Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Valley Care Center during CMS and state inspections, most recent first.
Improper dating and storage of refrigerated food items were observed in the kitchen. Surveyors found undated sandwiches, hot dogs, onion, and oranges in syrup, along with pumpkin puree, honeydew, and chicken gravy that were past the facility’s 3-day discard timeframe. The DM confirmed some items were expired and should have been discarded, and the administrator stated dietary staff were expected to follow the food safety policy for dating and disposal.
Conflicting code status information was found for a resident receiving hospice care who had severe cognitive impairment and dementia. The EMR banner showed DNR/comfort, but a linked POLST showed CPR/full resuscitative treatment, while another POLST in the chart showed comfort-focused treatment and no resuscitation. Staff said they relied mainly on the EMR banner to verify code status, and the care coordinator confirmed the discrepancy and was unsure how the incorrect POLST became attached.
Failure to monitor orthostatic BP for a resident receiving routine and PRN antipsychotics. The resident had severe cognitive impairment, hospice care, a hx of falls, and required a stand lift for transfers. The MAR lacked monthly orthostatic BP orders, and the record showed only intermittent orthostatic checks tied to falls, with none documented in some months. The MD stated monthly orthostatic BP monitoring was expected, while the consultant pharmacist confirmed she did not request it for the resident.
A resident with dementia, psychotic disorder, anxiety, and depression had an inaccurate Tylenol order on the MAR and provider order summaries. The order listed Tylenol 1 tablet q6h PRN pain but did not include a dosage, and both the MD and pharmacist confirmed the omission and that it should have been identified during provider sign-off.
Inaccurate Transcription of Tylenol Order: Facility staff inaccurately transcribed a provider order for a resident’s Tylenol, leaving out the dosage on the MAR. The HUC entered the initial orders, and the administrator, MD, and pharmacist all confirmed the order was incomplete and that accurate transcription of provider orders was the facility’s responsibility.
The consultant pharmacist failed to identify irregularities in monthly med regimen reviews for two residents. One resident’s Tylenol order lacked a dosage, and the pharmacist did not question the incomplete order. Another resident with severe cognitive impairment, falls, hospice care, and routine/PRN antipsychotic use had no monthly orthostatic BP monitoring ordered or documented in the pharmacy reviews, despite repeated falls and staff confirmation that such monitoring was expected.
A facility failed to keep its survey binder in the designated front desk location where residents could readily view state survey results and contact advocate agencies. The resident council president, who had intact cognition per MDS, said the binder had been missing for some time, and the SW and administrator confirmed the binder existed but were unsure why it was not where it belonged.
The facility inaccurately submitted staffing data to CMS for Q3 2024, showing low weekend staffing levels, despite internal reports indicating adequate staffing. The administrator confirmed consistent staffing levels throughout the week, and the business office was responsible for submitting data based on schedules and postings. The facility's policy mandates electronic reporting of staffing information to CMS, based on verifiable records.
A resident with severe cognitive impairment was consistently provided with plastic silverware during meals, unlike other residents who received regular silverware. This was due to the resident's history of collecting silverware and a past incident involving a butter knife. The facility did not conduct ongoing assessments or trials to reassess the resident's behavior, impacting the resident's dignity and eating habits.
A resident with severe cognitive impairment was observed using a nebulizer independently without a self-administration of medications (SAM) order. The facility's staff routinely set up the nebulizer and left the resident alone, despite the lack of a SAM order. The facility's policy required a comprehensive assessment for self-administration, which was not completed for this resident.
The facility failed to provide required SNFABN and NOMNC forms to two residents whose Medicare A coverage ended. Staff interviews revealed the forms were missing, and the facility's policy on beneficiary notices was not provided.
The facility failed to conduct required quarterly reassessments for two residents with severe cognitive impairments and histories of wandering and elopement risks. Despite having interventions like wander guards in place, the facility did not ensure these measures were still appropriate, as confirmed by staff interviews. This oversight could lead to inappropriate interventions being maintained, contrary to the facility's policy.
