Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Spring View Manor Healthcare And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found multiple sanitation issues in the kitchen, including improperly stored frozen and refrigerated foods such as open bags of food with ice crystals, an unsealed bag of meat, and an opened package of cheese. Dietary staff were observed delivering meals while placing their thumbs on the eating surfaces of plates. Dishwasher temperatures were measured below the level a staff member stated was needed for proper disinfection, and prior service reports showed low wash and final rinse temperatures. A staff member reported that the water heater pilot light went out at times and that staff were expected to monitor temperatures, while the written dishwashing policy lacked specific temperature requirements for cleaning and sanitizing dishware and cookware.
The facility did not ensure that all CNAs received the required minimum of 12 hours of annual in-service training, including topics such as dementia care and abuse prevention. Review of records for several CNAs employed more than one year showed that two CNAs had only seven and eight documented training hours over the prior year. An administrative nurse confirmed the 12-hour annual requirement and the absence of additional training records for these CNAs, and the facility was unable to provide a policy outlining its CNA in-service training program.
The facility failed to issue required CMS-10055 SNF Advanced Beneficiary Notices of Non-Coverage (ABN), including estimated costs, to two Medicare Part A beneficiaries when their skilled coverage ended and they remained for custodial care. Review of electronic medical records showed that both residents had defined Medicare Part A episodes followed by continued custodial stays, but there was no documentation that ABNs were provided. The facility’s own Advance Beneficiary Notice policy required timely notification of Medicare eligibility, coverage, and potential liability for payment before providing items or services that may not be covered, such as custodial care. An interview with social services staff revealed unawareness of the need to complete and issue the ABN, and the facility could not produce evidence that the CMS-10055 form was given to either resident.
A resident with obesity, O2 dependence, cognitive communication deficit, and skin cancer experienced respiratory symptoms and was transferred to the hospital after nursing staff documented shortness of breath, productive cough, and low O2 saturation, with a phone message left for the responsible party. Although the EMR showed a bed-hold assessment with verbal confirmation and the resident later returned for skilled therapy, there was no written notice explaining the reason for transfer provided to the resident or representative, nor was a copy sent to the ombudsman. Interviews with the resident, social services, and an administrative nurse revealed that staff were unaware or unsure of written notification requirements and that the facility had not been consistently issuing written transfer notices or ombudsman notifications, contrary to its own transfer/discharge policy requiring detailed written notice and appeal information.
Surveyors found that dietary staff did not follow the approved recipe for pureed green beans, using tap water instead of an appropriate hot liquid, which altered the food’s nutritive content. Staff also failed to consistently monitor and maintain required food temperatures, with pureed spaghetti and cooked spaghetti served below the facility’s 135°F hot holding standard and an Italian tossed salad served above the 41°F cold holding standard. A resident reported that tray-delivered meals were only “kind of warm,” and a dietary staff member acknowledged that they do not routinely take temperatures of cooked or pureed foods before service, despite facility policy requiring specific hot and cold holding temperatures.
Surveyors identified multiple infection control failures, including staff entering a resident’s room on EBP wearing gloves without prior hand hygiene and continuing incontinence care while wearing soiled gloves, then changing gloves without hand hygiene. Two residents’ nebulizer masks and equipment were found lying directly on bedside tables, one with residual fluid, and not stored in sanitary containers between treatments. An RN performed an enteral dressing change without a gown, used gloves taken from a pants pocket, and placed a new syringe plunger into a soiled container. The same RN performed wound care for another resident while repeatedly leaving and re-entering the room, assisting the roommate, kneeling on the floor, handling dressings, and completing the wound care without changing gloves or performing hand hygiene, despite facility policies requiring proper hand hygiene, glove changes between soiled and clean tasks, appropriate PPE, and sanitary storage of nebulizer equipment.
A resident’s EMR lacked required documentation showing that an influenza (flu) vaccine was offered, accepted, declined, or contraindicated, despite the facility’s policy to offer annual flu immunizations. During review, there was no record in the immunization section of the EMR of a flu vaccine, a documented offer, a legal representative’s informed declination, or a physician-documented contraindication. The IP, who tracks immunizations, reported having contacted the resident’s legal representative and stated the vaccine was declined, but this was not documented in the EMR in accordance with facility policy.
The facility did not ensure that daily nurse staffing sheets accurately reflected actual hours worked by RNs, LPNs, and CNAs. On the day reviewed, the posted staffing form, observed twice near the nurse’s station with a census of 40 residents, lacked actual hours worked per shift for licensed and unlicensed staff providing resident care. An LN and administrative nurses reported that nurses did not update the posted sheet when staff were late or absent and that the business office added actual hours at the end of the week, contrary to facility policy requiring real-time updates after each shift.
