Inspection Reports for Spring Valley Health and Rehabilitation Center
MO, 65804
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
15.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
184% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
156 residents
Based on a November 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Complaint Investigation
Census: 156
Deficiencies: 2
Nov 21, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding medication administration and tube feeding care at Spring Valley Health & Rehabilitation Center.
Findings
The facility failed to provide appropriate medication administration and documentation for one resident regarding boric acid vaginal suppository, including failure to notify the physician of missed doses and failure to care plan refusals. Additionally, the facility failed to ensure proper documentation and physician notification for tube feeding amounts that varied from the ordered amount for another resident at nutritional risk.
Complaint Details
Complaint # 2650298 was investigated regarding medication administration errors and tube feeding documentation and care.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to accurately document medication administration, ensure medication availability, notify physician of missed doses, and care plan medication refusals for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure sufficient nutrition and proper documentation of tube feeding intake, and failed to notify physician when tube feeding amounts varied from the ordered amount for one resident. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 156
Medication administration dates: 8
Tube feeding volume ordered: 1200
Tube feeding volume range: 1500
Tube feeding documented intake: 0
Tube feeding documented intake: 1100
Tube feeding documented intake: 240
Tube feeding documented intake: 2505
Tube feeding documented intake: 2200
Tube feeding documented intake: 600
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN D | Licensed Practical Nurse | Interviewed regarding medication administration and tube feeding documentation, described issues with medication availability and documentation practices. |
| RN A | Registered Nurse | Interviewed regarding medication administration and tube feeding documentation, described confusion and errors in documentation and physician notification. |
| LPN B | Licensed Practical Nurse | Interviewed regarding medication administration and tube feeding documentation, described lack of knowledge about medication orders and documentation. |
| LPN C | Licensed Practical Nurse / Unit Manager | Interviewed regarding medication administration and tube feeding documentation, described confusion about orders and documentation times. |
| CMT F | Certified Medication Technician | Interviewed regarding medication refusal notification and documentation. |
| Assistant Director of Nursing | ADON | Interviewed regarding policies on medication refusals and tube feeding documentation. |
| Director of Nursing | DON | Interviewed regarding medication availability, documentation, and tube feeding order confusion. |
| Administrator | Facility Administrator | Interviewed regarding medication ordering, documentation education, and tube feeding review. |
| Central Supply Staff Member | Central Supply Staff | Interviewed regarding ordering and stocking of boric acid vaginal suppository. |
Inspection Report
Complaint Investigation
Census: 149
Deficiencies: 13
Aug 25, 2025
Visit Reason
The inspection was conducted based on complaints regarding medication self-administration, bathing and hygiene, environmental cleanliness, temperature control, pest control, medication administration errors, wound care, nutrition, and food safety at Spring Valley Health & Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' rights to self-administer medications, timely and preferred bathing, maintaining a clean and homelike environment, appropriate temperature control, pest control, medication administration accuracy and documentation, wound care management, nutrition provision especially on dialysis days, and food safety and sanitation standards.
