Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Valley Springs Rehabilitation And Health Center during CMS and state inspections, most recent first.
The facility failed to develop individualized care plans for two residents, leading to deficiencies in addressing their specific needs. One resident with non-Alzheimer's dementia was not care planned for dementia-related behaviors, while another resident with missing toenails and respiratory issues was not provided with necessary wound care or BiPAP instructions. Facility staff confirmed these oversights, and the absence of a care plan policy was noted.
A facility failed to include monitoring instructions for a resident's BiPAP machine, despite the resident's respiratory conditions. The resident confirmed nightly use without staff monitoring. Additionally, a fall risk assessment was not completed for another resident after a fall, due to oversight during staff transition. The facility lacked a policy for quality of care and assessment accuracy.
The facility exhibited multiple deficiencies in food storage, cleanliness, and hand hygiene. Observations revealed uncovered food in the freezer, improper storage of hamburger buns, and unsanitary kitchen conditions with grease buildup and food debris. Dietary staff failed to follow hand hygiene protocols, handling clean equipment and food after touching dirty objects. CNAs did not sanitize hands between serving food trays to residents, increasing the risk of cross-contamination. These actions were contrary to the facility's infection control policies.
The facility failed to maintain infection control practices, as a resident's indwelling catheter was improperly managed, and a CNA did not perform hand hygiene between passing meal trays. The catheter was observed in a trash can and dragging on the floor, while the CNA admitted to not sanitizing hands between trays, despite facility policy requiring it.
A facility failed to accurately document a resident's use of a BiPAP device in their comprehensive assessment. The resident, admitted with respiratory issues, used a BiPAP nightly, but this was not reflected in the Medicare 5-Day MDS or the MAR. Interviews confirmed the oversight, highlighting a failure in assessing and documenting the resident's respiratory needs.
A facility failed to complete a PASRR for a resident with mental disorders, including psychosis and dementia, to ensure appropriate care. The resident's PASRR II or exemption was missing from their electronic chart. The Social Services Director confirmed the preadmission screening was not accepted due to unreceived revision requests, and acknowledged it should have been completed before admission. Staff interviews revealed unclear responsibilities for PASRR completion, with reliance on CMS policy instead of a specific facility policy.
A resident at risk for falls was found with a fall mat that had rips and tears, positioned 6-8 inches away from the bed. Despite the resident's care plan indicating the use of a fall mat as an intervention for previous falls, the mat was not maintained or positioned correctly. This was confirmed by a CNA and the ADON, highlighting a deficiency in maintaining a safe environment as per facility policy.
A facility failed to provide necessary care for a resident with non-Alzheimer's dementia, as the resident was admitted to a closed unit without proper assessment and lacked a care plan addressing dementia-related needs. The facility also did not ensure sufficient staff with dementia care training were available, and the resident's MAR lacked documentation for tracking behaviors. Interviews confirmed these deficiencies.
Deficiencies in Individualized Care Planning for Residents
Penalty
Summary
The facility failed to ensure that comprehensive care plans were developed and individualized for two residents, leading to deficiencies in addressing their specific needs. Resident #27, who was admitted with a diagnosis of non-Alzheimer's dementia, was not care planned for dementia-related behaviors and expressions of distress. Despite having a severe cognitive impairment score on the Brief Interview for Mental Status (BIMS) and being on multiple medications, including those with black box warnings, the care plan did not address these critical aspects. Interviews with the Assistant Director of Nursing (ADON) and the MDS Coordinator confirmed the oversight in care planning for dementia. Resident #236 was admitted with missing toenails and required wound care, as well as the use of a BiPAP machine for respiratory issues. However, the care plan did not include the necessary wound care for the missing toenails or instructions for BiPAP use, which was confirmed by both the resident and facility staff. The ADON and MDS Coordinator acknowledged the lack of care planning for these needs, which was further supported by the absence of a facility policy for care plans, as stated by the Administrator.