The facility did not conduct required annual evaluations for four CNAs and CMAs employed for over a year. Personnel files lacked documentation of these evaluations, contrary to the facility's policy. This was confirmed through a review and an interview with a consultant.
The facility failed to submit accurate direct care staffing information to CMS for the second and fourth quarters of 2023. The Payroll Base Journal (PBJ) submissions did not include agency staff used on weekends, leading to reports of excessively low weekend staffing. The facility lacked a policy for PBJ submission, contributing to the inaccurate reporting.
The facility failed to provide adequate education for informed decision-making regarding influenza, pneumococcal, and COVID-19 vaccinations for several residents. Medical records lacked documentation of education or evidence of vaccine receipt or declination, contrary to facility policies. Interviews confirmed the absence of proper documentation, leading to deficiencies in vaccine administration.
A resident with severe cognitive impairment and physical limitations did not receive adequate grooming, as staff failed to shave him regularly despite his discomfort with facial hair. The resident, who required assistance with ADLs, was observed with several days' worth of facial hair growth. Staff were unaware of his last shower, and the facility's grooming policy was not followed, affecting the resident's well-being.
The facility failed to follow physician orders and provide timely lab reporting for two residents. One resident did not have labs obtained promptly, delaying treatment for nausea and vomiting. Another resident did not receive medications as prescribed for weight gain and hypertension, with staff administering Lisinopril despite low blood pressure readings. The facility lacked a policy for following physician orders.
A facility failed to follow infection control practices during medication and insulin administration for two residents. A nurse did not sanitize a gastrostomy tube or syringe before administering medications to a resident with a swallowing disorder. Additionally, the same nurse did not perform hand hygiene between administering insulin to two residents, contrary to facility policy.
The facility did not ensure daily staff postings included actual hours worked, as required. A review of postings from February to April 2024 showed missing hours, confirmed by an interview with an administrative staff member. The business office recorded hours via a computer program, and the facility lacked a policy for daily staff posting.
Unsanitary Food Storage, Handling, and Dishwashing Practices
Penalty
Summary
Surveyors identified deficiencies in the facility’s food storage and preparation practices. During an initial kitchen tour with dietary staff, three open plastic bags of food were observed in the freezer with ice crystals formed directly on the food items, along with one unsealed bag of meat and one opened package of cheese. These items were not properly sealed, indicating improper storage of frozen and refrigerated foods. Additional observations showed dietary staff handling resident meal plates by placing their thumbs on the eating surfaces of the plates while delivering meals to residents. Surveyors also found deficiencies in dishwashing and sanitization practices. A dietary staff member measured the dishwasher water temperature at 103°F, and stated that the water temperature should be 120°F to properly disinfect and sanitize dishware and cookware. Review of recent kitchen service reports showed that both the wash and final rinse temperatures of the dishwasher had been recorded at 122–123°F on prior dates. Another staff member reported that the pilot light on the water heater went out at times and that staff were expected to monitor dishwasher temperatures and not run dishes if the temperature was below 120°F. The facility’s written dishwashing policy from 2020 did not specify required temperatures for cleaning, disinfecting, or sanitizing dishware and cookware.
Failure to Ensure Required Annual In-Service Training for CNAs
Penalty
Summary
The facility failed to develop, implement, and permanently maintain an in-service training program for CNAs that ensured at least 12 hours of annual education with required topics such as dementia care and abuse prevention. During a survey with a reported census of 40 residents, review of training records for five CNAs employed more than one year showed that two CNAs had less than 12 hours of documented in-service training in the previous 12 months. One CNA, employed since 12/20/23, had eight hours of documented training, and another CNA, employed since 07/22/24, had seven hours of documented training. The Administrative Nurse confirmed that all CNAs were required to have 12 hours of training annually and acknowledged there were no additional training records for these CNAs, and the facility did not provide a policy governing the in-service training program. These findings demonstrate that the facility did not ensure all CNAs received and had documentation of the minimum required annual in-service training hours, nor did it provide evidence of a formal policy to support and maintain the required training program.