Complaint Details
Complaints investigated included issues with medication self-administration, bathing, environmental cleanliness, temperature control, pest control, medication administration errors, wound care, nutrition, and food safety. Complaint numbers include 1534273, 1534275, 1534276, 2572207, 2585250, 2590129, 2591593, 2594499, 2595498, 2595716, and 2562196.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 13
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to ensure the right to self-administer medications when staff failed to assess, care plan, and obtain physician orders for bedside medication storage for three residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to promote and facilitate residents' right to self-determination by not providing timely bathing in the form preferred for four residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain cleanliness of floors, walls, doors, bathrooms, and furniture, and failed to address odors in resident rooms for multiple residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain comfortable temperature in resident rooms and family dining room, with temperatures exceeding recommended levels. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide activity programs meeting residents' needs, including lack of scheduled activities and documentation of one-on-one visits. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate pressure ulcer care including timely wound treatment orders and documentation for one resident with stage 3 pressure ulcers. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate catheter care and monitoring for one resident with an indwelling catheter, including documentation of urine output and abnormal urine color. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide sufficient meals and fluids to maintain health for one resident on dialysis, including failure to provide breakfast and sack meals on dialysis days. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide pharmacy services meeting residents' needs by not documenting medication administration or refusal for two residents and failing to follow up on outside medication orders for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medication error rates were below 5% due to incorrect medication doses, wrong medication administration, and failure to prime insulin pens for four residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain kitchen equipment in safe operating condition with three stove knobs missing. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain a sanitary environment in the kitchen with dirty floors, walls, appliances, vents, and failure to date and label opened food. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement and maintain an effective pest control system with multiple flies observed in resident rooms. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 149
Medication error rate: 20
Stage 3 pressure wound size: 8
Stage 3 pressure wound size: 6
Stage 3 pressure wound size: 0.4
Stage 3 pressure wound size: 12
Stage 3 pressure wound size: 7
Stage 3 pressure wound size: 0.4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Unit Manager | Documented resident admission and skin assessment; involved in wound care and medication order follow-up |
| Certified Medication Technician D | Prepared and administered incorrect folic acid dose; commented on medication administration practices | |
| RN C | Registered Nurse | Administered insulin without priming pen; commented on medication administration and insulin pen priming |
| RN O | Registered Nurse | Administered insulin without priming pen; involved in medication administration observations |
| Certified Medication Technician A | Commented on medication administration and insulin pen priming | |
| Director of Nursing | DON | Provided multiple interviews regarding medication administration, insulin pen priming, wound care, and facility policies |
| Administrator | Provided multiple interviews regarding facility policies, medication administration, pest control, and other deficiencies | |
| Dietary Manager | Provided interviews regarding food service and kitchen sanitation | |
| Housekeeping Supervisor | Provided interviews regarding cleanliness and pest control | |
| Maintenance Director | Provided interviews regarding maintenance and pest control |
Inspection Report
Complaint Investigation
Census: 157
Deficiencies: 3
Mar 14, 2025
Visit Reason
The inspection was conducted due to concerns about the facility's failure to provide appropriate catheter care and prevent urinary tract infections for residents with indwelling catheters, specifically focusing on Resident #1.
Findings
The facility failed to ensure proper catheter care for Resident #1, including failure to document catheter care completion, timely catheter changes, monitoring of output and signs of infection, updating physician orders, and updating the care plan. Staff did not consistently document catheter care or reasons for missed care, and orders for catheter care were not always transcribed or followed. The resident had a history of urinary tract infections and catheter-related complications, with multiple missed documentation and care failures noted over several months.
Complaint Details
The investigation was complaint-related focusing on Resident #1's catheter care. The complaint involved failure to provide appropriate catheter care, failure to document care and monitoring, and failure to update orders and care plans. The resident had a history of urinary tract infections and catheter complications, including hematuria and obstruction. Staff failed to document catheter care on multiple occasions and did not have consistent orders for catheter care or changes. The resident was seen by urology multiple times, but communication and order transcription issues persisted.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failure to document completion of catheter care and monitoring of output and signs/symptoms of infection. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to document catheter changes timely and update physician orders appropriately. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to update the care plan regarding catheter care and changes. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 157
Missed catheter care documentation: 20
Missed output monitoring documentation: 20
Catheter size: 16
Catheter change frequency: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse B | Licensed Practical Nurse | Mentioned in relation to catheter care provision and documentation |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Noted catheter changes, received verbal orders, and documented late entries related to catheter care |
| Family Nurse Practitioner | Family Nurse Practitioner (FNP) | Provided orders, assessed catheter-related erosion, and communicated with facility staff |
| Registered Nurse F | Registered Nurse | Described catheter care standards and documentation expectations |
| Director of Nursing | Director of Nursing (DON) | Provided expectations for catheter care orders and documentation |
| CNA A | Certified Nurse Aide | Described catheter care practices and reporting |
| CNA D | Certified Nurse Aide | Described catheter care practices and documentation |
| CNA E | Certified Nurse Aide | Described catheter care practices and documentation |
| Urology FNP | Urology Family Nurse Practitioner | Provided urology care, orders, and expectations for catheter management |
| Administrator | Facility Administrator | Described admission orders and communication with physicians and urology |
Inspection Report
Complaint Investigation
Census: 152
Deficiencies: 1
Feb 14, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure timely obtaining of an ordered urinalysis for one resident out of ten sampled residents.
