Spring Valley Care Center

Inspectors wroteBased on observation and interview, the facility failed to properly label, store and dispose of refrigerated items. This had the potential to affect all residents served out of the kitchen. During the initial kitchen tour on 12/15/25 at 11:45 a.m., with dietary manager (DM)-A the following undated or expired items were observed in the refrigerator: Undated bin of sandwiches,Undated hot dogs,Undated onion, Undated oranges in syrupPumpkin puree dated 12/10Honeydew dated 11/8Chicken gravy dated 11/20During interview 12/15/25 at 12:01 p.m., DM-A confirmed the previous listed items. She stated the sandwiches and pumpkin puree were expired and should have been discarded. The policy directs them to discard all items after 3 days. DM-A confirmed the importance of dating food was to ensure residents don't become ill from the foods they were served. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure advanced directives for emergency treatment were accurately reflected in all areas of the medical record to ensure the residents wishes would be implemented correctly in an emergent situation for 1 of 1 residents R39) reviewed for advanced directives.

Inspectors wroteBased on interview and record review the facility failed to ensure proper side effect monitoring for potential orthostatic hypotension (sudden drop in blood pressure that occurs when a person changes position from lying to sitting and/or standing) was completed for 1 of 1 resident (R45) reviewed for unnecessary medications who received antipsychotics. R45's quarterly Minimum Data Set (MDS) dated [DATE] indicated R45 had severe cognitive impairment with wandering but no other behaviors. R45 required partial to substantial assist for activities of daily living and was independent with side-to-side bed mobility and sitting on edge of the bed. He required substantial assists for all other transfers and position changes. R34 has a history of traumatic brain dysfunction, and palliative care. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure a resident had accurate physician orders for medications for 1 of 5 residents (R11) reviewed order accuracy.

Inspectors wroteBased on interview and document review, the facility failed to ensure facility staff appropriately transcribed physician orders for 1 of 5 residents (R11) reviewed for order entry.

Inspectors wroteBased on interview and record review, the facility failed to ensure the pharmacy consultant identified irregularities in monthly drug regimen reviews for 2 of 5 residents (R11 and R45) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the facility's state survey results were kept in a location that was readily accessible to all residents. This had the potential to affect all 42 residents and/or visitors who wished to review the information. R25's quarterly Minimum Data Set (MDS) dated [DATE], indicated R25 had intact cognition. During an interview with the facility resident council president on 12/17/25 at 2:43 pm., R25 (resident council president) stated the survey binder was usually at the front desk; it had been gone for some time though. R25 stated she would like to see it returned. During observation and interview on 12/18/25 at 10:31 a.m., social worker (SW) and administrator confirmed the facility had a survey binder; they were unsure why it wasn't in the designated spot at the front desk. [...]

Inspectors wroteBased on interview and record review, the facility failed to submit complete and/or accurate data for staffing information based on payroll and other verifiable data during 1 of 1 quarter (Quarter 3) reviewed, to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS.

Inspectors wroteBased on observation, interview, and document review, the facility failed to provide a dignified dining experience for 1 of 1 resident (R37) observed for dignity.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure residents were comprehensively assessed for self-administration of medications for 1 of 1 resident (R32) reviewed and observed for self-administration of medications.

Inspectors wroteBased on interview and document review, the facility failed to provide the required written Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) and Notice of Medicare Non-Coverage (NOMNC) forms to 2 of 3 residents (R7 and R16) reviewed whose Medicare A coverage ended and then remained in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to reassess behaviors and intervention of potential wandering to ensure safety and prevent possible elopement for 2 of 2 residents (R37 and R33) reviewed for accidents.

Inspectors wroteBased on observation, interview, and documentation review the facility failed to provide assistance with facial hair removal for 2 of 3 residents (R32 and R37) with grooming needs who was dependent upon staff for assistance.

Inspectors wroteBased on interview and document review, the facility failed to ensure proper treatment was provided to maintain hearing for 1 of 1 resident (R8) reviewed for hearing.

Inspectors wroteBased on observation, interview, and document review the facility failed to comprehensively assess past trauma and implement care plan interventions utilizing a trauma-informed approach for 1 of 1 (R37) resident reviewed who had a history of past traumatic experiences.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure side rails were assessed to determine appropriate and safe to use for 2 of 5 residents (R8 and R19) who were observed to have a side rail affixed to their beds.

Inspectors wroteBased on interview and document review, the facility failed to ensure the services of a registered nurse (RN) were available onsite for 8 consecutive hours seven days a week. This had the potential to affect all 41 residents who reside at the facility. Review of the facility staffing schedules dated 4/1/24 through 6/30/24, identified there was not eight consecutive hours of RN coverage for 6/2/24, 6/15/24 and 6/16/24. During interview on 11/21/24 at 12:59 p.m., the assistant director of nursing (ADON) verified there was no RN on for eight consecutive hours on 6/2/24, 6/15/24 and 6/16/24. The ADON stated the facility policy and practice was to have a RN on duty in the building eight consecutive hours but had call-ins for those dates and not sure what happened. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure adverse event monitoring was completed for 1 of 4 residents (R37) and failed to monitor adverse behaviors for 1 of 4 residents (R37) reviewed for unnecessary medication use and were taking an antipsychotic medication.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure appropriate hand hygiene and donning/doffing of personal protective equipment (PPE) was performed in order to prevent the spread of infection for 3 of 3 residents (R8, R32, and R21) observed for enhanced barrier precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities).

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the required and complete nurse staffing information was posted and readily available for viewing by the residents and visitors. Additionally, the facility failed to maintain the staffing logs for 18 months, as required, in the event this information was needed for review. This had the potential to affect all 41 residents and visitors who wanted to review the information.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure special instructions for wound care were transcribed and followed for 1 of 2 residents (R2) reviewed for pressure ulcers.