Below 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 Health And Rehab Center during CMS and state inspections, most recent first.
The facility did not designate a qualified director of food and nutrition services. The DM had no certifications or degree, had only recently started in the role, and relied on prior experience and an upcoming class. The NHA confirmed there was no full-time RD and no waiver in place, although an RD was available part-time.
Staff did not consistently monitor and document refrigerator, freezer, and dish machine temperatures. The DM stated logs were incomplete, some prior logs had been discarded, and no logs were available for some periods and kitchenette dishwashers. Records showed multiple missed temperature entries across coolers, freezers, and dishwashers, despite facility policy requiring routine checks and documentation.
Uncovered Garbage Dumpsters: The facility failed to ensure outside garbage storage receptacles were covered. Surveyors observed the dumpster and recyclable containers uncovered on multiple occasions, including while speaking with the DM and POD. The DM deferred responsibility to the POD, the POD stated there was no policy for garbage, and the NHA questioned whether the dumpsters were supposed to be closed.
Infection prevention and control deficiencies were identified when the facility lacked a complete IPCP surveillance system for resident and staff illnesses, and infection tracking was incomplete and delayed. Surveyors also observed an RN using the same gown while moving in and out of two residents’ rooms during PEG tube care, leaving the room with contaminated PPE, touching the med cart, and storing rinsed syringes and a graduate wet instead of allowing them to air-dry.
The facility did not ensure its designated ICP had completed IC training before taking on the role, and there was no oversight by another IC-trained individual. During an interview, the NHA identified the DON as the current ICP but stated no one in the facility had completed IC education since the prior DON left and that no other staff member was qualified. The NHA said an ICP had been hired and was expected to start at the end of December.
Call light system not visible or audible, resulting in prolonged unanswered call lights. Survey observations and staff interviews showed the monitor-based system could only be seen at the nurse’s station and had no audible alarm, while residents reported long waits for assistance. One resident with intact cognition and extensive ADL needs fell after waiting for help when an air mattress deflated, another reported waiting hours for incontinence care and developing irritation, and a third waited nearly 2 hours for morning assistance and missed therapy.
The facility failed to provide proper Medicare coverage notices for two residents when skilled Part A services ended before benefit days were exhausted. An ABN was documented after the survey was underway for both residents, and one resident also received a NOMNC only 1 day before coverage ended instead of the required 2-day notice; the AED confirmed there was no documentation explaining the shortened notice.
Missing Written Transfer and Bed-Hold Notices: The facility did not document required written transfer notices or bed-hold notices for two residents who were sent to the hospital multiple times. Records showed transfers for acute changes in condition, but the notices did not include the reason for transfer, destination, daily bed-hold rate, or appeal rights, and staff stated additional notices could not be found.
Late PASARR Level II Review: A resident admitted under a hospital discharge exemption with anxiety, depression, and PTSD did not receive the required Level II PASARR resident review within 40 calendar days after it became clear more than 30 days of care were needed. Surveyors could not locate the Level II screen in the EHR, and the SW stated it was late.
A resident with significant mobility limits, incontinence, and existing stage 4 pressure ulcers developed stage 3 PIs on both buttocks. Facility and wound clinic records showed worsening wounds, gaps in skin and wound assessments, and missing documentation of ordered repositioning every 2 hours. The ADON stated weekly wound assessments were expected but could not find them after a certain point in the record.
A resident with intact cognition and extensive care needs fell after reporting that the air mattress deflated and the bed rolled out from under her. The facility identified bed malfunction as the root cause, but staff had not been educated on air mattress settings or monitoring, and there was no routine maintenance or monitoring plan in place. CNAs and an RN stated they had not received training on checking air mattress functioning, and the NHA acknowledged the facility did not ensure ongoing monitoring or update fall interventions after the fall.
Feeding Tube Labeling and Placement Verification Deficiencies: The facility failed to ensure proper care for two residents with PEG tubes. A resident’s enteral feeding bag was observed without the required label information, and an RN administered meds and flushed PEG tubes after checking placement by auscultation instead of the measurement method referenced in the order and facility policy. The residents had significant cognitive and swallowing impairments and required extensive assistance with care.
A resident with PTSD, depression, and insomnia did not have a person-centered care plan for PTSD triggers or interventions. The care plan only addressed general mood/behavior concerns, and the CNA Kardex had no documentation of PTSD triggers or prevention measures. The ADON confirmed there was no PTSD care plan, and a CNA stated she was not aware of the resident’s PTSD interventions.
The facility's abuse, neglect, and exploitation policy referenced Nebraska regulations and contact information instead of Wisconsin's, and this incorrect policy was used for staff training and reporting guidance. The NHA confirmed the error and that the policy was likely intended for another facility, with no other policies used for staff education on this issue.
The facility failed to maintain a safe environment, resulting in falls and injuries for several residents. Two residents suffered major injuries due to falls, with care plans not updated and post-fall assessments not conducted. Other residents also experienced falls without proper interventions. Additionally, wet floors were left without warning signs, and a resident traveled on a busy highway in a power wheelchair without a safety assessment. These deficiencies highlight inadequate supervision and environmental safety measures.
The facility failed to follow food safety and hygiene standards, affecting all residents. Expired and undated food was found in the refrigerator, and food distributed to residents' rooms was uncovered. Staff did not adhere to proper hand hygiene or use hair restraints as required. The Culinary Director acknowledged these practices did not meet facility policies.