Findings
The facility failed to obtain an ordered urinalysis in a timely manner for Resident #1, with the sample collected 10 days after the order and lab results delayed. Staff interviews revealed issues with obtaining the sample, resident refusals, and lab pickup schedules. Policies require timely lab collection and notification of providers for changes in condition, which were not consistently followed.
Complaint Details
The complaint investigation focused on the failure to timely obtain an ordered urinalysis for Resident #1, who exhibited altered mental status and hallucinations. The urinalysis was ordered on 12/07/24 but was not collected until 12/17/24, with no documentation explaining the delay or notification to the provider.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to obtain an ordered urinalysis in a timely fashion for one resident. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 152
Days delay in obtaining urinalysis: 10
Urinalysis lab results dates: 12
Urinalysis lab results reported date: 15
Inspection Report
Complaint Investigation
Census: 159
Deficiencies: 2
Jan 23, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report and properly investigate an allegation of physical abuse by staff against a resident.
Findings
The facility failed to report an allegation of physical abuse by staff to management and the state licensing agency within the required two-hour timeframe. Additionally, the facility did not initiate a timely and complete investigation or take adequate steps to protect residents following the allegation. The accused staff member was suspended but no written investigation was provided.
Complaint Details
The complaint involved an allegation by Resident #1 that a Certified Nurse Aide (CNA C) jerked and broke the resident's leg during transfer. Staff failed to report this allegation to management and the state within two hours. Interviews revealed confusion and lack of awareness about reporting requirements. The facility did not conduct a documented investigation and did not protect residents adequately following the allegation.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to timely report allegations of abuse to management and the state licensing agency within two hours. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to immediately begin an investigation and take steps to protect residents after allegations of abuse. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 159
Admission date: Dec 13, 2024
MDS assessment date: Dec 20, 2024
Date of alleged incident: Jan 17, 2025
Date of inspection: Jan 23, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Interviewed regarding the abuse allegation and assessment of resident's leg |
| CNA C | Certified Nurse Aide | Accused staff member in the abuse allegation |
| CNA D | Certified Nurse Aide | Witness and interviewed regarding the transfer incident |
| CNA E | Certified Nurse Aide | Interviewed about abuse reporting procedures |
| CNA H | Certified Nurse Aide | Interviewed about abuse reporting and facility procedures |
| CMT F | Certified Medication Technician | Interviewed about abuse reporting and resident assessment |
| LPN G | Licensed Practical Nurse | Interviewed about abuse reporting and investigation |
| Social Service Director | Social Service Director | Interviewed about abuse reporting and investigation procedures |
| DON | Director of Nursing | Interviewed about abuse allegation and investigation |
| Administrator | Administrator | Interviewed about abuse allegation, reporting, and investigation |
Inspection Report
Routine
Census: 160
Deficiencies: 4
Dec 13, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility standards, including medication administration, wound care, infection control, and medication storage.
Findings
The facility was found deficient in multiple areas including failure to administer and document medications as ordered for several residents, failure to provide wound care per physician orders, failure to maintain infection control practices during blood sugar monitoring and insulin administration, and failure to secure medications properly.