Two residents with severe cognitive impairments were not provided with necessary grooming assistance, specifically shaving, despite their dependence on staff for all activities of daily living. Observations over several days showed both residents with noticeable facial hair, and interviews with staff revealed inconsistencies in the shaving routine. The facility's policy on shaving for cleanliness and dignity was not consistently followed.
A resident with a hearing impairment did not receive proper treatment to maintain hearing, as the facility failed to offer an audiology appointment or execute a standing order for ear flushing despite a history of cerumen buildup. Observations showed the resident often without hearing aids, and staff confirmed the resident's hearing had worsened. The facility's policy emphasized regular evaluation, but the lack of action led to communication difficulties.
A facility failed to provide trauma-informed care for a resident with PTSD and severe cognitive impairment. Despite a trauma questionnaire indicating past trauma, the care plan lacked individualized interventions. Staff were unaware of the resident's trauma history, and the social worker admitted that triggers and interventions were not identified. The facility's policy on trauma-informed care was not effectively applied.
The facility failed to assess the safety and necessity of side rails for two residents, leading to a deficiency. Both residents had side rails affixed to their beds without recent assessments, and staff interviews revealed a lack of adherence to the facility's policy on side rail safety. The policy required timely assessments and education on risks, which were not adequately implemented.
The facility did not ensure RN coverage for eight consecutive hours on specific dates, as required by policy. Staffing schedules showed gaps in RN coverage, confirmed by the ADON, who cited call-ins as a reason. The facility's policy mandates RN supervision for eight hours daily, including weekends and holidays.
A facility failed to monitor and document the use of antipsychotic medication for a resident with severe cognitive impairment. Despite receiving haloperidol for anxiety and agitation, the resident's care plan and medication records lacked evidence of behavior and side effect monitoring. Staff interviews confirmed the absence of necessary monitoring, which is required by the facility's policy on antipsychotic medication use.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents requiring such measures due to indwelling catheters and tube feedings. Observations showed a lack of PPE and signage, and staff interviews revealed insufficient training and awareness of EBP protocols. The assistant director of nursing confirmed that EBP was not in place, and the facility did not provide a policy on EBP when requested.
The facility did not ensure daily nurse staffing information was posted and available for residents and visitors, with postings not updated to reflect current staffing. The Health Unit Coordinator (HUC) was unaware of the requirement to retain staffing logs for 18 months, leading to unavailable records prior to a certain date. This affected all 41 residents and visitors who might want to review the information.
Improper Dating and Storage of Refrigerated Food
Penalty
Summary
The facility failed to properly label, store, and dispose of refrigerated food items in the kitchen. During the initial kitchen tour with the dietary manager, surveyors observed an undated bin of sandwiches, undated hot dogs, undated onion, undated oranges in syrup, pumpkin puree dated 12/10, honeydew dated 11/8, and chicken gravy dated 11/20 in the refrigerator. During interview, the dietary manager confirmed the listed items, stated the sandwiches and pumpkin puree were expired and should have been discarded, and acknowledged the facility policy that leftover food is to be discarded after 3 days. The administrator later stated dietary staff were expected to follow the facility food safety policy to accurately date and dispose of food items. A facility policy titled Food Receiving and Storage stated that all foods stored in the refrigerator or freezer will be covered, labeled, and dated, and that leftover food should be disposed of after three days.
