Health inspection·October 27, 2025

Spring Valley Post Acute LLC The following reflects the findings of the California Department of Public Health during the investigation of: Complaint: 2614122 Event ID: 1D6915-H1 Representing the Department, HFEN # 47206 State Citation B was written Regulations: Title 42 of the Federal Code of Regulations §483.10(e) Respect and Dignity The resident has a right to be treated with respect and dignity, including: §483.10(e)(1) The right to be free from any physical . . . restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2). §483.12 Right to be Free from Physical Restraints §483.12(a) The facility must— §483.12(a)(2) Ensure that the resident is free from physical. . . restraints imposed for purposes of discipline or convenience and that are not required to treat the resident’s medical symptoms. When the use of restraints is indicated, the facility must use the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints. Title 22 of the California Code of Regulations §72311. Nursing Service - General (a) Nursing service shall include, but not be limited to, the following: (1) Planning of patient care, which shall include at least the following: (B) Development of an individual, written patient care plan which indicates the care to be given, the objectives to be accomplished and the professional discipline responsible for each element of care. Objectives shall be measurable and time-limited. (C) Reviewing, evaluating and updating the patient care plan as necessary by the nursing staff and other professional personnel involved in the care of the patient at least quarterly, and more often if there is a change in the patient's condition. (2) Implementing each patient's care plan according to the methods indicated. Each patient's care shall be based on this plan. §72315. Nursing Service - Patient Care. (e) Each patient shall be encouraged and/or assisted to achieve and maintain the highest level of self-care and independence. Every effort shall be made to keep patients active, and out of bed for reasonable periods of time, except when contraindicated by orders of a licensed health care practitioner acting within the scope of his or her professional licensure. §72319. Nursing Service - Restraints and Postural Supports. (a) Written policies and procedures concerning the use of restraints and postural supports shall be followed. (b) Restraints shall only be used with a written order of a licensed healthcare practitioner acting within the scope of his or her professional licensure. The order must specify the duration and circumstances under which the restraints are to be used. Orders must be specific to individual patients. In accordance with Section 72317, there shall be no standing orders and in accordance with Section 72319(i)(2)(A), there shall be no P.R.N. orders for physical restraints. (c) The only acceptable forms of physical restraints shall be cloth vests, soft ties, soft cloth mittens, seat belts and trays with spring release devices. Soft ties means soft cloth which does not cause abrasion and which does not restrict blood circulation. (d) Restraints of any type shall not be used as punishment, as a substitute for more effective medical and nursing care, or for the convenience of staff. (e) No restraints with locking devices shall be used or available for use in a skilled nursing facility. On September 24, 2025, at 11:39 AM, an unannounced visit was conducted at the facility to investigate a complaint regarding quality of care. Three patients were observed restrained in their beds using metal shackles on September 24, 2025: Patient 1: Shackled at both ankles, which were secured to the end of the bed frame at 12:10 PM. Patient 2: Shackled at both ankles attached to the bed frame, and the left wrist was also shackled and secured to a side rail at 12:15 PM. Patient 3: Shackled at both ankles attached to the bed frame and the left wrist was also shackled and secured to a side rail at 12:26 PM. These patients were observed to be unable to move freely within the facility or to participate in activities outside of their rooms. The facility failed to: 1. Secure a physician’s order for the use of restraints for Patients 1, 2, and 3. 2. Provide a pre-restraining assessment before placing restraints/shackles to Patients 1, 2, and 3. 3. Develop a care plan for the use of restraints/shackles for Patients 1, 2, and 3. 4. Assess, monitor, and document skin integrity of Patients 1, 2, and 3 related to the use of restraints/shackles. 5. Allow attendance at activities, social interactions and freedom of movement within the facility for Patients 1, 2, and 3. 