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 Goldwater Care Spring Valley during CMS and state inspections, most recent first.
A resident with alcoholism and diabetes left the facility after a short stay and did not return, and staff failed to maintain complete and accurate documentation of the events surrounding the departure. The resident’s record lacked an AMA form, there was no sign-out entry identifying who took the resident out, and nursing staff did not document that the resident was missing at the time of a scheduled blood sugar check, that the CNA reported seeing the resident’s daughter take the resident out, or that the PM RN later confirmed with family that the resident refused to return. These omissions occurred despite facility policy requiring organized, accurate, and complete written records for each resident.
The facility failed to monitor prophylactic antibiotic use for five residents, as required by their Antibiotic/Antimicrobial Stewardship Program. The Assistant Director of Nursing, also the Infection Control Preventionist, did not track or review residents on prophylactic antibiotics, leading to unmonitored long-term antibiotic use without documented stop dates or diagnoses. This oversight was evident in the facility's infection log, which did not include these residents.
A facility failed to assess and implement a range of motion (ROM) program for a resident with multiple sclerosis and contractures. Despite the facility's policy requiring PROM assessments and exercises, there was no structured program in place, and the resident reported not receiving ROM exercises. Staff interviews confirmed the absence of a restorative program to address the resident's needs.
A resident with dementia and a history of falls did not have a Falling Leaf symbol on her door to indicate her fall risk, as required by the facility's Fall Prevention Program. This oversight was confirmed by both an LPN and the DON. The resident experienced multiple falls, including one in the dining room and another next to her bed, where necessary precautions were not adequately implemented.
A resident with a history of UTIs and pressure ulcers received improper catheter care, as an LPN used saline and peri wipes instead of soap and water, contrary to facility policy. This deviation was observed by the Infection Preventionist Nurse, and the DON confirmed that the use of peri wipes is not approved due to potential skin irritation.
A facility failed to document a rationale for the continued use of an antibiotic for a resident with a history of urinary tract infections. The resident's Physician Order Sheet indicated ongoing Nitrofurantoin 100 MG daily without a stop date. The Infection Preventionist was unaware of the duration of the antibiotic use, contrary to the facility's Antibiotic/Antimicrobial Stewardship policy.
A registered nurse in an LTC facility failed to follow proper hand hygiene protocols during medication administration by handling medications with ungloved hands. The nurse confirmed touching the medications before administering them to a resident, which was against the facility's guidelines. The Director of Nurses acknowledged that such practices should not occur.
A resident was transferred without a gait belt, contrary to facility policy, due to discomfort from a suprapubic catheter. Other CNAs reported no issues using a gait belt. Additionally, a mechanical lift sling tore during use, revealing lapses in equipment inspection and maintenance. The facility's policy requires both maintenance and nursing staff to assess slings, but this was not followed, leading to confusion about responsibilities.
Failure to Maintain Complete and Accurate Medical Record for Resident Who Left and Did Not Return
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident admitted with diagnoses including alcoholism and diabetes. The resident was admitted shortly before a holiday and remained in the facility for approximately two days before leaving and not returning. The resident’s record did not contain an Against Medical Advice (AMA) form, and there was no documentation of the resident signing out or being taken out of the facility. The social services staff member stated the resident left after about two days without signing an AMA form, and the AMA form itself was not present in the medical record. On the day the resident left, the day-shift RN reported that the resident mentioned his daughter might come to take him out for the holidays. Around lunchtime, the RN went to perform a blood sugar check but found the resident was not in his room and assumed the daughter had taken him out on pass, yet did not document the resident’s absence or inability to locate him. A CNA reported seeing the resident’s daughter take the resident out and stated she informed the day-shift RN, but this was also not documented. The PM-shift RN later checked the sign in/out sheet and found no record of the resident signing out or of who took him out, contacted the DON and the family, and learned the resident refused to return, but did not document these events in the progress notes. The DON stated it was important to document accurately in the resident’s record, especially when a resident was out of the facility, and the facility’s policy requires organized, accurate, and complete written records for each resident.
Failure to Monitor Prophylactic Antibiotic Use
Penalty
Summary
The facility failed to identify, monitor, and review prophylactic antibiotic use for five residents, which was a requirement under their Antibiotic/Antimicrobial Stewardship Program. The program was designed to ensure appropriate use of antibiotics to improve patient outcomes and reduce antibiotic resistance. However, the Assistant Director of Nursing, who also served as the Infection Control Preventionist, admitted to not tracking or reviewing residents on prophylactic antibiotics. This oversight was evident as the facility's January 2025 Monthly Infection Log Report did not include any of the five residents who were receiving prophylactic antibiotics. Specific cases highlighted include a resident with a long-term use of Nitrofurantoin without a documented stop date or diagnosis, and another resident on Nitrofurantoin for a personal history of urinary tract infections, also without a stop date. Additionally, a resident was on multiple antibiotics for DMAC without stop dates, and another was on Macrodantin for UTI suppression without a stop date. The Assistant Director of Nursing was unaware of these ongoing prophylactic antibiotic treatments, indicating a significant lapse in the facility's antibiotic monitoring and stewardship efforts.
Failure to Implement Range of Motion Program for Resident with Contractures
Penalty
Summary
The facility failed to assess and implement a range of motion (ROM) program for a resident with functional limitations. The facility's policy on Passive Range of Motion Exercises (PROM) requires staff to assess residents for their need for PROM and to provide exercises if recommended. However, the facility did not have a restorative nurse or aides, and the responsibility for restorative activities was informally assigned to CNAs without a structured program. The Director of Rehab mentioned that recommendations for restorative programs were given to nursing staff, but no formal program was in place, and the Care Plan Coordinator confirmed the absence of restorative programs in care plans. The resident in question, who has multiple sclerosis and contractures in the left shoulder and both knees, was observed with limited mobility and reported not receiving ROM exercises. The resident's care plan included monitoring and encouraging participation but did not include a specific ROM program. Interviews with facility staff, including the Assistant Director of Nurses and the Director of Rehab, confirmed the lack of a restorative program to address the resident's contractures, and the resident herself stated that no one performed ROM exercises with her.