Conflicting POLST and EMR Code Status Entries
Penalty
Summary
The facility failed to ensure advance directives for emergency treatment were accurately reflected in all areas of the medical record for one resident who had severe cognitive impairment, diagnoses of non-traumatic brain dysfunction and dementia, and was receiving hospice care. The resident’s MDS, MAR, care plan, and EMR banner all indicated DNR/comfort status, and staff reported they would use the EMR banner or assignment sheet to verify code status in an emergency. However, the EMR banner also contained a hyperlink to a signed POLST that indicated CPR and full resuscitative treatment, creating conflicting code status information within the resident’s record. During record review, another section of the medical record contained a separate POLST dated differently that indicated comfort-focused treatment and no attempts at resuscitation. Staff interviews showed the RN, TMA, and LPN relied primarily on the EMR banner to determine code status, with some stating they might use the hyperlink if needed, while the care coordinator confirmed the banner showed DNR but the linked POLST showed CPR/full resuscitative treatment and stated she was unsure how the POLST became attached. The administrator stated the admitting nurse entered code status into the EMR and acknowledged that having the incorrect POLST linked to the code status was a problem.
Failure to Monitor Orthostatic Blood Pressure With Antipsychotic Use
Penalty
Summary
The facility failed to ensure proper side effect monitoring for potential orthostatic hypotension for one resident who received routine and as-needed antipsychotic medications. The resident had severe cognitive impairment with wandering, required partial to substantial assistance with activities of daily living, and had diagnoses including brain bleed with loss of consciousness, encephalopathy, disorientation, and palliative care. The care plan identified hospice care, impaired cognition, transfer assistance with a stand lift, fall risk, incontinence, poor communication and comprehension, psychoactive drug use, and prior falls, and it also included monitoring for target behaviors and side effects related to antipsychotic use. The medication administration record did not include orders for monthly orthostatic blood pressures, and orthostatic blood pressures were only documented once in July, once in September, and once in October, each associated with a fall. No orthostatic blood pressures were obtained in August or November. The resident had 5 falls in July, 2 in August, 6 in September, and 2 in October, with the last documented fall on 10/19/25. During interviews, the medical director stated residents receiving antipsychotics should have monthly orthostatic blood pressures and that staff should attempt as many steps as the resident could physically perform, while the consultant pharmacist confirmed she did not request orthostatic blood pressure monitoring for the resident. The care coordinator stated the resident was not attempted for orthostatic blood pressures because he was a stand-lift transfer and could not stand long enough, but no documentation of a discussion with providers was available.
Incomplete Tylenol Order Lacked Dosage
Penalty
Summary
The facility failed to ensure a resident had accurate physician orders for medications. For one resident with diagnoses including dementia with psychotic and mood disturbance, psychotic disorder with delusions, cognitive function decline, anxiety, and depression, the Medication Administration Record listed Tylenol as 1 tablet every 6 hours as needed for pain, but the order lacked a dosage. The resident’s order summary reports, signed by the provider from 1/28/25 through 12/17/25, also lacked a dosage for Tylenol. During interview, the medical director confirmed the current Tylenol order lacked a dosage and stated an accurate order should include one. The medical director also stated the provider team should have identified the dosage discrepancy when signing the order summary and on each subsequent sign-off. The pharmacist likewise confirmed the Tylenol order lacked a dosage and stated medications missing a dosage should have been identified when the provider signed off on the order summary.
Inaccurate Transcription of Tylenol Order
Penalty
Summary
Facility staff failed to accurately transcribe a physician order for one resident admitted to the facility. The resident was admitted with an order from the sending facility for Tylenol 500 mg, 1 tablet by mouth every 6 hours as needed for pain. The resident’s MDS indicated no cognitive deficit, although diagnoses included dementia with psychotic and mood disturbance, psychotic disorder with delusions, cognitive function decline, anxiety, and depression. The MAR showed Tylenol to be given 1 tablet every 6 hours as needed for pain, but the dosage was missing from the order. The initial orders were transcribed into the medical record by the HUC. During interview, the administrator confirmed the Tylenol order was inaccurately transcribed at admission. The MD confirmed the current Tylenol order lacked a dosage and stated an accurate order should contain a dosage. The pharmacist also confirmed the order lacked a dosage and stated facility staff were responsible for entering new orders from the provider and that accurate transcription was important so the resident received the care the provider ordered. The facility policy stated physician orders are to be processed accurately, timely, and in compliance with federal and state regulations.
