Inspection Reports for
Springvale Nursing and Rehabilitation Center

The facility was found deficient in multiple areas including failure to notify resident representatives of changes in condition, inadequate protection of resident property, failure to timely report alleged abuse, inaccurate resident assessments, incomplete care plans, inconsistent assistance with activities of daily living, lack of emergency respiratory equipment, improper medication storage and labeling, failure to provide special eating utensils, food safety violations, ineffective infection control practices, pest control deficiencies, and untrained feeding assistants.

The state logged 145 complaints about this facility; 15 led to on-site inspections. This facility received 93.0 complaints per 100 beds vs. a statewide rate of 57.4. 27 citations resulted from those complaints (17.3 per 100 beds vs. 5.3 statewide).

Across 9 inspections, 72 citations were issued including 51 standard health and 21 Life Safety Code citations. All deficiencies were Level 2 or lower severity, indicating minor potential harm with no enforcement actions recorded.

The abbreviated survey was complaint-driven, investigating allegations of failure to notify family of significant changes, abuse incidents involving residents #5 and #7, and failure to provide psychiatric consultation after abuse allegations. Substantiation status is not explicitly stated.

The facility failed to notify a resident's representative of a significant change in condition, did not ensure residents remained free from abuse, failed to timely report suspected abuse, and did not provide appropriate psychiatric consultation following abuse allegations. Several residents experienced harm or potential harm due to these deficiencies.

The visit was complaint-related, triggered by allegations of resident-to-resident abuse involving Residents #1, #2, #3, and #4. The investigations concluded there was no cause to believe any alleged resident abuse or mistreatment had occurred, but the facility failed to timely submit required reports and update care plans accordingly.

The facility failed to ensure residents' right to be free from abuse in four residents involved in multiple resident-to-resident altercations. Investigations concluded no intentional abuse occurred, but care plans were not updated to reflect incidents. Additionally, the facility failed to timely submit investigative reports to the New York State Department of Health within 5 working days as required.

The facility failed to ensure that their facility assessment included an evaluation of the overall number of staff needed to meet residents' needs. The staffing plan documented nursing levels based on an average daily census of 185 but did not specify minimum staffing numbers or include Home Health Aides in the assessment.

The facility failed to ensure comprehensive discharge care plans with measurable objectives and timely interdisciplinary meetings for residents discharged in April 2024. Additionally, the facility did not maintain a safe environment free from accident hazards and failed to update fall risk care plans or implement timely interventions after multiple falls for a high-risk resident.

The facility failed to develop and implement a baseline care plan within 48 hours for a newly admitted resident, did not clarify conflicting hospital discharge orders for insulin and blood glucose monitoring, and lacked sufficient licensed nursing staff on one unit during a medical emergency involving the resident.

The visit was complaint-related, triggered by an incident where Resident #3 fell out of bed due to inadequate supervision by CNA #1. The investigation concluded no abuse or neglect occurred, but the deficiency was substantiated as a failure to provide adequate supervision.

The facility failed to ensure adequate supervision of Resident #3, who fell out of bed and sustained a fracture. The investigation found that CNA #1 left the resident unattended while obtaining supplies, despite prior education on safety and accident prevention. The facility had policies on accident hazards and fall prevention, and staff were educated on safety, but the incident occurred due to failure to follow these protocols. CNA #1 was suspended and re-educated, and the care plan was updated to include fall risk interventions.

The facility was found deficient in timely reporting of suspected abuse, implementation of care plans, nutritional care, infection control practices, call system accessibility, and maintaining a safe and clean environment. Specific issues included delayed reporting of an injury of unknown origin, failure to provide assistive devices as ordered, unaddressed significant weight loss, improper management of an indwelling catheter bag, inaccessible call bells in resident bathrooms, and unsanitary conditions in a resident's room.

The survey found deficiencies including failure to ensure resident dignity during interviews and meal assistance, inadequate advanced directives documentation and communication, improper food labeling and unsanitary conditions in refrigerators, and lapses in infection prevention practices such as failure to clean pulse oximeters and perform hand hygiene between resident contacts.