Deficiencies (4)
| Description |
|---|
| Failure to administer and document multiple medications as ordered for Residents #5, #8, and #9. |
| Failure to provide wound care per physician orders and failure to care plan pressure ulcers for Residents #6, #7, and #10. |
| Failure to maintain infection prevention and control practices including inadequate hand hygiene, failure to disinfect multi-use equipment between residents, and improper handling of insulin and blood glucose monitoring supplies for Residents #1, #2, #3, and #4. |
| Failure to secure medications properly, including leaving medications at bedside without physician orders and unlocked medication carts accessible to unauthorized persons. |
Report Facts
Medication administration documentation failures: 10
Medication administration documentation failures: 7
Medication administration documentation failures: 2
Medication administration documentation failures: 10
Medication administration documentation failures: 7
Medication administration documentation failures: 2
Medication administration documentation failures: 10
Medication administration documentation failures: 7
Medication administration documentation failures: 7
Medication administration documentation failures: 6
Medication administration documentation failures: 2
Medication administration documentation failures: 7
Medication administration documentation failures: 7
Medication administration documentation failures: 7
Medication administration documentation failures: 6
Medication administration documentation failures: 2
Medication administration documentation failures: 10
Medication administration documentation failures: 7
Medication administration documentation failures: 7
Medication administration documentation failures: 6
Medication administration documentation failures: 2
Medication administration documentation failures: 10
Medication administration documentation failures: 7
Medication administration documentation failures: 7
Medication administration documentation failures: 6
Medication administration documentation failures: 2
Medication administration documentation failures: 8
Medication administration documentation failures: 8
Medication administration documentation failures: 6
Medication administration documentation failures: 6
Medication administration documentation failures: 6
Medication administration documentation failures: 6
Medication administration documentation failures: 7
Medication administration documentation failures: 4
Medication administration documentation failures: 17
Medication administration documentation failures: 6
Medication administration documentation failures: 3
Medication administration documentation failures: 3
Medication administration documentation failures: 34
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician B | Certified Medication Technician | Interviewed regarding medication administration documentation and medication cart security. |
| Licensed Practical Nurse A | Licensed Practical Nurse | Interviewed regarding medication administration documentation, wound care, and infection control practices. |
| Administrator | Interviewed regarding facility policies on medication administration, wound care, infection control, and medication cart security. | |
| Director of Nursing | Director of Nursing | Interviewed regarding facility policies on medication administration, wound care, infection control, and medication cart security. |
| Certified Medication Technician C | Certified Medication Technician | Interviewed regarding infection control practices. |
| Licensed Practical Nurse F | Licensed Practical Nurse | Interviewed regarding infection control practices and medication administration. |
| Certified Medication Technician D | Certified Medication Technician | Interviewed regarding medication storage and medication administration practices. |
| Licensed Practical Nurse E | Licensed Practical Nurse | Interviewed regarding wound care orders and medication administration. |
Inspection Report
Routine
Census: 143
Deficiencies: 1
Apr 9, 2024
Visit Reason
The inspection was conducted to assess the facility's housekeeping and maintenance services related to maintaining a sanitary and comfortable environment in resident access areas.
Findings
The facility failed to maintain cleanliness in multiple resident shower rooms, bathrooms, and common areas, with observations of fecal matter, dirt, rust stains, and soiled linens. Housekeeping staff were not fully aware or responsive to priority cleaning needs, and the facility lacked a written policy specific to cleanliness maintenance.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide sufficient housekeeping and maintenance services to maintain a sanitary and comfortable environment, with dirty floors, shower rooms, bathrooms, and walls found with odor and stains. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 143
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper A | Housekeeper | Described cleaning routines and responsibilities, including cleaning residents' rooms and bedside tables. |
| Housekeeper B | Housekeeper | Described cleaning duties for assigned hall and shower rooms, and procedures for cleaning bowel smears. |
| Housekeeping Supervisor | Housekeeping Supervisor | Interviewed about cleaning assignments, checklists, and communication regarding cleaning priorities. |
| Certified Nurse Aide D | Certified Nurse Aide (CNA) | Described responsibilities for shower room sanitation after each resident. |
| Administrator | Administrator | Discussed housekeeping staff duties, use of checklists, and procedures for priority cleaning and maintenance involvement. |
| Director of Nursing | Director of Nursing (DON) | Participated in interview regarding housekeeping and cleaning procedures. |
| Corporate Quality Assurance Nurse | Corporate Quality Assurance Nurse (QA RN) | Participated in interview regarding housekeeping and cleaning procedures. |
Inspection Report
Complaint Investigation
Census: 147
Deficiencies: 2
Jan 24, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report and investigate an allegation of possible sexual abuse made by a resident.
Findings
The facility failed to ensure all allegations of possible abuse were reported immediately to the Administrator and within two hours to the State Survey Agency. The facility also failed to document a timely investigation and take immediate steps to protect residents when an allegation of sexual abuse was reported by a resident.