Failure to Implement Fall Precautions for At-Risk Resident
Penalty
Summary
The facility failed to implement fall precautions for a resident identified as R43, who was at risk for falls due to conditions such as dementia, depression, anxiety, and chronic pain. Despite having a history of falls, the facility did not place a Falling Leaf symbol on R43's door to indicate her fall risk, which is a part of the facility's Fall Prevention Program. This oversight was confirmed by both a Licensed Practical Nurse and the Director of Nurses, who acknowledged that the symbol was missing despite R43's recent falls. R43 experienced multiple falls, including an unwitnessed fall in the dining room where she hit her head, and another fall where she was found on the floor next to her bed. In both instances, the necessary precautions and interventions, such as ensuring the call light was within reach and activated, were not adequately implemented. The facility's failure to communicate and implement these safety interventions contributed to the repeated falls experienced by R43.
Improper Catheter Care Increases Infection Risk
Penalty
Summary
The facility failed to perform proper urinary catheter care for a resident, identified as R221, which increased the risk of infection. The facility's policy, revised in February 2019, specifies that catheter care should involve cleansing the peri area and meatal surface with soap and water, and discourages the use of antiseptic or antimicrobial solutions. However, during an observation, an LPN used normal saline and moisturizing peri wipes instead of soap and water to clean the resident's peri area. This deviation from the established protocol was observed by the Infection Preventionist Nurse. R221's medical history includes a traumatic amputation below the left knee, stage 3 and stage 4 pressure ulcers, and a history of urinary tract infections. The resident's physician orders required catheter care every shift, yet the observed practice did not align with the facility's policy. The Director of Nurses confirmed that the use of peri wipes, which can be irritating, is not part of the facility's approved catheter care procedure, as irritated skin can lead to urinary tract infections.
Failure to Document Rationale for Continued Antibiotic Use
Penalty
Summary
The facility failed to document a rationale for the continued use of an antibiotic for a resident, identified as R2, who was reviewed for unnecessary medications. The facility's policy on Antibiotic/Antimicrobial Stewardship, dated November 28, 2017, emphasizes the importance of reducing unnecessary antibiotic use and ensuring appropriate treatment duration. However, R2's current Physician Order Sheet, dated February 2025, indicates the resident was prescribed Nitrofurantoin 100 MG daily for a personal history of urinary tract infections, without a specified stop date. On February 4, 2023, the Infection Preventionist acknowledged that R2 was on continuous antibiotics due to a history of urinary tract infections and was unaware of how long the antibiotic had been administered, noting the absence of a stop date for the medication.
Failure in Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols during medication administration for a resident. A registered nurse, identified as V14, was observed preparing medications for a resident without wearing gloves. The nurse opened the top drawer of the mobile medication cart, withdrew community stock medication bottles, and poured each medication into her ungloved hand before placing them into a small plastic medication cup. The medications included Aspirin, Calcium with Vitamin D, Docusate Sodium, Multivitamin, Simethicone, and Omeprazole. The resident then took the medications with a glass of water provided by the nurse. Upon returning to the medication cart, the nurse confirmed that she had touched each of the resident's pills with her ungloved hands. The Director of Nurses, identified as V2, later stated that nurses should not touch medications they are preparing for administration with their ungloved hands. This incident highlights a breach in the facility's infection prevention and control program, specifically regarding hand hygiene during medication administration.
Failure to Ensure Resident Safety During Transfers and Equipment Maintenance
Penalty
Summary
The facility failed to ensure resident safety during transfers by not using a gait belt as required by their policy. A Certified Nursing Assistant (CNA) transferred a resident, identified as R4, from a wheelchair to a bed without using a gait belt, citing discomfort due to the resident's suprapubic catheter. However, other CNAs reported no issues using a gait belt with this resident. The resident's care plan indicated a risk for falls due to weakness and tiredness, and the facility's policy mandates the use of gait belts for all physical assist transfers. Additionally, the facility did not adhere to its policy regarding the inspection and maintenance of mechanical lift slings. An un-witnessed fall investigation revealed that a mechanical lift sling tore during use, although the resident was not injured. The Assistant Director of Nursing (ADON) and other staff confirmed that slings should be inspected before use, but this was not done. The Director of Nursing (DON) stated that laundry staff is responsible for checking slings, but the policy requires both maintenance and nursing staff to assess them. The incident involving the broken sling highlighted a lack of clarity and adherence to the facility's policy on equipment maintenance. The sling was not inspected before use, and there was confusion among staff about who was responsible for checking the slings. The broken sling was eventually brought to the DON, who was unsure of the procedure for handling it, indicating a gap in communication and policy enforcement within the facility.
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Illustrative
What surveyors actually found near you
We read the 75 citations issued within 25 miles in the last 12 months — including the 2 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
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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) |
|---|---|---|---|---|
| Allure Of Peru | 3.9 mi | ★★★★★ | 4 | 0 |
| Manor Court Of Peru | 4.1 mi | ★★★★★ | 11 | 1 |
| Goldwater Care Princeton | 13.2 mi | ★★★★★ | 5 | 0 |
| Manor Court Of Princeton | 13.4 mi | ★★★★★ | 1 | 0 |
| Allure Of Mendota | 15.6 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.