Deficiencies in BiPAP Monitoring and Fall Risk Assessment
Penalty
Summary
The facility failed to ensure that a resident's physician orders for a BiPAP machine included instructions for monitoring and frequency of use. The resident, who was admitted with acute respiratory failure, COPD, and obstructive sleep apnea, was observed with an oxygen concentrator and a BiPAP machine in their room. However, the order summary report lacked directions for monitoring the BiPAP settings or frequency of use, and the Medication Administration Record did not document BiPAP use. Interviews with the resident and staff confirmed the absence of monitoring instructions and documentation. Additionally, the facility did not complete a fall risk assessment for a resident who had a fall resulting in facial bruising. The resident, with a severely impaired mental status, had a fall on 1/14/2025, but the last documented fall risk assessment was dated before the incident. Interviews with the interim DON and ADON revealed that the fall risk assessment was overlooked due to a transition in staff responsibilities, and the facility lacked a policy for quality of care and accuracy of assessments.
Deficiencies in Food Storage, Cleanliness, and Hand Hygiene
Penalty
Summary
The facility failed to maintain proper food storage and cleanliness standards in the kitchen and dining areas. Observations revealed that food items such as steak fingers and egg rolls were left uncovered in the freezer, exposing them to potential contamination. Additionally, hamburger buns were improperly stored at room temperature instead of being frozen as per manufacturer's instructions. The kitchen environment was found to be unsanitary, with grease traps, floors, and food preparation areas exhibiting significant grease buildup and food debris. The ice machine used for resident beverages was also found to be dirty, with black and brown residue present. Dietary staff did not adhere to proper hand hygiene protocols, leading to potential contamination of food and equipment. Instances were noted where staff handled dirty objects and then proceeded to handle clean equipment or food without washing their hands. This included touching dirty grease traps, trash cans, and personal items like cellphones, followed by handling food trays and clean kitchen equipment. The facility's policy on handwashing and glove usage was not followed, as staff failed to wash or sanitize their hands between tasks, increasing the risk of cross-contamination. The facility's staff, including CNAs and dietary aides, did not consistently practice infection control measures when handling food trays for residents. CNAs were observed passing food trays without sanitizing their hands between residents, and one CNA was seen using a cellphone during meal service without washing hands afterward. These actions were contrary to the facility's infection control policies, which emphasize the importance of hand hygiene to prevent the spread of infection. The deficiencies highlight a lack of adherence to established protocols for maintaining a clean and safe food service environment.
Infection Control Deficiencies in Catheter Management and Hand Hygiene
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices, as evidenced by two main deficiencies observed by surveyors. Firstly, a resident with an indwelling catheter was observed with the catheter tube placed in a trash can and the catheter bag dragging on the floor while the resident was in a wheelchair. This resident required assistance with toileting hygiene due to an enlarged prostate and neurogenic bladder, as noted in their care plan and Minimum Data Set. The Assistant Director of Nursing confirmed that the catheter should not be placed in the trash can or dragged on the ground, acknowledging the infection control concern. Secondly, a Certified Nursing Assistant (CNA) was observed failing to perform hand hygiene between passing meal trays to residents. The CNA did not sanitize hands between each resident's tray and was seen touching a cellphone before handling another tray. The CNA admitted to not washing hands as required, and a Licensed Practical Nurse confirmed that hand hygiene is part of the facility's infection control policy. The facility's policy on hand washing and staff in-services indicated that staff should sanitize hands before and after assisting residents with meals.
Inaccurate Assessment of Resident's Respiratory Needs
Penalty
Summary
The facility failed to ensure a comprehensive assessment accurately reflected a resident's status and needs. During an observation, a resident was seen using an oxygen concentrator and a BiPAP device, which were not accurately documented in the resident's comprehensive assessment. The resident was admitted with acute respiratory failure, COPD, and obstructive sleep apnea, requiring the use of oxygen and a BiPAP device. However, the Medicare 5-Day Minimum Data Set (MDS) did not indicate the use of a BiPAP, and the Medication Administration Record (MAR) lacked documentation for BiPAP use. Interviews with the resident and facility staff confirmed the oversight. The resident confirmed nightly use of the BiPAP and noted that staff did not monitor the device's settings. The Assistant Director of Nursing and the MDS Coordinator acknowledged the inaccuracies in the resident's comprehensive assessment, confirming that the resident's use of a BiPAP was not documented as required. This oversight indicates a failure in accurately assessing and documenting the resident's respiratory needs and treatments.