Complaint Details
The complaint involved an allegation of sexual abuse reported by Resident #1 on 01/18/24. The facility staff did not report the allegation to the Administrator or the State Survey Agency within the required timeframe, nor did they initiate a timely investigation or take protective steps. The allegation was documented by Licensed Practical Nurse (LPN) A but was not reported. Interviews with facility staff including LPN A, Medical Director, Assistant Director of Nursing, and Administrator confirmed the failure to report and investigate as required.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to document a timely investigation of an allegation of sexual abuse and failed to immediately take steps to protect all residents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 147
Resident admission date: May 19, 2023
Resident MDS assessment date: Nov 8, 2023
Resident nurses' notes date: Jan 18, 2024
Report timeframe: 2
Investigation reporting timeframe: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in failure to report allegation of abuse documented in resident's progress notes |
| Medical Director | Interviewed regarding reporting and investigation of abuse allegations | |
| Assistant Director of Nursing | ADON | Interviewed regarding reporting and investigation of abuse allegations |
| Administrator | Administrator | Interviewed regarding awareness and reporting of abuse allegations |
Inspection Report
Routine
Census: 153
Deficiencies: 15
Dec 21, 2023
Visit Reason
Routine inspection of Spring Valley Health & Rehabilitation Center to assess compliance with healthcare facility regulations including resident care, medication administration, infection control, and facility environment.
Findings
The facility had multiple deficiencies including failure to accommodate resident needs such as wheelchair accessibility, failure to notify physicians of elevated blood sugars, inadequate privacy curtains, environmental maintenance issues, incomplete PASARR assessments, incomplete care plans, inconsistent bathing assistance, inaccurate smoking risk assessments, medication errors, missed medication documentation, inadequate dialysis communication, poor infection control practices, and food service issues including failure to honor food preferences and maintain kitchen cleanliness.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 15
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to keep a wheelchair readily accessible for one resident who did not have documented offers or refusals to get out of bed. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to notify resident's physician of elevated blood sugar levels and document notification. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide full visual privacy in five semi-private resident rooms due to insufficient privacy curtains. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain a homelike environment and make needed repairs in six resident rooms and the dining room. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to submit a new PASARR Level 1 assessment after a new mental illness diagnosis for one resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop comprehensive care plans addressing all pertinent health concerns for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to consistently provide bathing/showers for two residents dependent on staff assistance. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to accurately complete smoking risk assessments and care plan smoking safety for five residents identified as smokers. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to monitor daily weights as ordered and care plan nutritional needs for two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide safe and appropriate dialysis care and communication for one resident receiving hemodialysis. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medication error rate was below 5% with five medication errors out of 27 opportunities involving two residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure medication/treatment carts were locked when unattended and failed to remove expired medications from medication cart. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain complete and accurate medication administration documentation for three residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food was stored, prepared, and served per professional standards including kitchen cleanliness and honoring resident food preferences. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain infection control standards during IV medication administration, PPE disposal, and glucometer sanitization. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 38
Medication errors: 5
Medication error rate: 18.5
Residents affected: 153
Weight measurements missed: 33
Weight loss: 12.6
Weight loss percentage: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 4 | Licensed Practical Nurse | Named in medication error finding and late medication administration |
| CNA 3 | Certified Nurse Aide | Named in bathing assistance documentation finding |
| CNA 4 | Certified Nurse Aide | Named in bathing assistance documentation finding |
| ADON 1 | Assistant Director of Nursing | Named in PTSD diagnosis and medication documentation findings |
| ADON 2 | Assistant Director of Nursing | Named in medication administration and medication cart findings |
| ADON 3 | Assistant Director of Nursing/Infection Preventionist | Named in COVID isolation PPE bin placement and dialysis communication findings |
| DON | Director of Nursing | Named in medication administration, medication cart, glucometer sanitization, and dialysis communication findings |
| MDSC 1 | Minimum Data Set Coordinator | Named in smoking risk assessment and nutrition care plan findings |
| RN 1 | Registered Nurse | Named in bathing assistance documentation finding |
| RN 2 | Registered Nurse | Named in food preference observation |
| RN 4 | Registered Nurse | Named in PTSD diagnosis interview |
| LPN 6 | Licensed Practical Nurse | Named in glucometer sanitization observation |
| LPN 2 | Licensed Practical Nurse | Named in glucometer sanitization interview |
| LPN 3 | Licensed Practical Nurse | Named in medication cart locking interview |
| CMT 2 | Certified Medication Technician | Named in medication cart expiration check |
| DS | Dietary Supervisor | Named in kitchen cleanliness and food service findings |
| MS | Maintenance Supervisor | Named in kitchen cleanliness and sink pipe repair |
| LPN 5 | Licensed Practical Nurse | Named in IV medication administration observation |
| CNA 7 | Certified Nursing Aide | Named in PTSD diagnosis interview |
| ACTS | Activities Supervisor | Named in smoking risk assessment and smoking privileges interview |
Inspection Report
Complaint Investigation
Census: 154
Deficiencies: 2
Dec 5, 2023
Visit Reason
The inspection was conducted due to concerns about the care and documentation related to feeding tube administration and medication administration for residents at the facility.