The facility failed to establish a comprehensive Infection Control Program, leading to deficiencies such as inadequate water management to prevent Legionella, lack of infection tracking during outbreaks, and improper implementation of Enhanced Barrier Precautions. Staff were observed not following proper PPE protocols, and a nurse did not adhere to infection control practices during wound care. Interviews with staff revealed a lack of oversight and management in infection control practices.
A CNA in an LTC facility was observed applying Nystatin powder to a resident's skin, contrary to the facility's policy that only nurses should administer medications. The resident confirmed this was a common practice, and the CNA admitted to having no formal training. The DON acknowledged that this was against the expected protocol.
A resident with multiple vertebral fractures and a traumatic brain injury did not receive appropriate spinal precautions as per their care plan. Staff failed to perform log rolling during repositioning and did not ensure the resident wore a TLSO brace when the head of the bed was elevated above 30 degrees. Observations showed the resident without the brace and the head of the bed elevated beyond the prescribed limit. The Kardex lacked specific guidance on bed mobility, and the Director of Nursing was unaware of these issues.
Two residents in the facility did not receive adequate pressure ulcer care and prevention. One resident developed and reoccurred pressure injuries on the left heel and toes, with care plans not updated and repositioning not encouraged. Observations showed improper use of pressure-relieving devices. Another resident was admitted with a stage 3 pressure injury, and the facility failed to protect and reposition them adequately, with inconsistent wound assessments. The Director of Nursing acknowledged the lack of proper weekly assessments.
A resident with multiple fractures and a traumatic brain injury experienced significant weight loss due to the facility's failure to monitor and document weight as per physician orders. Despite interventions like health shakes and appetite stimulants, the facility did not weigh the resident weekly, and no weights were recorded from admission. The facility attempted to use Mid Arm Circumference (MAC) as an alternative measure without a formal process. Staff interviews revealed a lack of awareness and understanding of weight monitoring procedures.
The facility failed to document a rationale for the extended use of PRN lorazepam for two residents, beyond the 14-day limit. One resident, with multiple diagnoses including anxiety disorder, had lorazepam administered twice in June without a documented reason for its continued use. Another resident had a PRN order for lorazepam every 2 hours for anxiety, but the facility could not provide adequate documentation to justify the extended use. The DON acknowledged the lack of proper rationale and expected a more detailed explanation from the physician.
An incident involving a cognitively impaired female resident and a male resident with intact cognition highlighted deficiencies in safeguarding measures. The male resident was found in the female resident's room on two occasions, engaging in inappropriate behavior. Despite the female resident's severe cognitive impairment and inability to consent, the facility did not implement immediate safety measures, conduct an investigation, notify the police promptly, or assess the residents' capacity to consent. The female resident had a BIMS score of 3, indicating severe cognitive impairment, while the male resident had a BIMS score of 15, indicating intact cognition. The facility's actions led to a finding of immediate jeopardy due to the significant risk of harm.
The facility did not ensure CNAs received annual performance reviews, affecting four CNAs employed for over a year to more than three years. The Regional Director of Operations confirmed that no yearly performance reviews had been conducted for any employees, potentially impacting all 38 residents.
The facility failed to conduct and document a current facility-wide assessment to determine the necessary resources for resident care during day-to-day operations and emergencies. The provided assessment was outdated, with data from as far back as 2017, and lacked specific information on the current resident population, staff competencies, and other critical factors.
The facility failed to ensure that mandatory staffing data submitted to CMS was complete, accurate, and auditable. The PBJ Staffing Data Reports indicated a lack of 24-hour licensed nursing coverage on specified dates, but facility records showed coverage was present. The data was submitted by the corporate office, and the inaccuracy was confirmed by the Regional Director of Operations.
The facility failed to report allegations of sexual abuse involving two residents to the State Agency and law enforcement within the required timeframe. On two occasions, a CNA found a male resident in compromising situations with a female resident who has severe cognitive impairment. The facility did not assess the ability to consent and did not report the incidents within the mandated 2-hour window.
The facility failed to thoroughly investigate allegations of abuse involving two residents. Despite finding one resident in compromising situations with another cognitively impaired resident on two occasions, the facility did not conduct timely and thorough investigations as required by their policy.
The facility failed to ensure that two CNAs received the required 12 hours of in-service training each year. Despite multiple requests, the facility provided unreadable documentation, making it impossible to verify the training hours. This deficiency has the potential to affect the quality of care for all 38 residents.
Unqualified Dietary Manager and No Full-Time RD
Penalty
Summary
The facility did not designate a person to serve as the director of food and nutrition services who met the minimum qualification requirements for the position. Surveyor interview and record review showed that Dietary Manager M did not have any required certifications or a degree for the role, had started in the position about three weeks earlier, and stated she was qualified based on 3 years of experience at her prior job. She also stated she was enrolled in a class starting 12/17/25 and that a Registered Dietician was available about 10 hours a week. The Nursing Home Administrator stated the Dietary Manager had just started, was an experienced Dietary Manager, and was enrolled in a class, but also confirmed there was no full-time Registered Dietician and no waivers in place. On 12/3/25, the administrator provided email evidence of a Registered Dietician responding to a facility request.