Pharmacy Review Failed to Identify Incomplete Medication Order and Missing Orthostatic BP Monitoring
Penalty
Summary
The facility failed to ensure the consultant pharmacist identified irregularities during monthly drug regimen reviews for 2 residents. For one resident with diagnoses including dementia with psychotic and mood disturbance, psychotic disorder with delusions, cognitive function decline, anxiety, and depression, the MAR listed Tylenol as 1 tablet every 6 hours as needed for pain, but the order lacked a dosage. Monthly pharmacy reviews from July through December 2025 also lacked a Tylenol dosage. The medical director confirmed the order was incomplete and expected the pharmacist to question it during monthly reviews, and the pharmacist confirmed she failed to notice that the strength of Tylenol was missing. For another resident with severe cognitive impairment, wandering, a history of falls, traumatic brain dysfunction, palliative care, brain bleed with loss of consciousness, encephalopathy, disorientation, and hospice care, the MAR showed routine and PRN antipsychotic use, but it did not contain orders for monthly orthostatic blood pressures. The resident had multiple falls in July, August, September, and October, with the last documented fall on 10/19/25, and orthostatic blood pressures were only obtained once in July, September, and October with associated falls. Monthly drug regimen reviews from July through December 2025 lacked orthostatic blood pressure monitoring, and the pharmacist confirmed she did not request it for this resident.
Survey Results Not Readily Accessible to Residents
Penalty
Summary
The facility failed to ensure its state survey results were kept in a location that was readily accessible to all residents. During observation, interview, and document review, surveyors found that the survey binder was not in the designated spot at the front desk. The resident council president, whose quarterly MDS indicated intact cognition, stated during interview that the survey binder was usually at the front desk but had been gone for some time and that she would like to see it returned. On 12/18/25, the social worker and administrator confirmed the facility had a survey binder but were unsure why it was not in the designated location. A policy regarding posting survey results was requested but not received.
Inaccurate Staffing Data Submission to CMS
Penalty
Summary
The facility failed to submit complete and accurate staffing data to the Centers for Medicare and Medicaid Services (CMS) for the third quarter of the fiscal year 2024. The Payroll Based Journal (PBJ) report indicated excessively low weekend staffing levels, which contradicted the facility's daily staff schedules and staffing reports that showed adequate staffing on weekends. During an interview, the administrator confirmed that staffing levels did not change from weekdays to weekends and stated that the business office was responsible for submitting PBJ data based on schedules and daily postings. The facility's PBJ Reporting policy requires that staffing information be reported electronically to CMS, including staff hired directly, through an agency, or as contract employees, and must be based on payroll records or other verifiable information.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide a dignified dining experience for a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease and dementia. The resident required assistance with all activities of daily living, including eating. Despite this, the facility used plastic silverware for the resident during meals, while other residents were provided with regular silverware. This practice was observed over several days, and staff consistently assisted the resident with eating using plastic utensils. Interviews with staff and family members revealed that the use of plastic silverware was due to the resident's history of collecting and hoarding silverware, as well as a past incident where the resident held a butter knife towards a nurse. However, the facility did not conduct ongoing assessments or trials to determine if the resident's behavior had changed, which could have impacted the resident's dignity and eating habits. The facility's policy on dignity and respect emphasized treating residents with dignity, but the lack of reassessment and trial of regular silverware contributed to the deficiency.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was comprehensively assessed for self-administration of medications. The resident, identified as R32, had severe cognitive impairment and required assistance with all activities of daily living. Despite this, the resident was observed using a nebulizer machine independently without a self-administration of medications (SAM) order. The resident's medical record lacked evidence of an order for self-administration, and the SAM assessment completed earlier in the year indicated that the resident was physically unable to self-administer medications. Observations revealed that the nursing staff would set up the nebulizer treatment for the resident, apply the mask, and then leave the room, returning later to check on the resident and turn off the machine. Interviews with various staff members, including LPNs and RNs, confirmed that the resident did not have a SAM order and that the practice of leaving the resident alone during nebulizer treatments was routine. The staff acknowledged that only one resident in the facility had a SAM order, and it was not R32. The facility's policy on self-administration of drugs required a comprehensive assessment of a resident's mental and physical abilities to determine their capability to self-administer medications. This assessment was to be reviewed quarterly. The assistant director of nursing confirmed that an assessment should have been completed for R32, and an order should have been obtained to ensure the resident could safely self-administer medications. The policy emphasized the importance of ensuring residents can correctly, accurately, and safely self-administer medications, with regular reassessments to account for any changes in cognitive or physical status.