Findings
The facility failed to ensure adequate nutrition and proper documentation for a resident with a gastrostomy tube feeding, including failure to document administered feeding volumes and water flushes, and incorrect transcription of feeding orders. Additionally, the facility failed to maintain complete and accurate medication administration records for another resident, with multiple instances of undocumented medication administration.
Complaint Details
The complaint investigation focused on concerns about feeding tube care and medication administration documentation for specific residents. The investigation found substantiated deficiencies related to inadequate documentation and care.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to document administration of ordered volume of tube feeding and water flushes for Resident #1; failed to transcribe tube feeding order correctly. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to maintain complete and accurate medication administration records for Resident #3, with multiple undocumented medication administrations. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Facility census: 154
Tube feeding volume ordered: 1372
Tube feeding rate: 70
Water flush rate: 65
Medication doses missed: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse B | Night Charge Nurse | Provided interview details about feeding tube administration and resident behavior |
| Licensed Practical Nurse A | LPN | Provided interview details about feeding tube administration and documentation |
| Registered Nurse C | RN | Provided interview details about feeding tube administration and resident refusal |
| Assistant Director of Nursing | ADON | Provided interview details about feeding tube orders, staff responsibilities, and documentation |
| Director of Nursing | DON | Provided interview details about medication administration policies and documentation |
| Certified Medication Tech D | CMT | Provided interview details about medication administration and MAR documentation |
| Licensed Practical Nurse E | LPN | Provided interview details about medication administration and MAR documentation |
| Licensed Practical Nurse G | LPN | Participated in interview about medication administration and documentation |
| Administrator | Administrator | Provided interview details about staff responsibilities and medication administration |
Inspection Report
Complaint Investigation
Census: 141
Deficiencies: 2
Feb 15, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to provide timely toileting assistance and incontinent care, and failure to properly assess, treat, and document pressure ulcers and wound care, including failure to administer antibiotics as ordered.
Findings
The facility failed to ensure residents received timely assistance with activities of daily living, failed to properly assess and treat pressure ulcers, failed to administer prescribed antibiotics, and failed to document wound care adequately. These failures contributed to deterioration of a resident's wounds, resulting in hospitalization and above-the-knee amputation.