Failure to Complete PASRR for Resident with Mental Disorders
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASRR) for a resident with mental disorders and intellectual disabilities, which is necessary to ensure the resident receives appropriate care and services. The resident, who was admitted with diagnoses including unspecified psychosis, mood disturbance, anxiety, dementia, and major depressive disorder, did not have a PASRR II or exemption documented in their electronic chart. The facility's Social Services Director confirmed that a preadmission screening was not accepted by the State Designated Professional Associates due to revision requests that were not received, and acknowledged that the PASRR prescreening should have been completed prior to admission. Interviews with facility staff revealed a lack of clarity and responsibility regarding the completion of PASRR screenings. The Administrator stated that the facility did not have a specific policy for PASRR and relied on CMS policy. The MDS Care Plan Coordinator, who was also acting as the Interim Director of Nursing, indicated that the Social Services Director was responsible for completing PASRR screenings, which are typically done before admission. Despite being familiar with the resident, the MDS/CPC acknowledged that the PASRR should have been completed prior to the resident's admission, and the necessary documentation should have been included in the resident's records.
Deficiency in Fall Mat Maintenance and Positioning
Penalty
Summary
The facility failed to maintain fall mats in good condition for a resident identified as being at risk for falls due to impaired safety awareness. During an observation, the resident was found lying in bed with a fall mat that had rips and tears, positioned approximately 6-8 inches away from the bed. The resident's care plan documented multiple falls in the past, with interventions including the use of a fall mat. However, the fall mat was not properly maintained or positioned, which was confirmed by both a Certified Nursing Assistant and the Assistant Director of Nursing. The facility's policy on accident hazard prevention emphasizes the importance of maintaining a safe environment for residents, particularly those who are frail and vulnerable to hazards. Despite this policy, the fall mat for the resident was not in a condition that would effectively prevent accidents, as it was damaged and not placed correctly. This oversight in maintaining the fall mat in good condition and ensuring it was positioned correctly contributed to the deficiency identified by the surveyors.
Deficiency in Dementia Care and Staff Training
Penalty
Summary
The facility failed to provide necessary care and services for a resident diagnosed with dementia, as evidenced by the lack of a comprehensive assessment and care plan addressing the resident's dementia-related needs. The resident, who had a diagnosis of non-Alzheimer's dementia, was admitted to a closed unit without an appropriate assessment to determine if this placement was suitable. Furthermore, the resident's care plan did not include strategies to manage dementia-related behaviors and expressions of distress, despite the resident having a severe cognitive impairment as indicated by a Brief Interview for Mental Status (BIMS) score of 3. Additionally, the facility did not ensure that there was sufficient staff with specialized training in dementia care available to meet the needs of residents on the closed unit. The Medication Administration Record (MAR) for the resident did not include documentation for tracking targeted behaviors and expressions of distress, which is crucial for managing dementia-related symptoms. Interviews with the Assistant Director of Nursing and the MDS Coordinator confirmed these deficiencies, highlighting a lack of appropriate care planning and staff training for residents with dementia on the closed unit.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
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 39 citations issued within 25 miles in the last 12 months — including the 1 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Van Buren
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Blossoms At Van Buren Rehab And Nursing Center | 2.1 mi | ★★★★★ | 0 | 0 |
| Van Buren Healthcare And Rehabilitation Center | 2.2 mi | ★★★★★ | 3 | 0 |
| Legacy Health And Rehabilitation Center | 3.4 mi | ★★★★★ | 0 | 0 |
| Chapel Ridge Health And Rehab | 6.4 mi | ★★★★★ | 0 | 0 |
| Methodist Health And Rehab | 6.7 mi | ★★★★★ | 0 | 0 |
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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.