6. Follow its policies and procedures titled “Use of Restraints,” for Patients 1, 2, and 3. These failures posed serious risks on physical health of Patients 1, 2, and 3, including skin damage, pressure ulcers, nerve injury, and complications from prolonged immobility. Additionally, the lack of monitoring by trained staff increased the potential for psychological harm, such as loss of dignity, anxiety, depression, and suicidal thoughts. Findings: During an observation in Patient 1’s room on September 24, 2025, at 12:10 PM, Patient 1 was observed lying on bed, restrained with metal shackles on both ankles, which were attached to the end of the bed frame. Patient 1 appeared alert and calm during the observation. The skin around the shackles was assessed and found to be intact, with no evidence of redness, blistering, discoloration, or any other skin issues. During this observation, two correctional officers were present at the bedside, monitoring Patient 1. During a review of Patient 1’s Admission Record (general demographics) on September 24, 2025, the Admission Record indicated Patient 1 was admitted to the facility on June 11, 2025, with diagnoses which included hemiplegia (paralysis on one side of the body) and hemiparesis ( partial paralysis on one side of the body), heart failure (heart is not pumping blood as well as it should), and hypotension (low blood pressure). During an observation in Patient 2’s room on September 24, 2025, at 12:15 PM, Patient 2 was observed on bed in the same room as Patient 1. Patient 2 was restrained with metal shackles on both ankles, which were attached to the end of the bed frame. Additionally, a metal shackle was observed on his left wrist and was attached to one of the side rails of the bed, while two correctional officers were on bedside monitoring Patient 1 and 2. During a review of Patient 2’s Admission Record (general demographics) on September 24, 2025, the Admission Record indicated Patient 2 was admitted on May 21, 2025, with a diagnoses that included peripheral autonomic neuropathy (condition that affects the nerves that control involuntary body functions, such as heart rate, blood pressure, and sweating), acute kidney failure ( kidney suddenly stops working properly), and fracture of the left hand (break in one or more bones in the left hand). During an observation in Patient 3’s room on September 24, 2025, at 12:26 PM, Patient 3 was observed on bed, restrained with metal shackles on both ankles that were attached to the end of the bed frame. Additionally, a metal shackle was also observed on his left wrist and was attached to one of the side rails of the bed, while two correctional officers were watching him. During a review of Patient 3’s Admission Record (general demographics) on September 24, 2025, the Admission Record indicated Patient 3 was admitted to the facility on September 4, 2025, with a diagnoses that included cellulitis ( bacterial infection that gets into the deeper layer of the skin) of the right lower limb, neuropathy (damaged nerves), and hypertension (high blood pressure). During an interview on September 24, 2025, at 1:20 PM, with a Certified Nursing Assistant (CNA 1), CNA 1 stated, “ the shackles were removed when the patients are taken to the restrooms and receive a bath…” When asked how she repositions the patients while they are in shackles, she stated, “ I request the correctional officer to remove the shackles…” however, she noted the shackles are not usually removed because there is enough slack for the patients to move their legs around. During an interview on September 24, 2025, at 1: 31 PM, with Certified Nursing Assistant (CNA) 2. CNA 2 confirmed that she is assigned to the three patients who are in shackles. CNA 2 stated she requested the correctional officers to remove the shackles for Patient 1 and Patient 2 when they went to the toilet and when they took a shower. For Patient 3, CNA 2 stated she did not release the shackles throughout her shift, as he had not gone to the bathroom yet. When CNA 2 was asked if she had checked the wrists and ankles of Patient 1, Patient 2, and Patient 3 for bruises, CNA 2 mentioned she only observed briefly while she performed activities of daily living (ADL – basic tasks that patients perform to maintain their personal care). During an interview on September 24, 2025, at 1:50 PM, with the Activity Director (Director), Director stated, “…The inmates do not participate with the activities of other patients, they are only given magazines, reading materials about people, nature or any topics they are interested in…” The director confirmed the patients never leave their rooms except for showers and physical therapy sessions. During an interview on September 24, 2025, at 1:59 PM, with Licensed Vocational Nurse (LVN), LVN stated, “ the only time these shackles are removed is when the inmates go to the toilet or bathroom. The facility is a non- restraint facility, and