Failure to Provide Required Medicare Notices
Penalty
Summary
The facility failed to provide the required written Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) and Notice of Medicare Non-Coverage (NOMNC) forms to two residents whose Medicare A coverage ended while they remained in the facility. For one resident, the payer source changed from Medicare Part A to Private Pay, and for the other, it changed from Medicare Part A to Medicaid. In both cases, the medical records lacked evidence that the necessary forms were completed and reviewed with the residents or their representatives. Interviews with facility staff, including a social worker, registered nurse, and assistant director of nursing, revealed that the facility could not locate the required forms for the two residents. The staff acknowledged the importance of completing and maintaining these notices to ensure discussions about the discontinuation of services and potential financial responsibilities were held with the residents or their representatives. The facility's policy and procedure on beneficiary notices were requested but not provided.
Failure to Reassess Wandering and Elopement Risks
Penalty
Summary
The facility failed to reassess behaviors and interventions related to potential wandering and elopement risks for two residents, R37 and R33, as required by their policy. R37, who had severe cognitive impairment and a history of wandering and elopement attempts, was identified as an elopement risk in an assessment dated 7/14/23. However, there was no evidence of a comprehensive reassessment being conducted quarterly as required. Despite having a wander guard in place and documented incidents of wandering, such as an attempt to exit the building on 6/11/24, the facility did not perform the necessary quarterly reassessments to ensure the interventions remained appropriate. R33, also with severe cognitive impairment and a history of wandering, was last assessed for wandering risk on 8/22/23. The resident's care plan identified them as an elopement risk, and interventions included the use of a wander guard and redirection strategies. Observations showed R33 self-propelling in a wheelchair without attempts to exit the facility, and staff interviews confirmed that R33 had not attempted to leave the building in a long time. Despite this, the facility did not conduct the required quarterly reassessments to determine if the interventions, including the wander guard, were still necessary. Interviews with facility staff, including the social worker and assistant director of nursing, confirmed that the required quarterly reassessments for wandering and elopement risks were not completed for both residents. The facility's policy mandates quarterly assessments to ensure interventions are appropriate and to maintain resident safety. The lack of reassessment could lead to inappropriate interventions being in place, such as the unnecessary use of a wander guard, which could be a dignity concern for residents who no longer need it.
Failure to Assist Residents with Grooming Needs
Penalty
Summary
The facility failed to provide necessary assistance with grooming for two residents, both of whom had severe cognitive impairments and required help with all activities of daily living. The first resident, who had multiple diagnoses including Alzheimer's disease and dementia, was observed over several days with long facial hair on her chin, indicating a lack of shaving assistance. Her care plan did not document her shaving preferences, and staff interviews confirmed that she should have been shaved as part of her daily grooming routine. The second resident, also with severe cognitive impairment and similar diagnoses, was observed with facial hair on his face, chin, and neck over several days. A family member noted that this resident was particular about being clean-shaven, yet his care plan also lacked documentation of shaving preferences. Staff interviews revealed inconsistencies in the shaving routine, with some staff stating that shaving should occur during morning care or bath days, while others acknowledged that residents with facial hair should be shaved as needed. The facility's policy emphasized the importance of shaving for cleanliness and resident dignity, yet this was not consistently implemented for these residents.
