5 pts worse
19.8%
3.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 19.2% · Q3 13.6% · Q4 20.8% · 4Q avg 16.4%
Percentage of long-stay residents with pressure ulcers 8.6%
4.7%
3.9 pts worse
5.1%
3.5 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 10.3% · Q3 10.3% · Q4 8.4% · 4Q avg 8.6% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 99.9%
94.0%
5.9 pts better
81.7%
18.2 pts better
Short Stay · 2024Q4-2025Q3 · Q1 99.5% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.9%
Percentage of short-stay residents who had an outpatient emergency department visit 9.5%
11.2%
1.7 pts better
12.0%
2.5 pts better
Short Stay · 20240701-20250630 · Adjusted 9.5% · Observed 10.1% · Expected 11.8% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication 4.1%
1.5%
2.6 pts worse
1.6%
2.5 pts worse
Short Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.1% · Q3 4.8% · Q4 3.2% · 4Q avg 4.1% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 91.4%
93.2%
1.8 pts worse
79.7%
11.7 pts better
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.4%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 25.3%
23.2%
2.1 pts worse
23.9%
1.4 pts worse
Short Stay · 20240701-20250630 · Adjusted 25.3% · Observed 28.5% · Expected 26.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2024-11-21 · Fire 2024-11-21

8 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)

8 fire-safety deficiencies

Top issue: Smoke (6 deficiencies)

Cycle 2 Health 2022-02-04 · Fire 2022-02-04

13 health deficiencies

Top issue: Nutrition and Dietary (5 deficiencies)

13 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Cycle 3 Health 2019-04-15 · Fire 2019-04-15

17 health deficiencies

Top issue: Quality of Life and Care (6 deficiencies)

13 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-11-21

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-12-23

F · Potential for more than minimal harm 2024-11-21

K346 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the fire alarm was out of service for more than 4 hours.

Corrected 2024-12-23

F · Potential for more than minimal harm 2024-11-21

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-12-23

F · Potential for more than minimal harm 2024-11-21

K354 · Smoke Deficiencies

Fire Safety

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Corrected 2024-12-23

E · Potential for more than minimal harm 2024-11-21

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-12-23

E · Potential for more than minimal harm 2024-11-21

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2024-12-23

D · Potential for more than minimal harm 2024-11-21

K325 · Smoke Deficiencies

Fire Safety

Have properly installed hallway dispensers for alcohol-based hand rub.

Corrected 2024-12-23

D · Potential for more than minimal harm 2024-11-21

K912 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have power receptacles that are properly grounded.

Corrected 2024-12-23

E · Potential for more than minimal harm 2022-02-04

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2022-03-25

E · Potential for more than minimal harm 2022-02-04

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-03-25

D · Potential for more than minimal harm 2022-02-04

E31 · Emergency Preparedness Deficiencies

Fire Safety

Provide emergency officials' contact information.

Corrected 2022-03-25

D · Potential for more than minimal harm 2022-02-04

E37 · Emergency Preparedness Deficiencies

Fire Safety

Establish staff and initial training requirements.

Corrected 2022-03-25

D · Potential for more than minimal harm 2022-02-04

E6 · Emergency Preparedness Deficiencies

Fire Safety

Conduct risk assessment and an All-Hazards approach.

Corrected 2022-03-25

D · Potential for more than minimal harm 2022-02-04

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2022-03-25

D · Potential for more than minimal harm 2022-02-04

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2022-03-25

D · Potential for more than minimal harm 2022-02-04

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2022-03-25

D · Potential for more than minimal harm 2022-02-04

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2022-03-25

D · Potential for more than minimal harm 2022-02-04

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2022-03-25

D · Potential for more than minimal harm 2022-02-04

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2022-03-25

D · Potential for more than minimal harm 2022-02-04

K919 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the use of electrical equipment.

Corrected 2022-03-25

D · Potential for more than minimal harm 2022-02-04

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2022-03-25

E · Potential for more than minimal harm 2019-04-15

K291 · Egress Deficiencies

Fire Safety

Install emergency lighting that can last at least 1 1/2 hours.

Corrected 2019-07-10

E · Potential for more than minimal harm 2019-04-15

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2019-07-10

E · Potential for more than minimal harm 2019-04-15

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2019-07-10

D · Potential for more than minimal harm 2019-04-15

E26 · Emergency Preparedness Deficiencies

Fire Safety

Establish roles under a Waiver declared by secretary.

Corrected 2019-07-10

D · Potential for more than minimal harm 2019-04-15

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2019-07-10

D · Potential for more than minimal harm 2019-04-15

E7 · Emergency Preparedness Deficiencies

Fire Safety

Address patient/client population and determine types of services needed.

Corrected 2019-07-10

D · Potential for more than minimal harm 2019-04-15

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2019-07-10

D · Potential for more than minimal harm 2019-04-15

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2019-07-10

D · Potential for more than minimal harm 2019-04-15

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2019-07-10

D · Potential for more than minimal harm 2019-04-15

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-07-10

D · Potential for more than minimal harm 2019-04-15

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2019-07-10

D · Potential for more than minimal harm 2019-04-15

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2019-07-10

D · Potential for more than minimal harm 2019-04-15

K920 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure proper usage of power strips and extension cords.

