Inspection Reports for
Spring Valley Health and Rehabilitation Center

Complaint # 2650298 was investigated regarding medication administration errors and tube feeding documentation and care.

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.

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.

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.

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.

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.

The facility failed to ensure all residents with catheters received care per standards of practice, including documentation of catheter care, monitoring for infection signs, and updating physician orders and care plans. Deficiencies were noted in catheter care completion, monitoring, and documentation for one resident with an indwelling catheter.

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.

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.

The facility failed to ensure all residents received care per professional standards when staff did not obtain an ordered urinalysis in a timely manner for one resident. The facility census was 152 at the time of inspection.

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.

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.

The complaint investigation was triggered by allegations of physical abuse to Resident #1 by staff. The facility failed to report the abuse allegations timely and did not conduct a proper investigation. Interviews with multiple staff and review of records confirmed these failures.

The facility failed to ensure all allegations of possible abuse were reported immediately to management and the state licensing agency. The facility also failed to promptly begin an investigation and take steps to protect residents after the allegation. Staff interviews revealed inconsistent knowledge about abuse reporting requirements.

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.

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.

The facility failed to maintain a safe, clean, and homelike environment as evidenced by insufficient housekeeping and maintenance services, resulting in unsanitary conditions in resident areas. Multiple observations documented dirty shower rooms, fecal matter in resident bathrooms, and soiled linens, with no written policy for maintaining cleanliness.

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.

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.

The investigation was triggered by a complaint alleging sexual abuse of Resident #1. The complaint was substantiated as the facility failed to report and investigate the allegation properly.

The facility failed to report allegations of possible abuse immediately to the Administrator and the State Survey Agency within the required timeframes. The facility also failed to conduct a timely investigation and take immediate protective steps when staff documented an allegation of sexual abuse.

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.

The facility was found to be in noncompliance with emergency preparedness training requirements and multiple life safety code deficiencies including exterior emergency lighting, exit signage, fire alarm system testing, smoke detection, and gas equipment qualifications. These deficiencies had the potential to affect all 154 residents.

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.

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.

The facility failed to ensure proper documentation and administration of tube feeding for Resident #1, including failure to document feeding volumes and water flushes. Additionally, the facility did not maintain complete and accurate medical records for Resident #3, including medication administration documentation.

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.

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.

The survey was complaint-driven, investigating complaints #MO00212484, MO00212898, and MO00213675. The facility was found to have implemented corrective action to remove the immediate jeopardy level "J" violation at the time of exit. The severity of deficiencies was lowered to Class I and II levels.

The facility was found deficient in providing adequate ADL care for dependent residents and in preventing and treating pressure ulcers. Deficiencies included failure to provide timely incontinence care, inadequate wound care documentation, and medication administration issues.

The facility failed to ensure all staff could quickly access the front door in a timely manner and did not have an appropriate process for one high-risk resident with a wanderguard device. The front door alarm system was inadequate, and staff lacked knowledge of the door code. The facility also lacked policies for maintenance of door alarms and the wanderguard system.

The facility was found deficient in several areas including residents' rights related to smoke break opportunities, safe and clean environment maintenance, and frequency of meals/snacks at bedtime. Multiple residents reported inadequate housekeeping and showering services, and the facility failed to provide consistent and timely care in these areas.

The facility failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious contaminants, specifically staff failing to perform hand hygiene before, during, and after wound care on three residents. Multiple observations and record reviews confirmed these deficiencies.

The facility failed to ensure proper medication administration and pain management for residents, including failure to discontinue medications as ordered and inadequate follow-up on pain medication effectiveness. Resident census was 132 during the inspection.

The complaint investigation was substantiated. The facility failed to report allegations of abuse involving a staff member and a resident to the State Survey Agency within two hours as required.

The facility failed to ensure all staff were trained on verifying residents' code status, resulting in incorrect code status for one resident. The facility also failed to report allegations of abuse involving a staff member and a resident to the State Survey Agency within required timeframes.

The facility failed to ensure all staff were properly trained on emergency procedures and fire suppression system use. Multiple deficiencies were found related to fire safety, including inadequate fire barrier maintenance, sprinkler system issues, electrical equipment hazards, and smoking regulation violations.

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.

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.

The investigation was triggered by a complaint about medication errors involving a resident with seizures. The complaint was substantiated by findings of missed medications and lack of proper physician notification.

The facility failed to ensure residents were free of significant medication errors, including failure to administer ordered seizure medication and notify the physician. Staff did not document reasons for missed medications, and policies for medication administration and physician notification were not properly followed.

The facility failed to document all physician orders, monitor a fracture with a cast, and ensure a follow-up appointment was kept for one resident, resulting in an almost two-month delay in seeing a specialist. The facility was found to be in compliance with COVID-19 emergency preparedness requirements.

The complaint investigation substantiated that the facility failed to document timely and accurate medical records for Resident #1, including fall assessment, physician notification, x-ray orders, and pain medication administration.

The facility was found in compliance with COVID-19 emergency preparedness requirements but failed to ensure one resident's medical record was complete and accurate, including timely documentation of a fall, physician notification, x-rays, and pain medication administration.

Complaint number MO00175580 was investigated. The complaint was substantiated as the facility failed to properly destroy and document discontinued medications within required timeframes.

The facility failed to maintain an ongoing monitoring process for accurate documentation and accountability of expired or unusable medications. Medications that could not be returned to the pharmacy were not destroyed in a timely manner for ten residents, and the facility lacked a policy addressing proper documentation, destruction, and disposal of medications.

The facility failed to fully implement infection control practices including appropriate use of PPE, hand hygiene, social distancing, and mask wearing among staff and residents. Multiple observations showed staff and residents not adhering to CDC and CMS recommended infection control measures.

The complaint investigation was substantiated based on the finding that the nurse left the medication cart unattended, leading to the misappropriation of narcotic medication.

The facility failed to prevent the misappropriation of one resident's narcotic medication card from the medication cart. The investigation revealed that a nurse left the medication cart unattended and did not immediately count the cart upon discovering the discrepancy.

The facility failed to consistently serve food at safe and appetizing temperatures, prepare food in forms meeting individual resident needs, and provide food accommodating resident allergies, preferences, and substitutes. Multiple residents reported receiving cold food or incorrect portions, and the facility did not properly monitor or document food temperatures.

The complaint investigation was substantiated with findings of abuse, neglect, medication errors, and failure to provide adequate care and services to residents.

The facility was found to have multiple deficiencies including failure to provide dignified care, inadequate supervision, medication errors, improper handling of resident needs, and failure to prevent abuse and neglect. The facility census was 142 at the time of inspection.

The facility failed to maintain sprinkler heads free from obstruction by insulation, maintain smoke resistive properties of corridor doors, ensure electrical receptacles in wet locations had ground-fault circuit interrupter protection, and properly manage power strips and extension cords. These deficiencies posed potential risks to residents, staff, and visitors in the event of fire or electrical hazards.

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.

The facility was found deficient in multiple areas including resident rights, Medicaid/Medicare coverage notices, safe and homelike environment, pharmacy services, food procurement and safety, infection prevention and control, and environmental conditions. Specific issues included lack of privacy for catheter bags, failure to provide required Medicare notices, unclean privacy curtains, expired medications, unsafe food handling practices, and inadequate infection control procedures.

The facility failed to meet certain Life Safety Code requirements related to corridor doors, fire door inspections, and emergency generator fuel testing. These deficiencies had the potential to affect all residents, staff, and visitors.