Inconsistent Temperature Monitoring for Food Storage and Dishwashing
Penalty
Summary
The facility did not maintain safe storage and a sanitary environment for food preparation and distribution because staff did not consistently monitor refrigerator, freezer, and dishwasher temperatures. The facility policy required refrigerator temperatures to be between 35 and 39 F and to be checked at least two times each day, freezer temperatures to be maintained frozen solid and checked at least two times each day, and dish machine temperatures to be monitored throughout the dishwashing process with wash and rinse cycle temperatures recorded at each meal. During the kitchen tour, the Dietary Manager was not initially available, and staff stated that refrigerator and freezer temperatures were taken twice daily, but logs for the month had not been started and prior logs were not on clipboards. When the Dietary Manager later provided records, she stated she had discarded logs before September 2025 after being told only 3 months needed to be kept. Logs provided showed multiple missed temperature entries for several coolers and freezers in September and October, with no November logs provided. For the dishwashers, logs from the main kitchen and other kitchenettes also showed multiple missed temperature entries, and the Dietary Manager stated there were no logs for the kitchenette dishwashers. She further stated she had provided all logs she had for dishwashing temperatures, refrigerator temperatures, and freezer temperatures.
Uncovered Garbage Dumpsters
Penalty
Summary
Garbage and refuse were not properly disposed in the outside garbage storage receptacles. On 12/1/25 at 4:30 PM, the surveyor observed the garbage dumpster and recyclable containers uncovered. On 12/2/25 at 1:01 PM, the surveyor again observed the dumpster and recyclable containers uncovered while with the Dietary Manager, who stated to talk to the Plant Operations Director because he handled that. When asked whether dietary staff took garbage out to the dumpsters, the Dietary Manager questioned whether that was their problem, and the surveyor stated it was the responsibility of whoever took the garbage out to close them after using. The surveyor interviewed the Plant Operations Director on 12/2/25 about garbage pickup service and dumpster management, and he stated that GLF takes care of the garbage on Tuesday mornings and did not think there was a policy. The surveyor later observed the dumpster still uncovered at 5:30 PM on 12/2/25 with 4-5 garbage bags inside, and on 12/3/25 at 7:48 AM the dumpsters remained open. When interviewed on 12/3/25, the Nursing Home Administrator stated, in response to being asked about the dumpsters, what were they supposed to be closed, then said the garbage man came the night before. On 12/4/25, the Plant Operations Director stated there was no policy for garbage.
Infection Prevention and Control Program Deficiencies
Penalty
Summary
The facility did not establish an Infection Prevention and Control Program that included outcome surveillance systems to prevent the transmission of disease and infection. Surveyors found that the facility had no surveillance system to track and monitor staff illnesses or infections, and resident illness/infection surveillance was incomplete and untimely. The Infection Preventionist role had changed multiple times, and the Nursing Home Administrator stated the current Infection Preventionist was the Director of Nursing, who had only been employed for 3 weeks and was trying to catch up on surveillance entries. Record review showed the facility did not have a complete resident surveillance process. The facility did not use a map tracking infections by room since the last standard survey, and the surveillance documents did not consistently include details such as symptoms, tests performed with dates and results, isolation status, symptom resolution date, hospitalization, or death unless specifically documented elsewhere. Several infection tracking forms were incomplete or reviewed late, including one set with 7 infections, another with 2 infections, another with 5 infections where one was not reviewed at all and four were reviewed after 2 months, another with 4 infections reviewed after surveyors entered the facility, and another with 3 infections not reviewed for over 2 weeks. Surveyors also observed improper infection control practices during tube feeding care for two residents with PEG tubes and other care needs. An RN wore the same gown while moving in and out of both residents’ rooms, despite enhanced barrier precautions being indicated for residents with PEG tubes, wounds, and similar high-contact care. The RN left the room multiple times with contaminated gown and gloves, touched the medication cart while still wearing the gown, and continued care without changing the gown. The RN also rinsed syringes and a graduate cylinder after flushing or administering medications via PEG tube, then placed the wet syringe back together and stored it in a wet graduate without allowing it to air dry, which was observed for both residents. During interview, the RN stated the gown should have been changed when leaving the room, and the ADON stated both gown and gloves should be changed when leaving the room.
Unqualified ICP Assigned Without Infection Control Training
Penalty
Summary
The facility did not ensure its designated Infection Control Preventionist (ICP) completed infection control training before assuming the role, and there was no oversight by another infection control trained individual. During an interview on 12/03/2025 at 2:00 PM, the Surveyor asked the NHA about the current ICP, and the NHA identified the DON as the facility’s current ICP. When asked for the DON’s professional credentials regarding infection control training, the NHA stated that no one in the facility had completed infection control education since the prior DON’s employment ended on 11/20/25 and confirmed there was no other staff in the building who was qualified. The NHA also stated that an ICP had been hired and was planned to start at the end of December.
Call light system not visible or audible, resulting in prolonged unanswered call lights
Penalty
Summary
The facility did not ensure all portions of the call light system were working properly. Survey observations and staff interviews showed the call light system was only visible on a computer monitor at the nurse’s station, was not visible in all hallways, and did not have an audible alarm. Staff stated they had to be close to the screen to see which resident had a call light on, and the Director of Nursing stated the system had no audible or visible notification outside the monitor and that this was a concern for safety and resident care. The facility did not provide a policy when requested by the surveyor. Resident R5 had diagnoses including idiopathic peripheral neuropathy, atrial fibrillation, overactive bladder, localized edema, and a stage 4 pressure ulcer of the back, buttock, and hip. R5’s MDS showed intact cognition with a BIMS score of 15 and extensive assistance needs for transfers, toileting, dressing, bathing, and mobility. Records showed multiple call lights that remained unanswered for long periods, including numerous call lights taking 20 to 30 minutes to be acknowledged and many taking over 30 minutes to be cleared. On 10/28/25, R5 reported turning on the call light when the air mattress began deflating, but no one came; the mattress deflated, R5 rolled out of bed, and the call light log showed the light remained on for more than 40 minutes before it was answered. Resident R12 had diagnoses including morbid obesity with diabetic neuropathy, Crohn’s disease, diabetes mellitus type 2, chronic pain syndrome, and generalized anxiety disorder, with a BIMS score of 15 and dependence for multiple ADLs. R12 stated she frequently waited 20 minutes or longer for staff and described an incident in which she waited about 6 hours for help with a soiled brief, during which staff told her they did not have time and turned off the call light. R12 reported burning and irritation from sitting in the soiled brief for several hours. Resident R3, who had diagnoses including BMI 60-69.9, edema, peripheral vascular disease, kidney disease, immobility syndrome, atrial fibrillation, congestive heart failure, restless legs, sleep apnea, and muscle weakness, also had intact cognition and required extensive assistance with transfers and personal care. During observation, R3’s call light was activated and remained unanswered for 116 minutes before he was assisted up for the day, causing him to miss therapy exercises and delaying his morning care.
