Inspection Reports for
Pine Valley Center for Rehabilitation and Nursing
661 N Main St, Spring Valley, NY, 10977
Back to Facility Profile6 Reports
Inspection Report — Dec 22, 2025
Annual Inspection CMS
Date: Dec 22, 2025
Visit Reason
The inspection was conducted as a recertification survey and annual inspection to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including timely completion of Minimum Data Set assessments, accurate resident assessments, development and implementation of comprehensive care plans, pressure ulcer prevention and treatment, appropriate use of splints and braces, medication storage security, and proper food labeling and storage.
Citations (8)
F0638: The facility did not ensure residents' Minimum Data Set assessments were completed at least quarterly for one resident.
F0641: The facility did not ensure Minimum Data Set assessments accurately reflected residents' status for one resident who was an active smoker but was coded as a non-smoker.
F0656: The facility did not develop or implement a comprehensive care plan addressing hoarding behavior for one resident.
F0657: The facility did not review and revise the care plan timely for one resident who used bilateral siderail enablers but was observed without them.
F0686: The facility failed to provide appropriate pressure ulcer care and heel offloading as ordered for three residents at risk for pressure ulcers.
F0688: The facility did not ensure residents with limited range of motion received appropriate treatment and services, including use of splints and braces, for four residents.
F0761: The facility did not ensure drugs and biologicals were stored securely; a medication cart was found unlocked and unattended.
F0812: The facility did not ensure food was properly labeled and dated in refrigerators, freezers, and storage areas, with 25 items found unlabeled or undated.
Report Facts
Residents reviewed for Accidents: 7
Residents reviewed for Pressure Ulcers: 8
Residents reviewed for Positioning and Mobility: 6
Food items unlabeled or undated: 25
Residents affected by deficiencies: Few or Some or Many
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #20 | Licensed Practical Nurse | Named in medication cart security deficiency |
| Minimum Data Set Coordinator #3 | Named in Minimum Data Set assessment deficiencies | |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan and pressure ulcer care deficiencies |
| Director of Rehabilitation | Director of Rehabilitation | Interviewed regarding splint and brace use deficiencies |
| Food Service Director | Food Service Director | Interviewed regarding food labeling and storage deficiencies |
| Registered Nurse Unit Manager #6 | Registered Nurse Unit Manager | Interviewed regarding pressure ulcer care and splint use |
| Certified Nurse Aide #7 | Certified Nurse Aide | Interviewed regarding pressure ulcer care and splint use |
| Licensed Practical Nurse #9 | Licensed Practical Nurse | Interviewed regarding pressure ulcer care |
Inspection Report — Dec 18, 2025
Certification/complaint State
Date: Dec 18, 2025
Visit Reason
State-compiled facility profile showing 10 inspections from June 2022 to May 2026 with citation and complaint history.
Complaint Details
The state logged 47 complaints about this facility; 7 led to on-site inspections.
Findings
Across 10 inspections, 7 resulted in citations totaling 37, mostly Level 2 minor potential harm standard health and life safety code violations. The facility had 47 complaints with 7 on-site inspections and no formal enforcement actions.
Citations (24)
Standard Health Citation — quality of care: Accuracy Of Assessments not properly conducted.
Standard Health Citation — quality of care: Care Plan Timing And Revision deficiencies noted.
Standard Health Citation — quality of care: Failed to develop/implement comprehensive care plan.
Standard Health Citation — quality of care: Food procurement, storage, preparation, and serving not sanitary.
Standard Health Citation — quality of care: Failed to increase or prevent decrease in range of motion/mobility.
Standard Health Citation — quality of care: Quarterly assessments not conducted at least every 3 months.
Standard Health Citation — quality of care: Treatment/services to prevent or heal pressure ulcers inadequate.
Life Safety Code Citation — NFPA requirements: Discharge from exits not compliant.
Life Safety Code Citation — NFPA requirements: Exit signage deficiencies.
Life Safety Code Citation — NFPA requirements: Sprinkler system maintenance and testing inadequate.
Standard Health Citation — quality of care: Reporting of alleged violations deficient.
Standard Health Citation — quality of care: Free from abuse and neglect not ensured.
Standard Health Citation — quality of care: Infection prevention and control inadequate.