Failure to Maintain Hearing Treatment for Resident
Penalty
Summary
The facility failed to ensure proper treatment was provided to maintain hearing for a resident with a known hearing impairment. The resident, who had intact cognition and required assistance with all activities of daily living, was identified to have minimal difficulty with hearing and wore hearing aids. Despite having a care plan that acknowledged the resident's communication problem related to hearing deficit, the electronic health record lacked evidence of an audiology appointment being offered. The resident had a history of cerumen buildup, and there was a physician's order to flush both ears as needed for wax buildup, which had not been completed in the past six months. Observations revealed that the resident frequently did not have hearing aids in place and reported that the hearing aids were not functioning well, with batteries only improving hearing temporarily. Interviews with staff, including a nursing assistant, LPN, RN, and the assistant director of nursing, confirmed the resident's hearing had worsened, and the standing order for ear flushing had not been executed. The facility's policy on the care of hearing-impaired residents emphasized regular evaluation, but the lack of action in addressing the resident's hearing needs led to communication difficulties and potential dignity concerns.
Failure to Implement Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to comprehensively assess and implement trauma-informed care for a resident with a history of past traumatic experiences. The resident, identified as R37, had severe cognitive impairment and a history of Alzheimer's disease, aphasia, dementia, depression, polyneuropathy, and low back pain. Despite a trauma questionnaire indicating past trauma, the facility did not obtain additional information to identify triggers or coping mechanisms, and the resident's care plan lacked individualized trauma-informed approaches or interventions. Interviews with staff revealed a lack of awareness regarding the resident's past trauma. A family member reported that the resident exhibited behaviors consistent with PTSD, such as seeing imaginary people, disassembling items, and collecting silverware, which were not addressed in the care plan. Nursing assistants and licensed practical nurses were unaware of the resident's trauma history, indicating a communication gap in the facility's care planning process. The social worker responsible for completing trauma assessments acknowledged that the resident's trauma was not included in the care plan and admitted that triggers and interventions should have been identified and implemented. The assistant director of nursing confirmed that the care plan should have included behavior monitoring and strategies to avoid PTSD triggers. The facility's Trauma Informed Care policy emphasized the importance of recognizing and responding to trauma, but these principles were not effectively applied in the resident's care plan.
Failure to Assess Side Rail Safety for Residents
Penalty
Summary
The facility failed to ensure that side rails were appropriately assessed for safety and necessity for two residents, R8 and R19. Both residents were observed to have side rails affixed to their beds without recent assessments to determine their safety or necessity. R8, who had intact cognition and required assistance with activities of daily living, had a care plan indicating the use of side rails for bed mobility. However, the last assessment for side rail use was completed several months prior, and there was no evidence of alternative methods being tried before the installation of the side rails. Similarly, R19, who had moderate cognitive impairment and required assistance with daily activities, also had side rails without a recent assessment, with the last completed assessment being over a year old. Interviews with staff revealed a lack of awareness and adherence to the facility's policy on assessing the safety of side rails. Nursing staff, including a registered nurse and an assistant director of nursing, confirmed that assessments were not conducted based on the residents' conditions or needs but rather on the equipment available in the room. The staff also admitted to not being aware of alternative methods to side rails and did not conduct assessments to determine the most appropriate type of side rail or grab bar for the residents. The facility's policy on assessing the safety of side rails was not followed, as evidenced by the lack of timely assessments and documentation. The policy required staff to alert the RN about any side rail use, conduct assessments to ensure safety, and educate residents and their families about the risks associated with side rails. However, these steps were not adequately implemented, leading to the deficiency in ensuring the safe use of side rails for the residents involved.