Failure to Provide Required Medicare Coverage Notices
Penalty
Summary
The facility did not provide appropriate Medicare coverage notices for two residents whose Medicare Part A skilled service episodes ended before benefit days were exhausted. For one resident, the facility/provider initiated discharge from Medicare A services and the SNF Beneficiary Protection Notification Review form indicated that an Advanced Beneficiary Notice (ABN) had been provided, but the date was entered after the survey was already in process. For the second resident, the same form also indicated that an ABN had been provided, with the date likewise entered after the survey was in process. For one of the residents, the facility also failed to provide the required 2-day Notice of Medicare Non-Coverage (NOMNC). The resident received and dated the NOMNC only 1 day before Medicare coverage ended, and the surveyor found no documentation in the EHR explaining why only 1 day notice was given. The Assistant Executive Director stated she did not know why the notice was only 1 day and later confirmed that only 1 day notice had been given and no notes could be found explaining it.
Missing Written Transfer and Bed-Hold Notices
Penalty
Summary
The facility did not ensure residents and/or their representatives were notified in writing of the bed-hold rate and did not document the Wisconsin Bed Hold and Notice of Transfer for 2 of 3 residents reviewed, including R5 and R3. Facility policy stated that before a resident is transferred to a hospital or placed on therapeutic leave, written notification must be provided that specifies the bed-hold period, and a copy or documentation of the notice must be placed in the medical record. The transfer policy also required notifying the resident’s representative of the pending transfer, including appeal notification, and completing transfer and bed-hold information to be sent with the resident. R5 was transferred to the hospital on 06/07/25 for a change in mentation and chest pain, and again on 11/04/25 for increased weakness and dizziness; in both instances, family and the provider were notified, but no written notice of transfer documenting the reason for transfer and destination was found, and no bed-hold notice showing the daily rate to reserve the bed or appeal rights was documented. R3 was transferred to the hospital on 3/11/25, 10/25/25, and 11/04/25 for acute changes including hypertension, tachycardia, confusion, light-headedness, pallor, dizziness, lethargy, and being off baseline; documentation showed physician notification in some instances and a voicemail left for family on 3/11/25, but no required written transfer notices were documented, and bed-hold notices with the daily rate and appeal rights were not documented. On 11/7/25, after hospital discharge, R3 returned to the hospital for rectal bleeding, and the available Notice of Transfer/Discharge did not document the specific reason for hospitalization or the daily rate for bed hold. The Health Information Clerk and Assistant DON stated they could not find additional bed-hold or transfer notices.
Late PASARR Level II Review
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not completed within the required timeframe for one resident. The resident was admitted with diagnoses including anxiety, depression, and PTSD, had intact cognition, and made own decisions. The resident entered the facility as an exempted hospital discharge with a 30-day exemption, but later required more than 30 days of care. During survey review, the Level II PASARR screening could not be located in the electronic health record, and the Social Worker provided only the Level I PASARR screen, which identified a major mental disorder and the hospital discharge exemption. The Social Worker stated that the Level II PASARR screen was late. At the time of survey, the resident had been in the facility 68 days, with 28 days out of compliance.
Failure to document weekly wound assessments and implement pressure injury interventions
Penalty
Summary
Facility staff did not implement professional standards of practice to ensure that a resident with existing pressure injuries received necessary treatment and services to promote healing and prevent additional pressure injuries. The resident had diagnoses including idiopathic peripheral neuropathy, atrial fibrillation, overactive bladder, localized edema, and pressure ulcer stage 4 of the back, buttock, and hip. The resident required extensive assistance with mobility and personal care, was always incontinent of bowel and bladder, and had care plan interventions related to pressure ulcer prevention, wound care, pressure relief, low air loss mattress use, and repositioning. The resident developed a stage 3 pressure injury on the right buttock and later a stage 3 pressure injury on the left buttock. Facility and wound clinic documentation showed changes in wound size and depth over time, including worsening measurements and undermining. After the resident returned from hospitalization, the record did not show a skin assessment on readmission, and there was a 6-day gap before the next documented wound assessment. Later, there were additional periods where no wound clinic visits, facility assessments, or wound measurements were documented for the buttock wounds, including a span from 09/26/25 through 10/16/25 and another from 10/17/25 through 10/28/25. The record also showed that ordered interventions were not consistently documented as implemented. A wound clinic order for turning and repositioning every 2 hours was noted, but there was no documentation that this intervention was carried out or that the resident refused it. The care plan did not include a specific repositioning intervention matching the later wound clinic order, and the facility record lacked weekly wound assessments after 09/18/25. On interview, the ADON stated nurses were expected to document wound assessments weekly, could not find the resident’s facility wound assessments after 09/18/25, and stated it was a concern that the assessments should have been documented weekly to monitor for changes.