Failure to Issue Required ABNs When Medicare Part A Coverage Ended
Penalty
Summary
The facility failed to provide required CMS-10055 Skilled Nursing Facility (SNF) Advanced Beneficiary Notices of Non-Coverage (ABN), including estimated costs for continued services, to two Medicare Part A beneficiaries when their skilled coverage ended and they remained for custodial care. Record review showed that one resident had a Medicare Part A episode from 09/18/25 to 10/20/25 and then remained in the facility for custodial care, but the electronic medical record contained no evidence that an ABN was issued. Another resident had a Medicare Part A episode from 10/25/25 to 12/24/25 and also remained for custodial care, with no documentation in the electronic medical record that an ABN was provided. The facility’s policy on Advance Beneficiary Notices, reviewed 05/07/25, required timely notices regarding Medicare eligibility and coverage and informing beneficiaries of potential liability for payment, including issuing a liability notice upon admission or during the stay before providing items or services that may not be covered because they are not medically reasonable and necessary or are custodial care. Interviews confirmed that the responsible social services staff member was not aware of the requirement to complete and issue the ABN, and the facility was unable to produce evidence that the CMS-10055 form was given to either resident.
Failure to Provide Required Written Transfer and Bed-Hold Notifications
Penalty
Summary
Surveyors identified a failure to provide required written notification of transfer for a resident who was hospitalized. The resident had diagnoses including obesity, dependence on supplemental oxygen, cognitive communication deficit, and skin cancer. On 12/11/25, nursing notes documented the resident was short of breath, coughing up yellow sputum, and had an oxygen saturation of 88%, leading to new medication, lab orders, and a mobile chest X-ray. Later that day, a nurse documented leaving a message for the responsible party that the resident was going to the hospital, and that the resident left with emergency services. The resident returned to the facility on 12/22/25 and was to receive skilled therapy services. The EMR contained a bed-hold assessment with verbal confirmation but lacked documentation of written notification to the resident and/or representative explaining the reason for the transfer to the hospital. During interviews, the resident stated he was supposed to sign the bed hold but was not given it before leaving for the hospital. Social Service staff reported that one social worker obtained bed holds when a resident left, but they were not aware of or unsure about sending written letters to residents or representatives or notifying the ombudsman. Administrative nursing staff confirmed the facility had not been sending written notifications to families with the reason for transfer, nor sending notifications to the ombudsman, noting that an email had been sent one month prior but not since. This practice was inconsistent with the facility’s Transfer and Discharge policy, which requires that a transfer/discharge notice be provided to the resident and representative, including the specific reason for transfer, effective date, destination, appeal rights and procedures, and contact information for the state appeal entity, ombudsman, and protection and advocacy agencies where applicable.
Failure to Follow Puree Recipe and Maintain Safe Food Temperatures
Penalty
Summary
Surveyors identified a deficiency related to food preparation and service temperatures. During observation of meal preparation, a dietary staff member added tap water to green beans while pureeing them, despite the facility’s recipe specifying that, if thinning was needed, staff should gradually add an appropriate hot liquid such as broth, gravy, milk, or reserved cooking liquid. This deviation from the recipe altered the nutritive content of the pureed green beans. The facility’s written recipe and procedures did not authorize the use of tap water for this purpose. Additional observations showed that staff did not consistently ensure hot and cold foods were served at safe and appetizing temperatures. Pureed spaghetti delivered to the dining room was measured at 127°F, and a plated hall tray of cooked spaghetti delivered to a resident’s room was measured at 130°F, both below the facility’s required hot holding/serving temperature of 135°F or higher. The Italian tossed salad on the same tray was measured at 52°F, above the required cold holding/serving temperature of 41°F or below. A resident reported that food served to their room was not hot but “kind of warm.” One dietary staff member stated they do not obtain temperatures on cooked food or cooked pureed food before sending it to the dining room, while another dietary staff member acknowledged the facility’s expectations that hot foods be maintained at 135°F or above and cold foods at 41°F or below, as outlined in the facility’s 2020 Monitoring Food Temperatures for Meal Service policy.
Failure to Follow Hand Hygiene, PPE, and Nebulizer Storage Practices Under EBP
Penalty
Summary
The deficiency involves failures in infection prevention and control practices, including improper hand hygiene, PPE use, and storage of nebulizer equipment. Surveyors observed that two staff members entered a resident’s room on Enhanced Barrier Precautions (EBP) wearing gloves but without performing hand hygiene. During incontinence care, one staff member continued to pull up the resident’s pants while still wearing soiled gloves, then removed and reapplied gloves without hand hygiene. In separate observations, two residents’ nebulizer masks and equipment were found lying directly on bedside tables, one with residual fluid in the chamber, and not stored in sanitary containers between treatments, contrary to facility expectations. Additional observations showed a nurse performing dressing changes without adhering to EBP and infection control standards. For one resident with an enteral feeding site, the nurse used gloves taken from his pants pocket, did not don a gown for the dressing change, and placed a new syringe plunger into a soiled container without cleaning it. For another resident receiving wound care, the same nurse donned gloves from his pocket and a gown, left and re-entered the room multiple times without changing gloves or performing hand hygiene, assisted the roommate while wearing the same gloves, knelt on the floor, handled dressing supplies, cleansed and dressed the wound, and used a marker from his pocket to date the dressing, all without changing contaminated gloves. Facility leadership and the Infection Preventionist later confirmed that nebulizers should be bagged between treatments, PPE (including gowns) should be worn for dressing changes, gloves should be changed between soiled and clean tasks, and hand hygiene should be performed between glove changes, as required by the facility’s hand hygiene and EBP policies.