the staff are not trained in the use of restraints….” Furthermore, the staff indicated he does not visually check the patient’s wrists and ankles. He also stated that the facility does not classify shackles as a means of restraint, and there is no “official” order for restraint as it is not part of the physician’s orders. During a concurrent interview and record review on September 24, 2025, at 2:15 PM, with the Registered Nurse supervisor (RN supervisor), the medical records for Patients 1, 2, and 3 have no documentation of the following: a. no physician’s order for the use of restraints. b. no care plan in place for restraints. c. no assessment conducted regarding the use of restraints; nor restraint was coded on Minimum Data Set (MDS-a standardized assessment tool used collect information about patients’ health, functional abilities, and psychosocial status). d. no nursing progress notes documenting the placement and removal of the restraint; and e. no assessment of skin integrity associated with the use of restraints. These findings were verified by the RN supervisor, who stated that the facility is a no-restraint facility. The three patients, under the supervision of correctional officers, admitted to the facility in shackles; however, the facility does not consider those shackles to be restraints. During an interview on September 24, 2025, at 2:59 PM, with the Director of Staff Developer (DSD), the DSD stated, “This is a no restraint facility, we don’t have patients on restraints, federal guards are the ones releasing the shackles when the staff requested during patient [patient] care like when they go to shower…” The DSD further stated the staff are not trained in the use of restraints. During an interview on September 24, 2025, at 3:10 PM, with Patient 3, he stated, “ I do not go out, they only give me magazines to read.” The patient stated his shackles are only released when he goes to the bathroom and toilet and when he does physical therapy training in the evening at least once a day. During an interview on September 24, 2025, at 3:39 PM, Patient 1 confirmed he does not participate in any activity, and his shackles are only released during toileting, showers, and physical therapy training. Patient 1 also stated that PT training is conducted in his room in the evening at least once a day. During an interview on September 24, 2025, at 3:44 PM, Patient 2 confirmed his shackles are only released when he goes to the bathroom, showers and does physical therapy training at least once a day, for a few minutes in the evening. Patient 2 also stated he does not participate in any activities. During an interview on September 24, 2025, at 3:48 PM, with the Correction Officer (Officer), the Officer stated, “inmates does not go out from their rooms, and the staff does not released shackles.” Officer confirmed that they are with the patients twenty-four (24) hours a day, and they have to be on shackles per their policy. During a concurrent interview and record review on September 24, 2025, at 4:45 PM, with the administrator and the DSD, the facility’s policy and procedure (P&P) titled, “ Use of Restraints,” dated October 2022, was reviewed. The P&P defined physical restraints, “… as any manual method or physical or mechanical device, material or equipment attached or adjacent to the patient’s body that the individual cannot remove easily, which restricts freedom of movement or restricts normal access to one’s body…” The P&P also states, “ Prior to placing a patient in restraints, there shall be a pre-restraining assessment, ….” The P&P further states “ Restraints shall only be used upon the written order of a physician…” Also, the P&P mandates, “A patient placed in a restraint will be observed at least every thirty (30) minutes by nursing personnel,” When asked if this P&P was being followed, the administrator responded, “The patients came with restraints,” citing that they are inmates under the custody of correctional officers. Conclusion: In violation of the above cited standards, the facility failed to: 1. Secure a physician’s order for the use of restraints for Patients 1, 2, and 3. 2. Provide a pre-restraining assessment before placing restraints/shackles to Patients 1, 2, and 3. 3. Develop a care plan for the use of restraints/shackles for Patients 1, 2, and 3. 4. Assess, monitor, and document skin integrity of Patients 1, 2, and 3 related to the use of restraints/shackles. 5. Allow attendance at activities, social interactions and freedom of movement within the facility for Patients 1, 2, and 3. 6. Follow its policies and procedures titled “Use of Restraints,” for Patients 1, 2, and 3. These violations, jointly, separately, or in any combination, had a direct or impact on the health, safety, or security of patients.