Failure to Monitor Air Mattress Functioning and Update Fall Interventions
Penalty
Summary
The facility failed to ensure the resident environment remained free of accident hazards and that residents received adequate supervision and assistive devices to prevent accidents for one resident, R5. R5 was admitted with idiopathic peripheral neuropathy, osteoporosis, bilateral sensorineural hearing loss, atrial fibrillation, overactive bladder, localized edema, and a stage 4 pressure ulcer of the back, buttock, and hip. R5’s most recent MDS showed intact cognition with a BIMS score of 15/15 and extensive assistance needs for transfers, toileting, dressing, bathing, and mobility. The care plan identified R5 as at risk for falls and included general fall interventions, but the record noted no new safety interventions after the fall on 10/28/25. On 10/28/25, R5 had an unwitnessed fall in the room and was found on the floor on the right side next to the bed. R5 stated the bed deflated and rolled out of bed, and reported hitting the head, face, and right shoulder, with bruising and an abrasion to the left outer ankle. The facility investigation identified the root cause as bed malfunction, and DME was contacted to inspect the bed and replace the air mattress. The report also stated the facility did not initiate immediate intervention to prevent future falls, complete staff education, or review and revise the care plan fall interventions after the incident. Survey findings showed the facility had not educated staff on air mattress settings or monitoring to ensure proper functioning, and there was no routine maintenance or monitoring plan in place for air mattresses before the fall. Multiple CNAs stated they had not received training on monitoring air mattresses or knowing the correct settings, and an RN stated she was not aware of any responsibility to check or document air mattress functioning. The Plant Operations Director stated no assessment of air mattress settings or functioning had been completed before the incident, and the Nursing Home Administrator acknowledged the facility failed to follow up to ensure weekly monitoring was being completed and that nursing staff should have been educated on air mattress functioning and appropriate settings.
Feeding Tube Labeling and Placement Verification Deficiencies
Penalty
Summary
The facility did not ensure appropriate care for 2 residents with feeding tubes, including R19 and R7, when enteral feeding bags were observed without the required label information and when gastrostomy tube placement was not verified as ordered before medication administration. The facility policy stated feeding tubes should be used in accordance with clinical standards and that placement must be verified before feeding, flushing, or giving medications through the tube. The report also cited guidance that enteral nutrition delivery systems should be labeled with the resident’s demographics, the person preparing and hanging the formula, and the date and time the formula was prepared and hung. R19, who had cerebral palsy, epilepsy, dysphagia, aphasia, Rett’s syndrome, severe intellectual disability, and a gastrostomy tube, was cognitively impaired, unable to respond, wheelchair dependent, and fully dependent for care. Survey observation found R19’s tube feeding running without a label on the bag or tube identifying the formula, date, or time started. Staff interviews confirmed the bag should have been labeled, but it remained unlabeled during the observation. The report also documented that RN O administered medications through R19’s PEG tube after checking placement by auscultation, while the DON stated placement should be verified by measuring the tube length according to the physician order. R7, who had protein-calorie malnutrition, adult failure to thrive, dysphagia, and an unstageable pressure ulcer, was moderately cognitively impaired and required assistance with mobility and care. During observation, RN O flushed R7’s PEG tube, changed the dressing, and administered medications after checking tube placement by auscultation rather than by measuring the tube length as described by the DON and in the facility order. The report states RN O used the same contaminated gown while continuing the procedure after leaving and re-entering the room, and the placement check was performed by listening for air rather than by the measurement method referenced in the resident’s order and facility policy.
Failure to Provide Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility did not ensure that 1 resident with a diagnosis of PTSD received culturally competent, trauma-informed care in accordance with professional standards of practice and the resident’s experiences and preferences. The resident was admitted with diagnoses including PTSD, depression, and insomnia, had intact cognition with a BIMS score of 15/15, and made own decisions. Review of the care plan showed no plan created for PTSD, and the existing care plan only addressed noncompliance with plan of care and mood/behavior with general monitoring and notification interventions. Survey review of the CNA Kardex found no documentation of possible PTSD triggers or interventions to prevent triggers. During interview, the ADON stated there was not a PTSD care plan, noted the resident saw an in-house psych provider weekly, and said the resident’s PTSD was from childhood and that the resident had recent suicide attempts and would get quiet. The ADON stated she would get a care plan in right away. A CNA interviewed during the investigation stated she was not aware of who had PTSD or what the interventions were for the resident.
Abuse Policy References Incorrect State Regulations
Penalty
Summary
The facility failed to develop and implement an Abuse, Neglect, and Exploitation policy that was compliant with the appropriate state regulations. The policy in use referenced Nebraska reporting regulations and contact information, rather than those for Wisconsin, where the facility is located. This policy was used for staff training and guidance on reporting abuse, neglect, and exploitation, despite the incorrect state references. The Nursing Home Administrator (NHA) confirmed that the policy originated from a management company and was likely intended for a different facility in another state. During interviews, the NHA acknowledged that the facility relied on this incorrect policy and Relias training for staff education regarding abuse and neglect. The surveyor verified that, in practice, self-reports were being made to the correct Wisconsin authorities, but the written policy and training materials did not reflect the correct state requirements. No other policies were identified as being used for staff education on this topic.