Failure to Document Influenza Vaccination Offer and Declination
Penalty
Summary
The deficiency involves the facility’s failure to follow its influenza vaccination policy by not properly documenting the offer, consent, declination, or contraindication for an influenza vaccine for Resident 28. The facility had a census of 40 residents, with a sample of 12 residents and 5 reviewed for immunization status. Record review of Resident 28’s EMR under the Immunization tab showed no documentation that the influenza vaccine was offered or declined, and no record of a historical influenza vaccination or a physician-documented contraindication, despite the resident’s admission earlier in the month. Although the facility later provided a declination form for the annual influenza vaccination dated the day after the record review, this documentation was not present at the time of the initial review. During an interview, the Infection Preventionist, who was responsible for tracking immunizations, stated she had left a message with the resident’s legal representative regarding immunizations and reported that the legal representative had declined the influenza vaccination, but this declination was not documented in the EMR as required by facility policy. The facility’s written Influenza Vaccination policy stated that it was the policy of the facility to minimize the risk of acquiring, transmitting, or experiencing complications from influenza by offering annual influenza immunization to residents, staff, and volunteers, but the required documentation of this process was not completed for Resident 28.
Failure to Post Accurate Daily Nurse Staffing Hours
Penalty
Summary
The facility failed to ensure that the posted daily nurse staffing sheets contained accurate and identifiable information, specifically the actual hours worked per shift by licensed and unlicensed staff providing resident care. On the survey date, the posted nurse staffing form for that day, observed near the nurse’s station, did not include the actual hours worked for RNs, LPNs/LVNs, and CNAs. The form was observed twice on the same day and on both occasions lacked the required actual hours worked per shift. The facility census at the time was 40 residents. Staff interviews confirmed that actual hours were not being updated on the posted staffing sheets as required by facility policy. An LN reported that nurses do not change the time or add actual hours on the posted sheet, even when staff arrive late, and that the business office updates the information later. An administrative nurse stated she placed the staffing sheet out and that the office added actual hours at the end of the week, with no adjustments made before then. Another administrative nurse stated that nurses should be entering the actual hours on the posted staffing sheet after the start of each shift. This practice conflicted with the facility’s written Nurse Staffing Posting Information policy, which required daily posting of staffing sheets with actual hours worked and updates after the start of each shift to reflect staff absences and call-outs.
Failure to Conduct Annual Evaluations for CNAs and CMAs
Penalty
Summary
The facility failed to ensure that four out of five Certified Nurse Aides (CNA) and Certified Medication Aides (CMA/CNA) who were employed for over a year received their required annual evaluations. The personnel files of these staff members, specifically CNA N, CNA M, CNA O, and CMA R, lacked documentation of annual evaluations. This deficiency was identified during a review of personnel files and confirmed through an interview with consultant GG, who stated that she expected staff to have evaluations annually. The facility's policy, implemented in December 2019, mandates a formal written evaluation of employees' work performance annually, which was not adhered to in these cases.
Inaccurate PBJ Submission for Weekend Staffing
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to the Centers for Medicare and Medicaid Services (CMS) for the second and fourth quarters of 2023. Specifically, the facility did not accurately report weekend staffing, as the Payroll Base Journal (PBJ) submissions did not include agency staff used to supplement the nursing staff employed by the facility. This resulted in the PBJ triggering for excessively low weekend staffing for both quarters. The facility lacked a policy for PBJ submission, which contributed to the inaccurate reporting of hours. An interview with Administrative Staff A revealed that the corporate office was responsible for submitting the PBJ, and the omission of agency staff led to the deficiency.