Standard Health Citation — quality of care: Nurse aide performance review and in-service training deficient.
Standard Health Citation — quality of care: Reporting of alleged violations deficient.
Standard Health Citation — quality of care: Reporting to National Health Safety Network deficient.
Standard Health Citation — quality of care: Essential equipment not in safe operating condition.
Standard Health Citation — quality of care: Food procurement, storage, preparation, and serving not sanitary.
Standard Health Citation — quality of care: Failed to increase or prevent decrease in range of motion/mobility.
Standard Health Citation — quality of care: Infection prevention and control inadequate.
Standard Health Citation — quality of care: Investigate, prevent, and correct alleged violations deficient.
Standard Health Citation — quality of care: Nutrition and hydration status maintenance deficient.
Standard Health Citation — quality of care: Quality of care deficiencies noted.
Standard Health Citation — quality of care: Resident rights and exercise of rights not fully ensured.
Report Facts
Inspections on page: 10
Total violations/deficiencies cited: 37
Inspections with violations: 7
Inspections without violations: 3
Complaints total: 47
On-site complaint inspections: 7
Complaint citations issued: 6
Enforcement actions: 0
Inspection Report — Oct 6, 2025
Abbreviated Survey CMS
Date: Oct 6, 2025
Visit Reason
The abbreviated survey was conducted to evaluate the facility's compliance with timely reporting requirements for suspected abuse, neglect, or theft.
Findings
The facility failed to report an allegation of sexual abuse within the required two-hour timeframe to the New York State Department of Health for one of three residents reviewed. The allegation was reported approximately 21 hours late after an internal investigation was conducted.
Citations (1)
F 0609: The facility did not report an allegation of sexual abuse within two hours to the New York State Department of Health as required. The report was delayed until the following day after an internal investigation concluded no abuse occurred.
Report Facts
Residents reviewed for abuse: 3
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in relation to delayed reporting of abuse allegation | |
| Director of Activities | Reported the abuse allegation to the Director of Nursing | |
| Administrator | Provided explanation for delayed reporting of abuse allegation |
Inspection Report — Dec 2, 2024
Abbreviated Survey CMS
Date: Dec 2, 2024
Visit Reason
The survey was conducted as an abbreviated inspection focusing on allegations of abuse, failure to report abuse, nurse aide performance reviews, and infection control practices at the Pine Valley Center for Rehabilitation and Nursing.
Findings
The facility failed to protect a resident from abuse by staff, did not timely report suspected abuse to law enforcement, failed to complete required nurse aide performance reviews and in-service education, and did not ensure proper infection control practices including gown use during care of residents on enhanced precautions.
Citations (4)
F 0600: The facility did not ensure a resident was free from abuse. Video evidence showed staff using more force than necessary to provide care to Resident #1.
F 0609: The facility failed to timely report suspected abuse of Resident #1 to local law enforcement, leaving the decision to the family and only notifying the Department of Health.
F 0730: The facility did not ensure that nurse aides received performance reviews at least once every 12 months or the required 12 hours of in-service education per year.
F 0880: The facility failed to implement infection prevention and control practices. Staff did not wear gowns when providing care or transferring residents on enhanced precautions.
Report Facts
Performance evaluations missing: 2
In-service education hours: 12
Residents reviewed for abuse: 3
Residents affected: Few
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #1 | Named in abuse findings and infection control violations. | |
| Certified Nursing Assistant #4 | Named in abuse findings and infection control violations. | |
| Resident Assistant #2 | Named in abuse findings. | |
| Resident Assistant #3 | Named in abuse findings. | |
| Certified Nursing Assistant #7 | Named in infection control observation. | |
| Licensed Practical Nurse #9 | Named in infection control observation. | |
| Resident Assistant #15 | Named in infection control observation. | |
| Certified Nursing Assistant #6 | Named in infection control observation. | |
| Certified Nursing Assistant #8 | Named in infection control observation. | |
| Director of Nursing | Director of Nursing | Interviewed regarding abuse allegations and staff suspensions. |
| Administrator | Administrator | Interviewed regarding reporting of abuse to law enforcement. |
Inspection Report — Jul 14, 2023
Annual Inspection CMS
Date: Jul 14, 2023
Visit Reason
The survey was a recertification annual inspection conducted from 7/10/2023 to 7/14/2023 to assess compliance with regulatory requirements for Pine Valley Center for Rehabilitation and Nursing.