Deficiencies in Fall Prevention and Environmental Safety
Penalty
Summary
The facility failed to ensure a safe environment for residents, leading to multiple incidents of falls and injuries. Two residents, identified as R26 and R31, experienced falls resulting in major injuries, including a right shoulder fracture and a compression fracture of the C7 vertebra, respectively. Despite being assessed as at risk for falls, their care plans were not updated with new interventions after previous falls, and post-fall assessments were not conducted. This lack of action contributed to subsequent falls and injuries. Additionally, other residents, including R6 and R2, also experienced falls without proper post-fall assessments or updates to their care plans. R2 had multiple falls over several months, with only one documented interdisciplinary team review and no updated interventions for most incidents. The facility's failure to implement and document appropriate fall prevention strategies placed these residents at risk for further harm. The facility also neglected to address environmental hazards, as observed with wet floors in several residents' rooms without proper signage to warn of the danger. Furthermore, a resident, R14, was allowed to leave the facility and travel on a busy highway in a power wheelchair without a safety assessment or care plan in place. This oversight highlights the facility's inadequate supervision and failure to maintain a safe environment for its residents.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, affecting all 33 residents. Observations revealed that expired and undated food items were stored in the refrigerator, contrary to the facility's policy requiring leftovers to be labeled, dated, and discarded within seven days. The Culinary Director acknowledged that opened foods should be dated and discarded after five days, but several items, including diced pineapple, potatoes, pudding, poke cake, ham, and undated lobster meat, were found in the refrigerator past this timeframe. Additionally, food distributed to residents' rooms was not covered, exposing it to potential contamination. The Culinary Director confirmed that food should be covered when transported outside the dining area, but no policy was provided to support this practice. The facility also failed to ensure proper hand hygiene and use of hair restraints among staff. Dietary Aide F was observed serving breakfast with a hair net that did not fully cover their hair, and a CNA was seen preparing a breakfast tray without a hair net. Furthermore, Dietary Aide F was observed handling food with gloves without washing hands before donning them, and subsequently touching various items with the same gloves, leading to potential contamination. The Culinary Director acknowledged that the observed practices did not align with the facility's policies on hand hygiene and glove use.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to establish a comprehensive Infection Control Program, which resulted in several deficiencies affecting both residents and staff. The facility lacked a clear water management process to prevent Legionella transmission, as evidenced by the absence of maintenance records, inspections, or flushing of areas prone to stagnation. The Water Management Plan was not individualized to the facility's water systems and did not include a flow diagram or risk assessment. Additionally, the facility did not have a tracking program for early detection of infections during outbreaks, such as COVID-19 and Norovirus, leading to incomplete and inconsistent surveillance logs. The facility also failed to implement Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling medical devices. Certified Nurse Assistants (CNAs) were observed entering EBP rooms without proper Personal Protective Equipment (PPE) and not sanitizing equipment like Hoyer lifts after use. Furthermore, a Registered Nurse (RN) did not adhere to appropriate infection control practices during wound care, failing to change gloves or perform hand hygiene between tasks, and using contaminated gloves to handle clean supplies. Interviews with facility staff, including the Director of Nursing (DON) and the Infection Control Nurse, revealed a lack of proper infection control management and oversight. The DON acknowledged the deficiencies and attributed them to staff turnover, while the Infection Control Nurse confirmed the failure to follow established policies and procedures. These lapses in infection control practices have the potential to affect all residents in the facility.
Unqualified Staff Administering Medication
Penalty
Summary
The facility failed to ensure that prescription medications were administered by qualified staff, as observed by a surveyor. A Certified Nursing Assistant (CNA) was seen applying Nystatin powder, a prescription antifungal medication, to a resident's abdominal folds and groin area. This action was not in compliance with the facility's policy, which requires that only nurses administer such medications. The resident confirmed that CNAs typically applied the powder when assisting them out of bed, indicating a routine practice that deviated from the expected protocol. The surveyor's review of the resident's medical record revealed a physician's order for the Nystatin powder to be applied topically twice a day to the abdominal folds. However, the CNA involved admitted to having no formal training in administering the medication. The Director of Nursing confirmed that the expectation was for nurses, not CNAs, to administer the Nystatin powder, highlighting a clear breach in protocol and training within the facility.
Failure to Follow Spinal Precautions for Resident
Penalty
Summary
The facility failed to provide appropriate spinal precautions and treatment for a resident, identified as R21, who was admitted with multiple vertebral fractures and a traumatic brain injury. R21's care plan required log rolling for bed mobility and the use of a thoracic-lumbar-sacral orthosis (TLSO) brace when the head of the bed was elevated above 30 degrees. However, observations revealed that staff did not adhere to these precautions. R21 was observed without the TLSO brace while the head of the bed was elevated beyond the prescribed limit, and staff did not perform log rolling during repositioning. Interviews with R21 and staff indicated a lack of compliance with the prescribed spinal precautions. R21 acknowledged not wearing the brace due to discomfort and weight loss, and the brace was found stored improperly in the room. Certified Nurse Assistants (CNAs) were observed repositioning R21 without log rolling, contrary to the care plan and physician orders. Additionally, the Kardex, which staff relied on for care instructions, lacked specific guidance on bed mobility for R21. The Director of Nursing (DON) was unaware of the non-compliance with the head of bed elevation and the absence of log rolling. The DON confirmed that the Kardex should have included the necessary precautions and acknowledged that a nurse had improperly discontinued the TLSO brace without appropriate physician orders. The facility's failure to follow the care plan and physician orders resulted in a deficiency in maintaining R21's highest practicable level of physical well-being.
Inadequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, R2 and R187, leading to deficiencies in their treatment. R2 developed pressure injuries on the left heel and right great toe, which reoccurred, and a new pressure injury on the left great toe. The care plan for R2 was not updated since August 2023, and R2 was not repositioned or encouraged for pressure relief as needed. Observations revealed that R2's shoes were on while in a recliner, with no pillow to float the heels, and Podus boots were not applied as required. Additionally, there was a lack of comprehensive documentation and assessment of R2's pressure injuries, and wound care orders were not consistently followed. R187 was admitted with a stage 3 pressure injury to the left posterior thigh. The facility did not ensure proper protection and repositioning for R187, and there were inconsistent assessments of the wounds. Observations showed R187 lying in bed with pressure applied to the buttocks, and scattered open areas were noted on the posterior thighs and buttocks. The documentation lacked comprehensive assessments and updates to the physician regarding the pressure injuries. The Director of Nursing acknowledged that weekly assessments were not completed adequately for R187. The facility's failure to adhere to professional standards of practice for pressure injury care and prevention resulted in inadequate treatment and monitoring of pressure injuries for both residents. The lack of updated care plans, consistent repositioning, and comprehensive documentation contributed to the deficiencies observed by the surveyors.
Failure to Monitor Nutritional Status and Weight Loss
Penalty
Summary
The facility failed to ensure acceptable parameters of nutritional status to maintain the usual body weight for a resident, identified as R21, who was reviewed for nutritional status. R21 was admitted with multiple fractures and a traumatic brain injury, requiring total assistance and being bedbound. Despite physician orders for regular weight monitoring, the facility did not weigh R21 weekly as required, and no weights were recorded from the time of admission until the survey. The lack of weight monitoring led to a significant weight loss that was not appropriately assessed or documented. R21's care plan included interventions for nutrition and hydration, but the facility did not follow through with the necessary documentation and monitoring. The dietician's notes indicated a poor appetite and suggested the use of health shakes and an appetite stimulant, but the facility failed to obtain regular weights to assess the effectiveness of these interventions. The facility attempted to use Mid Arm Circumference (MAC) as an alternative measure of weight status, but there was no formal process or documentation to support this practice. Interviews with staff revealed a lack of awareness and understanding of the procedures for monitoring R21's weight. The Director of Nursing (DON) was unaware of the MAC practice and admitted that the staff had not been properly measuring or documenting R21's weight. The DON also acknowledged that the facility had not weighed R21 at all during the entire stay, highlighting a significant oversight in the care and monitoring of R21's nutritional status.
Failure to Document Rationale for Extended PRN Lorazepam Use
Penalty
Summary
The facility failed to ensure that two residents, identified as R16 and R31, were free from unnecessary medications, specifically regarding the use of lorazepam prescribed on a PRN basis beyond the 14-day limit without documented rationale. R16, who was admitted with diagnoses including chronic obstructive pulmonary disease, heart failure, anxiety disorder, and schizophrenia, had a PRN order for lorazepam starting on 04/04/2024, with an end date of 10/03/2024. The medication was administered twice in June, but there was no documented rationale for its continued use beyond the 14-day limit. A physician's signature was present on a faxed communication from the facility, but it lacked a response or reason for the extended PRN order. Similarly, R31 had a PRN order for lorazepam every 2 hours for anxiety until 12/09/2024. When the surveyor requested a rationale for the extended use, the Director of Nursing (DON) B could only provide a prescription with a diagnosis of anxiety, without further documentation to justify the extended PRN use. During an interview, DON B acknowledged the lack of a proper rationale and stated that they would have expected a more detailed explanation from the physician. This oversight indicates a failure in the facility's medication management practices, particularly in ensuring compliance with regulations regarding the use of psychotropic medications.
Deficiency in Protecting Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
The report details a concerning deficiency in protecting a resident from sexual abuse within the facility. The incident involved a cognitively impaired female resident (R1) and a male resident (R2) with intact cognition. On two separate occasions, R2 was found in R1's room engaging in inappropriate behavior, including exposing himself and attempting sexual contact with R1. Despite R1's severe cognitive impairment and incapacity to consent, the facility failed to implement immediate safety measures to prevent further abuse. The facility did not conduct an investigation, notify the police promptly, or assess the residents' capacity to consent to a sexual relationship. R1's medical history indicated diagnoses of Alzheimer's disease, disorientation, and depression, with a Brief Interview for Mental Status (BIMS) score of 3 out of 15, indicating severe cognitive impairment. R2, on the other hand, had diagnoses of Parkinson's disease, Alzheimer's disease, and hallucinations, with a BIMS score of 15 out of 15, indicating intact cognition. Despite R1's vulnerability and incapacity to consent, the facility did not take appropriate steps to prevent the sexual abuse from occurring, leading to a finding of immediate jeopardy. The facility's failure to protect residents from sexual abuse not only violated the residents' rights but also created a significant risk of harm. The lack of appropriate interventions, timely notification to authorities, and failure to assess the residents' capacity to consent highlight serious deficiencies in the facility's protection measures. The incidents involving R1 and R2 underscore the critical importance of implementing robust safeguards to prevent abuse and ensure the safety and well-being of all residents, especially those who are cognitively impaired and vulnerable to exploitation.
Lack of Annual Performance Reviews for CNAs
Penalty
Summary
The facility did not ensure Certified Nursing Assistants (CNAs) received a performance review every 12 months for four CNAs reviewed. Specifically, CNA H, CNA M, CNA N, and CNA O did not have documented annual performance reviews despite being employed for periods ranging from over a year to more than three years. On a specific date, a random sample of CNAs was selected for review, and it was found that none of the CNAs had completed annual performance reviews. The Regional Director of Operations confirmed that the facility had not conducted yearly performance reviews for any employees for quite some time. This deficiency had the potential to affect all 38 residents residing in the facility.