Complaint Details
Complaint numbers MO00212484, MO00212898, and MO00213675 triggered the investigation. The complaint involved failure to provide timely toileting assistance and incontinent care, and failure to properly assess, treat, and document pressure ulcers and wound care, including failure to administer antibiotics as ordered.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Level of Harm - Immediate jeopardy to resident health or safety: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to provide timely toileting assistance and incontinent care for a resident in the dementia unit. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to have a process to routinely track and assess pressure sores, failure to administer prescribed antibiotics, and failure to follow physician orders for wound care, resulting in deterioration of wounds and hospitalization. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Facility census: 141
Pressure ulcer measurements: 2.8
Pressure ulcer measurements: 2
Pressure ulcer measurements: 0.3
Pressure ulcer measurements: 12
Pressure ulcer measurements: 3.3
Pressure ulcer measurements: 0.3
Pressure ulcer measurements: 7.5
Pressure ulcer measurements: 2
Pressure ulcer measurements: 0.3
Pressure ulcer measurements: 6
Pressure ulcer measurements: 4
Pressure ulcer measurements: 0.1
Antibiotic dosage: 875
Antibiotic dosage frequency: 2
Antibiotic treatment duration: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN D | Wound Nurse | Responsible for weekly wound assessments, skin assessments, and skin treatments; involved in wound care documentation and communication with physicians. |
| RN E | Registered Nurse | Assessed residents when new wounds were reported, informed wound nurse, and notified physicians as needed. |
| LPN J | Licensed Practical Nurse | Completed skin treatments and documented wound care. |
| CMT L | Certified Medication Technician | Documented medication administration codes and handled medication strips; did not administer certain antibiotics as ordered. |
| LPN K | Licensed Practical Nurse | Completed admission assessment and documented pressure ulcers; notified wound nurse of pressure ulcers. |
| LPN G | Unit Manager | Reviewed medication orders and MARs, responsible for ensuring medication administration and physician communication. |
| FNP H | Family Nurse Practitioner | Provided medical oversight, reviewed wound assessments, and communicated expectations for wound care and antibiotic administration. |
| CNA A | Certified Nurse Assistant | Reported resident condition and care challenges on dementia unit. |
| CNA B | Certified Nurse Aide | Reported pressure ulcers to charge nurse. |
Inspection Report
Complaint Investigation
Census: 127
Deficiencies: 12
May 17, 2021
Visit Reason
The inspection was conducted based on complaints alleging mismanagement of resident trust funds, misappropriation of resident property, use of physical restraints without orders, failure to report abuse, failure to update care plans, failure to follow physician orders for oxygen and wound care, late meal service, expired medications, and facility maintenance issues.
Findings
The facility failed to maintain accurate resident trust account reconciliations; failed to protect residents from misappropriation of property; failed to ensure residents were free from unauthorized physical restraints; failed to timely report alleged abuse; failed to investigate abuse allegations promptly; failed to update care plans and invite residents/families to care plan meetings; failed to follow physician orders for oxygen and wound care; failed to provide timely meals according to posted schedules; failed to dispose of expired medications; and failed to maintain facility environment including cleanliness of kitchen equipment and repair of physical plant.
Complaint Details
Complaint investigation included allegations of misappropriation of resident property, improper use of restraints, failure to report abuse, failure to investigate abuse allegations, failure to update care plans, failure to follow physician orders, late meal service, expired medications, and facility maintenance issues.
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to maintain a system to ensure resident trust accounts were reconciled monthly and accurately for all accounts. | — |
| Failed to keep two residents free from misappropriation of property when staff took resident's debit card and cash. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure all residents were free from manual restraint without physician orders; staff physically restrained a resident against his/her wishes. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to timely report an alleged misappropriation of resident property to the State Survey Agency within 24 hours. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to start an immediate investigation and take steps to protect residents when an allegation of manual restraint was reported. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failed to revise and update comprehensive care plans for one resident and failed to invite resident or family to care plan meetings for three residents. | — |
| Failed to follow professional standards of practice when staff failed to administer oxygen as ordered and failed to care plan oxygen usage for one resident. | — |
| Failed to provide appropriate wound care as ordered, failed to follow physician orders timely, failed to document wound assessments and tracking, and failed to update care plans for wounds for multiple residents. | — |
| Failed to dispose of expired medications and supplies by the expiration date. | — |
| Failed to provide meals in a timely manner according to posted schedules and resident preferences. | — |
| Failed to ensure steam table wells and frying pans were clean and free of buildup and food debris; failed to ensure all opened or leftover food was dated. | — |
| Failed to maintain facility environment including repair of floors, walls, nightlight grates, closet doors, and installation of backflow preventers on hoses. | — |
Report Facts
Facility census: 127
Resident trust accounts managed: 84
Resident trust account balances: Monthly balances ranged from $57,333.18 to $102,293.91 from May 2020 to April 2021
Deficiency counts: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN V | Registered Nurse | Named in physical restraint finding and investigation |
| CNA X | Certified Nurse Aide | Named in physical restraint finding and investigation |
| CNA R | Certified Nurse Aide | Named in misappropriation of resident property finding |
| Business Office Manager | Interviewed regarding resident trust account reconciliation | |
| Director of Nursing | DON | Interviewed regarding multiple findings including abuse, care plans, wound care, and medication management |
| LPN A | Licensed Practical Nurse | Wound nurse named in wound care findings |
| Dietary Manager | DM | Interviewed regarding meal service and kitchen sanitation |
| Maintenance Supervisor | Interviewed regarding facility maintenance issues |
Inspection Report
Routine
Census: 142
Deficiencies: 19
May 7, 2019
Visit Reason
The inspection was a routine survey of Spring Valley Health & Rehabilitation Center to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, inadequate call light placement, failure to provide showers as per care plans, poor environmental cleanliness, verbal abuse of a resident by staff, delayed reporting of abuse, incomplete care plans, inadequate assistance with eating, medication errors, improper infection control practices, failure to honor dietary preferences, and failure to maintain a clean medication room.