Corrected 2019-07-10

Inspection history

Recent health citations

K · Immediate jeopardy 2025-09-26

F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Corrected 2025-10-17

D · Potential for more than minimal harm 2025-03-13

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-04-07

E · Potential for more than minimal harm 2024-11-21

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2024-12-13

D · Potential for more than minimal harm 2024-11-21

F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Corrected 2024-12-13

D · Potential for more than minimal harm 2024-11-21

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-12-13

D · Potential for more than minimal harm 2024-11-21

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2024-12-13

D · Potential for more than minimal harm 2024-11-21

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2024-12-13

D · Potential for more than minimal harm 2024-11-21

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-12-13

D · Potential for more than minimal harm 2024-11-13

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-11-25

D · Potential for more than minimal harm 2024-06-12

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2024-07-08

D · Potential for more than minimal harm 2023-10-09

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-10-30

D · Potential for more than minimal harm 2023-09-26

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2023-10-16

D · Potential for more than minimal harm 2023-08-31

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-09-11

D · Potential for more than minimal harm 2023-08-23

F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Corrected 2023-09-12

L · Immediate jeopardy 2022-02-04

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2022-04-05

F · Potential for more than minimal harm 2022-02-04

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2022-04-05

E · Potential for more than minimal harm 2022-02-04

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2022-04-05

E · Potential for more than minimal harm 2022-02-04

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2022-04-05

E · Potential for more than minimal harm 2022-02-04

F805 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Corrected 2022-04-05

E · Potential for more than minimal harm 2022-02-04

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-04-05

D · Potential for more than minimal harm 2022-02-04

F646 · Resident Assessment and Care Planning Deficiencies

Health

Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.

Corrected 2022-04-05

D · Potential for more than minimal harm 2022-02-04

F726 · Nursing and Physician Services Deficiencies

Health

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Corrected 2022-04-05

D · Potential for more than minimal harm 2022-02-04

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2022-04-05

D · Potential for more than minimal harm 2022-02-04

F802 · Nutrition and Dietary Deficiencies

Health

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Corrected 2022-04-05

D · Potential for more than minimal harm 2022-02-04

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2022-04-05

L · Immediate jeopardy 2019-04-15

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2019-05-22

F · Potential for more than minimal harm 2019-04-15

F801 · Nutrition and Dietary Deficiencies

Health

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Corrected 2019-05-22

F · Potential for more than minimal harm 2019-04-15

F802 · Nutrition and Dietary Deficiencies

Health

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Corrected 2019-05-22

F · Potential for more than minimal harm 2019-04-15

F803 · Nutrition and Dietary Deficiencies

Health

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected 2019-05-22

F · Potential for more than minimal harm 2019-04-15

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2019-05-22

E · Potential for more than minimal harm 2019-04-15

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2019-05-22

D · Potential for more than minimal harm 2019-04-15

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2019-05-22

D · Potential for more than minimal harm 2019-04-15

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2019-05-22

D · Potential for more than minimal harm 2019-04-15

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2019-05-22

D · Potential for more than minimal harm 2019-04-15

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2019-05-22

D · Potential for more than minimal harm 2019-04-15

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2019-05-22

D · Potential for more than minimal harm 2019-04-15

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2019-05-22

D · Potential for more than minimal harm 2019-04-15

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2019-05-22

Penalties and ownership

What sits behind the stars

$15,920 2025-09-26

Fine

Fine · fine $15,920

Fine

$4,587 2023-11-06

Fine

Fine · fine $4,587

Fine

$4,587 2023-10-17

Fine

Fine · fine $4,587

Fine

$4,587 2023-10-10

Fine

Fine · fine $4,587

Fine

$4,587 2023-10-02

Fine

Fine · fine $4,587

Fine

$4,587 2023-09-25

Fine

Fine · fine $4,587

Fine

$4,587 2023-09-18

Fine

Fine · fine $4,587

Fine

$4,587 2023-09-11

Fine

Fine · fine $4,587

Fine

$4,587 2023-09-05

Fine

Fine · fine $4,587

Fine

$4,587 2023-08-28

Fine

Fine · fine $4,587

Fine

$4,587 2023-08-21

Fine

Fine · fine $4,587

Fine

$4,587 2023-08-14

Fine

Fine · fine $4,587

Fine

$10,586 2023-07-17

Fine

Fine · fine $10,586

Fine

$2,823 2023-06-26

Fine

Fine · fine $2,823

Fine

$2,470 2023-06-20

Fine

Fine · fine $2,470

Fine

$707 2023-05-23

Fine

Fine · fine $707

Fine

Ownership

Chambers, Thomas

Operational/Managerial Control · Individual

0% 9 facilities 2013-10-08
Johnson, David

Operational/Managerial Control · Individual

0% 42 facilities 2013-10-08
Meridian Management Services LLC

Operational/Managerial Control · Organization

0% 6 facilities 2013-12-20
Reddy, Hari

Operational/Managerial Control · Individual

0% 2 facilities 2023-01-01
Soni, Preyas

Operational/Managerial Control · Individual

0% 1 facilities 2023-07-16
Spring Valley Post Acute LLC

Operational/Managerial Control · Organization

0% 1 facilities 2013-12-20

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Knolls West Post Acute LLC

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3-star overall rating with 3-star inspections with 16 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle

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5-star overall rating with 5-star inspections with $8,021 in total fines with 4 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle

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#3

Mountains Community Hosp DP/SNF

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5-star overall rating with 5-star inspections with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

Overall
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Health
5 / 5
Staffing
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Fines
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