Deficiency in Vaccine Education and Documentation
Penalty
Summary
The facility failed to ensure that residents received proper education for informed decision-making regarding vaccinations, leading to deficiencies in the administration of influenza, pneumococcal, and COVID-19 vaccines. Specifically, two residents, R21 and R11, did not receive education for the 2023 influenza vaccine, and R21 also lacked education for the pneumococcal vaccine. Additionally, three residents, including R21 and R3, did not receive education for informed decision-making regarding the COVID-19 vaccine. The medical records for these residents lacked documentation of education provided for informed decision-making or evidence of receipt or declination of the vaccines. The facility's policies on influenza, pneumococcal, and COVID-19 vaccinations, implemented in 2019 and 2022, instructed staff to offer and educate residents about these vaccines. However, interviews with the administrative nurse confirmed the absence of documented declinations or undated declinations for the residents involved. This lack of documentation and education resulted in the facility's failure to provide residents with the opportunity to make informed decisions about their vaccinations, as required by the facility's policies.
Failure to Provide Adequate Grooming for Resident
Penalty
Summary
The facility failed to provide adequate personal grooming for a resident with severe cognitive impairment and physical limitations. The resident, who had a history of hemiplegia, hemiparesis, cerebral vascular accident, and major depressive disorder, was assessed as requiring staff assistance with activities of daily living, including personal hygiene. Despite the care plan indicating the resident was dependent on staff for bathing and personal hygiene, observations revealed the resident had several days' worth of facial hair growth, which he did not desire and found uncomfortable. Interviews with staff indicated that the resident was typically shaved on shower days, but there was a lack of awareness regarding the resident's last shower. The resident had refused showers on several occasions during the evening shift, and staff confirmed he needed a shave. The facility's policy on grooming facial hair instructed staff to assist residents in maintaining proper hygiene, yet the resident did not receive grooming opportunities according to his preferences, impacting his sense of well-being.
Failure to Follow Physician Orders and Timely Lab Reporting
Penalty
Summary
The facility failed to provide timely pharmaceutical services for two residents, leading to deficiencies in care. For one resident with chronic respiratory and heart failure, diabetes, and kidney failure, the facility did not obtain laboratory values in a timely manner. Despite the physician's instructions to obtain a Complete Blood Count (CBC) and Comprehensive Metabolic Panel (CMP) due to the resident's ongoing nausea and vomiting, the facility delayed obtaining these labs by two days. This delay was attributed to the laboratory's failure to provide a phlebotomist promptly. Additionally, the facility did not report the laboratory results to the physician on the day they were obtained, further delaying necessary medical intervention. Another resident with hypertension, heart failure, and chronic kidney disease did not receive medications as per physician orders. The facility failed to administer Bumex for weight gain as instructed, despite documented weight increases that met the criteria for administration. Furthermore, the facility administered Lisinopril for hypertension even when the resident's blood pressure readings were below the parameters set by the physician. These failures were compounded by the absence of a facility policy for following physician orders, leading to non-compliance with prescribed medical care.
Infection Control Lapses in Medication and Insulin Administration
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during the administration of medications and insulin for two residents. For Resident 1, who had a history of cerebral vascular accident and a swallowing disorder, a Licensed Nurse (LN) was observed administering medications through a percutaneous gastrostomy tube without cleaning or sanitizing the tube or syringe. The syringe was placed directly on a paper towel on the resident's bedside table, which did not adhere to the facility's policy requiring infection control precautions to minimize contamination risk. In another instance, a Licensed Nurse was observed administering insulin to a resident with diabetes without performing hand hygiene between residents. The nurse picked up an insulin pen and prepared to administer insulin without sanitizing her hands, although she later verified the need to do so. This action was contrary to the facility's policy, which required hand hygiene and glove use before and after insulin administration. These lapses in infection control practices could potentially lead to the spread of infections among residents.
Failure to Record Actual Staff Hours on Daily Postings
Penalty
Summary
The facility failed to ensure that the daily staff postings included the actual hours worked by staff, as required. During a review of the daily staff postings from February, March, and April 2024, it was found that the postings lacked the actual hours worked for staff members. An interview with Administrative Staff A confirmed that the facility did not record the actual hours worked on the daily staff posting sheets. Instead, the business office documented these hours through a computer program. Additionally, the facility did not have a policy in place for daily staff posting, contributing to the deficiency.
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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.
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Nursing homes near Conway Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Clearwater Nursing & Rehabilitation Center | 11.7 mi | ★★★★★ | 23 | 2 |
| Wellington Health And Rehab | 15 mi | ★★★★★ | 16 | 0 |
| Botkin Care And Rehab | 16.4 mi | ★★★★★ | 0 | 0 |
| Cheney Golden Age Home | 18.7 mi | ★★★★★ | 0 | 0 |
| Medicalodges Goddard | 19.3 mi | ★★★★★ | 17 | 0 |
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