Deficiencies (19)
| Description | Severity |
|---|---|
| Failure to ensure staff provided care in a manner that promoted dignity when a resident's catheter bag was not kept covered and was visible from the hallway. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to place a call light within reach for a resident dependent on staff for care. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide showers/baths per care plan and/or resident's preference for three residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide a clean, orderly, homelike environment including strong urine odors, unclean resident rooms, and stacked trays on resident tables. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to protect one resident from verbal abuse by a licensed practical nurse who yelled and made threats, with no intervention by other staff. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to timely report an allegation of abuse to management and the Survey Agency when staff overheard a nurse yelling at a resident. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to obtain orders for PICC line dressing changes and failure to change the dressing per standards of practice; failure to complete treatments per physician orders for two residents; failure to document death for one resident. | — |
| Failure to provide adequate assistance with dining to a resident at risk for aspiration who required extensive assistance with eating. | — |
| Failure to meet dietary recommendations timely, failure to ensure medications were administered as ordered, failure to complete wound care following infection control guidelines, and failure to ensure a wound was seen by a physician after significant decline for one resident. | — |
| Failure to ensure staff performed catheter care in a manner to prevent potential urinary tract infections. | — |
| Failure to ensure staff changed oxygen equipment per professional standards for three residents. | — |
| Failure to follow physician orders or dietitian recommendations for a resident with a gastric/enteral feeding tube. | — |
| Failure to provide safe, appropriate pain management including timely administration of pain medications and ensuring medications were on-hand. | — |
| Failure to ensure medication error rate was less than 5% when staff failed to prime insulin pens and administered wrong eye drops. | — |
| Failure to ensure stock medication was stored in original packaging and failure to date insulin vial when opened. | — |
| Failure to ensure staff followed acceptable infection control standards when cleaning glucometers. | — |
| Failure to serve residents palatable and attractive food. | — |
| Failure to determine and honor one resident's religious food preferences. | — |
| Failure to maintain a clean medication room floor. | — |
Report Facts
Medication errors: 5
Resident census: 142
Wound measurements: 13
Wound measurements: 15
Wound measurements: 6
Wound measurements: 7
Wound measurements: 7
Wound measurements: 6
Weight loss: 8.9
Weight loss: 6
Weight loss: 7.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN X | Licensed Practical Nurse | Named in verbal abuse incident with Resident #70. |
| CNA Y | Certified Nurse Aide | Witnessed verbal abuse incident with Resident #70 and did not report. |
| CNA Z | Certified Nurse Aide | Witnessed verbal abuse incident with Resident #70 and did not report. |
| RN K | Registered Nurse/Unit Manager | Discussed pain medication availability and abuse reporting. |
| RN Q | Registered Nurse | Performed wound care and discussed wound deterioration. |
| CMT A | Certified Medication Technician | Administered eye drops and catheter care, discussed hand hygiene. |
| CMT B | Certified Medication Technician | Administered insulin without priming pen. |
| LPN M | Licensed Practical Nurse | Administered insulin without priming pen and discussed insulin vial dating. |
| DA E | Dietary Aide | Observed preparing and serving food with poor hygiene practices. |
| DA F | Dietary Aide | Observed preparing and serving food with poor hygiene practices. |
| DM | Dietary Manager | Discussed food preparation and hygiene practices. |
| DON | Director of Nursing | Provided multiple interviews regarding care deficiencies and abuse. |
| Administrator | Facility Administrator | Provided interviews regarding care deficiencies and abuse. |
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