Outdated Facility-Wide Assessment
Penalty
Summary
The facility did not conduct and document a facility-wide assessment to determine the necessary resources to care for its residents competently during both day-to-day operations and emergencies. The assessment provided was outdated, with the most recent review dates being February 2022 and March 2023, but the data within the assessment was from as far back as 2017. The assessment included outdated statistics and did not reflect the current census trends, staffing needs, or rehospitalization data. Additionally, the assessment lacked specific information on the current resident population, staff competencies, physical environment, and other critical factors necessary for a comprehensive facility assessment. During an interview, the Regional Director of Operations acknowledged that the provided assessment needed to be updated to a different format. However, the surveyor noted that the current assessment did not reflect the facility's current population or the resources needed to care for the residents. The facility failed to review and update the assessment as necessary and at least annually, which has the potential to affect all 38 residents in the facility.
Inaccurate Staffing Data Submission
Penalty
Summary
The facility did not ensure that mandatory staffing data submitted to CMS for FY Quarter 4, 2023, and FY Quarter 1, 2024, was complete, accurate, and auditable. The Payroll-Based Journal (PBJ) Staffing Data Reports indicated that the facility failed to have licensed nursing coverage 24 hours per day on specified dates. However, upon review, the facility's timecard sheets and daily schedule sheets showed that there was licensed nursing coverage on all the specified dates. The Regional Director of Operations (RDO) confirmed that the data was submitted by someone from the corporate office and acknowledged that the facility had Registered Nurse (RN) coverage on the dates in question. The surveyor was unable to audit the exact documents submitted, leading to the conclusion that the data was inaccurately reported.
Failure to Report Allegations of Sexual Abuse Timely
Penalty
Summary
The facility failed to implement policies and procedures for reporting a reasonable suspicion of a crime in accordance with section 1150B of the Act. Specifically, the facility did not report allegations of sexual abuse involving two residents to the State Agency and law enforcement within the required timeframe. On two separate occasions, a Certified Nursing Assistant (CNA) found Resident 2 in compromising situations with Resident 1, who has severe cognitive impairment. The first incident occurred on 03/28/24, where Resident 2 was found shirtless in Resident 1's bed while Resident 1 was standing without pants. The second incident occurred on 04/01/24, where Resident 2 was found with pants and brief pulled down, exposing his penis, while lying next to Resident 1 in bed. Both incidents were not reported to the State Agency or law enforcement within the mandated 2-hour window. Resident 1, a female with severe cognitive impairment due to Alzheimer's disease, was involved in both incidents. Resident 2, a male with intact cognition but diagnosed with Parkinson's disease and Alzheimer's disease, was found in compromising situations with Resident 1. The Director of Nursing (DON) admitted that the facility did not assess the ability of Resident 1 to consent to the interactions and initially considered the encounters consensual. The facility's failure to report these incidents promptly to the appropriate authorities constitutes a significant deficiency in adhering to mandated reporting requirements.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility did not ensure that allegations of abuse involving two residents were thoroughly investigated. On two separate occasions, a Certified Nursing Assistant (CNA) found Resident 2 in compromising situations with Resident 1, who has severe cognitive impairment. On the first occasion, Resident 2 was found shirtless in Resident 1's bed while Resident 1 was standing without pants. On the second occasion, Resident 2 was found with pants and briefs pulled down, exposing his penis, while lying next to Resident 1 in bed. Despite these incidents, the facility did not conduct thorough investigations as required by their policy on abuse, neglect, and exploitation. The facility's Director of Nursing (DON) admitted that the incidents were viewed as consensual without assessing Resident 1's ability to consent, given her severe cognitive impairment. The facility's documentation shows that the families of both residents were informed, but no further action was taken beyond separating the residents and implementing 15-minute checks. The facility failed to interview staff involved in the incidents or take timely and thorough investigative actions to prevent recurrence, thereby not adhering to their own policies and procedures for handling allegations of abuse.
Deficiency in CNA In-Service Training Documentation
Penalty
Summary
The facility did not ensure that two out of five Certified Nursing Assistants (CNA H and CNA N) employed for more than one year received the required minimum of 12 hours of in-service training each year. This deficiency was identified during a survey on 04/25/24, where the surveyor requested in-service training records for CNA H and CNA N. CNA H, hired on 11/16/20, and CNA N, hired on 02/13/23, did not receive the necessary training in communication, behavioral health, and dementia care. The facility provided unreadable documentation, making it impossible to verify the total yearly training hours. Despite multiple requests, the Director of Nursing (DON B) failed to provide clear and readable documentation. This lack of proper training documentation has the potential to affect the quality of care for all 38 residents in the facility. The surveyor informed the Director of Nursing (DON B), Regional Director of Operations (RDO K), and Director of Clinical Operations (DCO L) about the training deficiencies.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 84 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
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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) |
|---|---|---|---|---|
| Park View Home | 8.3 mi | ★★★★★ | 3 | 0 |
| Baldwin Care Center | 9.8 mi | ★★★★★ | 11 | 0 |
| Ellsworth Health Services | 12.5 mi | ★★★★★ | 6 | 0 |
| Hammond Health Services | 12.9 mi | ★★★★★ | 3 | 0 |
| Plum City Care Ctr | 15 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.