Findings
The facility was found deficient in multiple areas including resident dignity related to urinary catheter care, incomplete investigation of an injury of unknown origin, delayed treatment of a resident's burn, failure to provide timely restorative nursing for limited range of motion, inadequate monitoring of significant weight loss, improper food handling and storage practices, lapses in infection prevention and control practices, and failure to maintain essential kitchen equipment in safe and sanitary condition.
Citations (8)
F 0550: The facility failed to ensure urinary catheter drainage bags were concealed to maintain resident dignity for 3 residents, with bags visible from the hallway.
F 0610: The facility did not thoroughly investigate an injury of unknown origin for Resident #118 who sustained a burn from hot water, with incomplete documentation and delayed reporting.
F 0684: Resident #118 did not receive timely treatment for a right thigh burn, and the medical provider was unaware of the injury until days later.
F 0688: The facility delayed ordering restorative nursing for Resident #75 with limited range of motion, despite therapy recommendations.
F 0692: Resident #48 experienced significant weight loss that was not addressed by the dietitian for over one month.
F 0812: Food service staff failed to follow food safety standards including improper hair restraint, forged temperature logs, and uncovered raw chicken stored improperly.
F 0880: Infection prevention lapses included CNAs buttering toast with bare hands, uncovered linen carts, and failure to use PPE and hand hygiene when handling dishes from a resident on contact precautions.
F 0908: The facility failed to maintain kitchen equipment in safe and sanitary condition; the walk-in freezer door was broken causing frost buildup and the ice machine was visibly soiled and corroded.
Report Facts
Residents reviewed for accidents: 5
Residents reviewed for quality of care: 5
Residents reviewed for ADL decline: 4
Residents reviewed for nutrition and hydration: 3
Weight loss in pounds: 19
Burn size in centimeters: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Named in injury investigation and burn treatment findings for Resident #118. |
| RNUM #1 | Registered Nurse Unit Manager | Named in findings related to catheter dignity and infection control. |
| CNA #1 | Certified Nurse Aide | Named in catheter dignity and nutrition findings. |
| NP #1 | Nurse Practitioner | Named in burn treatment findings for Resident #118. |
| FSW #1 | Food Service Worker | Named in food safety findings for improper hair restraint. |
| FSW #3 | Food Service Worker | Named in forged temperature log findings. |
| CNA #4 | Certified Nurse Aide | Named in infection control finding for buttering toast with bare hands. |
| CNA #5 | Certified Nurse Aide | Named in infection control finding for buttering toast with bare hands. |
| CNA #6 | Certified Nurse Aide | Named in infection control finding for failure to use PPE and hand hygiene. |
| Housekeeping Staff #1 | Housekeeping Staff | Named in infection control finding for uncovered linen cart. |
Inspection Report — Nov 25, 2019
Annual Inspection CMS
Date: Nov 25, 2019
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with regulatory requirements for nursing care and infection prevention.
Findings
The facility failed to ensure appropriate catheter care for one resident, resulting in improper use of a urinary leg bag while the resident was in bed. Additionally, staff did not follow proper hand hygiene and gloving techniques during wound care, and soiled linens were improperly stored on the floor, increasing risk of infection.
Citations (2)
F 0690: The facility did not provide appropriate care for an indwelling catheter for Resident #91, who had the catheter leg bag attached while lying flat in bed instead of the bedside drainage bag.
F 0880: The facility failed to implement an infection prevention program, as staff did not follow proper hand hygiene and gloving techniques during wound care for Resident #348, and soiled linens and diapers were found on the floor in an occupied resident room.
Report Facts
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager (LPN #1) | Interviewed regarding facility policy on urinary drainage bags | |
| Nurse Practitioner | Interviewed regarding facility policy on urinary drainage bags | |
| Director of Nurses | Advised surveyor about facility's Leg Bag policy | |
| Licensed Practical Nurse (LPN #2) | Observed and interviewed regarding improper wound care and hand hygiene | |
| Certified Nursing Assistant (CNA) | Interviewed about soiled linens on floor |
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