Failure to Maintain RN Coverage for Required Hours
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) onsite for eight consecutive hours, seven days a week, as required. This deficiency was identified through a review of staffing schedules from April 1, 2024, to June 30, 2024, which revealed that there was no RN coverage for eight consecutive hours on June 2, June 15, and June 16, 2024. During an interview on November 21, 2024, the Assistant Director of Nursing (ADON) confirmed the absence of an RN for the required hours on these dates, attributing the issue to call-ins and uncertainty about the situation. The facility's Departmental Supervision policy mandates that nursing services be supervised by a Registered or Licensed Practical/Vocational Nurse at all times, with a specific requirement for an RN to be on duty for eight hours each day, including weekends and holidays.
Failure to Monitor Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure proper monitoring and documentation for a resident receiving antipsychotic medication, specifically haloperidol, for anxiety, restlessness, and agitation. The resident, who had severe cognitive impairment and required assistance with all activities of daily living, was diagnosed with Alzheimer's disease, aphasia, dementia, depression, polyneuropathy, and low back pain. Despite the administration of haloperidol three times daily, the resident's care plan and medication records lacked evidence of behavior and side effect monitoring, which are essential for assessing the necessity and effectiveness of the medication. Interviews with facility staff, including a registered nurse and the assistant director of nursing, confirmed the absence of necessary monitoring and documentation. The staff acknowledged that antipsychotic medication should be included in the care plan with specific side effects and target behaviors to monitor. The facility's policy on antipsychotic medication use emphasized the importance of documenting and reporting the resident's symptoms and any side effects to the attending physician. However, the facility did not adhere to this policy, resulting in a deficiency in monitoring and documentation for the resident receiving antipsychotic medication.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement appropriate infection prevention and control measures, specifically Enhanced Barrier Precautions (EBP), for three residents who required such precautions due to their medical conditions. Observations revealed that residents with indwelling catheters and those receiving tube feedings did not have the necessary personal protective equipment (PPE) or signage indicating EBP in place. This lack of implementation was noted during observations of resident care activities, where PPE carts and hand hygiene supplies were absent, and no signage was posted to inform staff of the required precautions. Interviews with staff, including licensed practical nurses (LPNs) and nursing assistants (NAs), indicated a lack of awareness and training regarding EBP. Staff members were not familiar with the specific requirements of EBP and were not following the necessary protocols for residents with catheters or tube feedings. The assistant director of nursing (ADON) confirmed that EBP had not been implemented in the facility, despite acknowledging its importance for resident and staff safety. The facility's failure to implement EBP was further highlighted by the absence of a policy on Enhanced Barrier Precautions, which was requested but not provided. This deficiency in infection control practices was evident in the care of residents with significant cognitive impairments and medical conditions requiring enhanced precautions, as staff did not utilize gowns or other necessary PPE during high-contact care activities, such as catheter care and resident transfers.
Failure to Post and Retain Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the required and complete nurse staffing information was posted daily and readily available for residents and visitors. Observations on multiple dates revealed that the nurse staff postings were not updated to reflect the current day's staffing, with postings remaining from the previous day. Interviews with the Assistant Director of Nursing (ADON) and the Health Unit Coordinator (HUC) confirmed that the postings were not current and that the HUC was responsible for updating them. The HUC admitted to not posting the information immediately in the morning and was unaware of the requirement to retain staffing logs for 18 months. The facility's policy, dated July 2024, mandates that staffing information be posted within two hours of each shift's start and retained for 18 months. However, the HUC was unable to provide staff postings prior to November 18, 2024, as they were unavailable and had to be recreated upon request. The ADON acknowledged that the new HUC was not informed about the retention requirement. This deficiency had the potential to affect all 41 residents and visitors who might want to review the staffing information.
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 112 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
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 Spring Valley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ostrander Care And Rehab | 6 mi | ★★★★★ | 3 | 0 |
| Meadow Manor | 8.9 mi | ★★★★★ | 5 | 0 |
| Stewartville Care Center | 12.1 mi | ★★★★★ | 2 | 0 |
| Chosen Valley Care Center | 14.6 mi | ★★★★★ | 2 | 0 |
| Gundersen Harmony Care Center | 21.8 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Spring Valley Care Center.
100% money-back within 48 hours.
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.